Validity of self-reported skin screening histories.

Screening by whole-body clinical skin examination may improve early diagnosis of melanoma and reduce mortality, but objective scientific evidence of this is lacking. As part of a randomized controlled trial of population screening for melanoma in Queensland, Australia, the authors assessed the validity of self-reported history of whole-body skin examination and factors associated with accuracy of recall among 2,704 participants in 2001. Approximately half of the participants were known to have undergone whole-body skin examination within the past 3 years at skin screening clinics conducted as part of the randomized trial. All positive and negative self-reports were compared with screening clinic records. Where possible, reports of skin examinations conducted outside the clinics were compared with private medical records. The validity of self-reports of whole-body skin examination in the past 3 years was high: Concordance between self-reports and medical records was 93.7%, sensitivity was 92.0%, and specificity was 96.3%. Concordance was lower (74.3%) for self-reports of examinations conducted in the past 12 months, and there was evidence of "telescoping" in recall for this more recent time frame. In multivariate analysis, women and younger participants more accurately recalled their history of skin examinations. Participants with a history of melanoma did not differ from other participants in their accuracy of recall.

A randomised trial of population screening for melanoma.

OBJECTIVES: Melanoma is a significant cause of morbidity and mortality worldwide and incidence is increasing. Survival after treatment is inversely related to the thickness of the tumour at diagnosis. Population screening has the potential to reduce mortality but there is no conclusive evidence of benefit. Such evidence can come best from a randomised trial. Here we describe the design of a community based randomised trial of a population screening programme for melanoma in Queensland, Australia and early results of the first phase of the trial. METHODS: A total of 44 communities (aggregate population 560 000 adults aged 30 years or more) will be randomised to receive either a community based screening programme for 3 years or normal practice. The screening programme promotes thorough skin self examination and whole body skin examination by a doctor and provides open access skin cancer screening clinics. In its first phase, the trial is underway in nine intervention and nine control communities. The primary outcome measure is mortality from melanoma during 15 years of follow up. RESULTS: The first phase of the trial has shown the feasibility of implementing a population skin screening programme including regular skin cancer screening clinics, and has shown the strong support of communities and doctors for the programme. There has been a significant 2.5-fold increase in participation in screening in the intervention communities in this first phase after the first 12 months of the trial and no significant increase in participation in screening in control communities during this period. CONCLUSIONS: The design of a community based randomised trial of screening for melanoma has been successfully peer reviewed and the intervention has been shown to be feasible in practice. This randomised trial may be one of the last opportunities to develop the evidence required for public health recommendations for population screening for melanoma.

Reducing indigenous mortality in Australia: lessons from other countries.

Mortality rates from all causes in Maoris in New Zealand and Native Americans have fallen substantially since the early 1970s. Comparable mortality rates for Australian Aboriginals and Torres Strait Islanders in 1990-1994 were at or above the rates observed 20 years ago in Maoris and Native Americans, being 1.9 times the rate in Maoris, 2.4 times the rate in Native Americans, and 3.2 times the rate for all Australians. Circulatory diseases, respiratory diseases, injuries and endocrine diseases (mostly diabetes) are responsible for almost 70% of these excess deaths. Mortality rate trends in indigenous populations in other countries suggest the feasibility of substantial and rapid reductions in mortality rates of Australia's indigenous people.

Measurement of human exposure to ultraviolet-B solar radiation using a CR-39 dosimeter.

CR-39 (allyl diglycol carbonate) dosimeters were tested for measurements of ultraviolet-B (erythemal dose) solar radiation with a rotating model head and a human survey during solar exposure. The ratio of summer dose to winter dose for the vertex is 3.3, and for the eye and lower face is greater than 1. A survey suggests the relation of the ultraviolet-B dose to outdoor activities.

Patterns of treated non-melanoma skin cancer in Queensland--the region with the highest incidence rates in the world.

The incidence of non-melanoma skin cancer, comprising basal cell carcinoma and squamous cell carcinoma, was studied in Queensland during 1984. The world-standardised annual incidence rates (per 100,000 population) for the number of persons with non-melanoma skin cancer were estimated to be 1372 for men and 702 for women, the highest recorded incidence rates in the world. Rates in men were nearly double the rates in women and age-specific incidence rates increased curvilinearly with age. There were, on average, 1.4 skin cancers per person with non-melanoma skin cancer and the ratio of basal cell carcinomas to squamous cell carcinomas was approximately three to one. The age-standardised annual incidence rate (per 100,000 population) of basal cell carcinoma for residents of the Gold Coast was 1.83 times the Brisbane rate for men and 1.57 times that for women, indicating significant differences between the two regions. For squamous cell carcinoma the regional differences were not statistically significant. The average potential number of non-melanoma skin cancers (per person) treated during the lifetime of a cohort of 100,000 was estimated to be 0.014 for men and 0.009 for women by age 40. By age 65, these numbers increased to 0.22 for men and 0.11 for women. At age 90, these average numbers were 1.09 and 0.42, respectively. Although the incidence of non-melanoma skin cancer is much higher in the older age groups, it should be kept in mind that it also affects the younger population; 1028 Queenslanders under 40 required treatment for 2300 non-melanoma skin cancers in 1984. This study which provides baseline information about the occurrence of non-melanoma skin cancer in Queensland emphasises the importance of developing safe sun-exposure habits, detecting non-melanoma skin cancer early and protecting and restoring the atmosphere.

Experience with multiple intracranial haematomas in New South Wales.

A retrospective survey of head injuries in NSW in 1977 and 1978 was conducted by the Trauma Subcommittee of the Neurosurgical Society of Australasia. This paper describes the findings for 129 patients who had more than one significant intracranial haematoma. Overall, the case fatality rate for these patients was 85%. The presence of low or fluctuating blood pressure was associated with a significantly higher mortality than in the rest of the group. Bilateral reacting pupils or an improvement in level of consciousness following decompressive surgery carried a more favourable prognosis. There was 100% fatality if surgery was not carried out or if the bleeding was not found at operation. A subset of patients who died was selected on the basis of a calculated prognostic variable, and compared with a similar subset of survivors. A higher proportion of patients who died had a delay in the provision of definitive treatment and failure to correct shock. This comparison was made on two criteria. Using the first accepted optimal treatment in 1984, nearly all cases were treated suboptimally, as might be expected. Using the second, acceptable treatment in 1977-78, it was calculated that between nine and 12 patients died with MIH in NSW in the 2 years of the survey, whose deaths might have been prevented.

Experience with extradural haematomas in New South Wales.

A retrospective study of 126 patients with extradural haematomas was made to determine whether their outcome could be modified by alteration of their management. Poor outcome occurred in those over 65 years of age, in motor smash victims, in those with fixed pupils, in those with major associated injuries or those comatose on hospital admission. The detection of skull fracture or of a lucid interval was not prognostically useful. A graduation in mortality according to the type of hospital was present but did not reach statistical significance. Failure to correct shock and delay in instituting definitive treatment were the major preventable factors which could be modified to improve outcome.

Experience with spinal injuries in New South Wales.

Two hundred and two patients with acute and severe spinal injuries were treated in various hospitals in New South Wales during 1977 and 1978. Of these, 132 (65%) were cervical, 60 (30%) thoracic, eight (4%) lumbar and two were inadequately recorded. A major concurrent injury to the head was present in every third patient, to the chest in every fourth patient, and to the limbs in every fifth patient. The outcomes of patients reported in this series make it one of the worst in the literature. Sixty-nine (34%) patients died in hospital; of the 133 survivors, only 22 (11%) have resumed work, the remainder being partially or totally disabled. It is estimated that another 302 patients died before arrival in hospital. In country areas, the time lags between accident and ambulance notification, and between notification and arrival at hospital, were uncertain in many cases, but periods in excess of 2 hours were recorded in 28 (14%). One-man ambulances or private vehicles were used in at least 43 cases (21%). After admission, 139 patients were transferred to other hospitals for definitive treatment, arriving after an average time of 22 h (median time 9 h); for such patients, the original hospital presumably served as a first aid station. A case control study suggests that preventable delay in transport, inappropriate treatment, and failure to correct shock may have been causative factors in 16 deaths in this series. Reduction of the time lag between accident and institution of definitive treatment will save lives, and may avoid some crippling neurological deficits.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with chronic subdural haematomas in New South Wales.

This study considered 135 cases of chronic subdural haematoma following head injury in 1977 and 1978. The majority were in the older age group and more often males. Falls were the commonest cause. Among intracranial haematomas they carry a much better prognosis. However, there was a mortality rate of 9% and delay in diagnosis was the most likely preventable factor contributing to this. Accordingly the possibility of this complication after head injury should be known to those concerned in the later hospital treatment and follow-up management especially of older patients and alcoholics. When the diagnosis has been made, the preferred surgical method of treatment is drainage through burrholes. Follow-up CT scanning should be arranged usually about 8 weeks afterwards unless there are clinical indications for an earlier examination.

Logistics of early management of head and spinal injuries.

The logistics of early management have been studied in a series of 1161 patients with head and/or spinal injuries, who were admitted to hospital in NSW in 1977-78. Special attention has been given to three subgroups: 336 head injuries with records of impaired consciousness before first hospital admission, 355 head injuries later transferred because of deterioration, and 202 serious spinal injuries. It was found that in at least 18% of unconscious head injuries, and a similar percentage of spinal injuries, first aid and transport to hospital were provided by ambulances recorded to have only one trained staff member. In country areas, 41% of unconscious head injuries reached hospital after periods of time exceeding 1 h. For administrative as well as geographic reasons, more than 80% of initially unconscious head injuries and spinal injuries were first admitted to hospitals without neurosurgical and/or spinal services; the majority of cases in both groups, therefore, had to be transferred to other hospitals, often within 6 h of first admission. In the subgroup of cases transferred because of deterioration, mortality increased with distance from a neurosurgical unit. These findings are related to the concept of an integrated regional trauma service.

Preventable causes of death and disability from neurotrauma.

Preventable causes of death and disability have been studied retrospectively in a series of 1161 cases of neurotrauma occurring in New South Wales in 1977-78, and prospectively in 153 cases of neurotrauma occurring in country districts in South Australia in 1981-82. In the first study, it was found that at least 80 deaths could be attributed to preventable causes; chiefly, transfer to an inappropriate hospital and/or delay in instituting treatment. Apparent failures in initial management of shock and airway obstruction were evident in this study and also in the South Australian study, which identified major deficiencies in cardiorespiratory management in 7% of cases transferred from country areas. These studies confirm that there is a need for better training, at all levels, in the management of neurotrauma. They also provide powerful arguments for the concept of an integrated regional trauma service.

Epidemiology and clinical outcomes of neurotrauma in New South Wales.

This study of 1161 neurotrauma patients in New South Wales hospitals was designed to examine the role of preventable causes of death and disability in cases of spinal injury, extradural, subdural and multiple intracranial haematomas in order to make recommendations for improvements in accident, emergency, ambulance and hospital services. Methods have been developed for standardizing diagnosis in different classes of hospital for the assessment of severity in terms of the patient's age, sex, physical signs, head and spine injuries and other injuries. Estimates have been made of the number of preventable deaths by a case control study of each category of neurotrauma under study.

Trauma to the central and peripheral nervous systems. Part II: A statistical profile of surgical treatment New South Wales 1977.

The epidemiological aspects of the mortality, morbidity and the costs of neurotrauma in New South Wales 1977 were outlined in Part I of this report. Part II outlines the profile of surgical work in this field in New South Wales in 1977. In all, 21,973 patients were admitted to New South Wales Hospitals in 1977 for neurotraumatic conditions (85% with head, 13% with spinal and 2% with peripheral nerve injuries); and 1,513 patients required surgery (49% with head, 22% with spinal and 29% with peripheral nerve injuries). The profile of surgery for disc disease is outlined. The participation of neurosurgeons in the management of neurotrauma is assessed.

Trauma to the central and peripheral nervous systems: Part I: an overview of mortality, morbidity and costs; N.S.W. 1977.

An epidemiological study of neurotrauma in New South Wales, South Australia and the Australian Capital Territory, 1977, was initiated and sponsored by the Neurosurgical Society of Australasia, conducted by its Trauma Subcommittee in collaboration with the Division of Health Services Research, Health Commission of New South Wales, funded by the Australian Brain Foundation and the Commonwealth Department of Health and supported by the Health Commissions of New South Wales and South Australia. The following communication is structured so as to present the essential findings on mortality, morbidity and costs in New South Wales in 1977 in the first part and the more specific statistical profile of surgical treatment in New South Wales, 1977, in a separate, second part. The most revealing data found by this research is that cranio-cerebral and spinal injury was the leading cause of death up to the age of 44 in New South Wales (and South Australia) and up to the age of 49 in the male population and in the country regions. It accounted for 45% of all deaths to those aged 15 to 24. Cranio-cerebral and spinal injury caused 71% of all deaths on the roads. Sixty-four per cent of those dying in road accidents never reached hospital. The figures for mortality and morbidity in the country regions were significantly worse than those in the metropolitan regions. The most important causes were identified and recommendations aimed at reducing this record were formulated.

Fatal injuries of the head and spine: epidemiological studies in New South Wales and South Australia.

In 1977, 1402 people died in New South Wales and 325 in South Australia from injuries to the brain or spinal cord. Records indicate that neurological injury is the leading cause of death in these States in the age range 0-44 years, accounting for more than 20% of deaths. A high proportion (41%) of accidents causing neurological injury occurred in country areas. We considered factors contributing to preventable causes of death. We found evidence of excessive consumption of alcohol in one-third of those tested; however, this estimation was omitted in many cases in both States. In the SA series at least 6% of deaths showed features suggesting that the primary neurological injury was not lethal. Potentially lethal secondary complications, such as respiratory obstruction or intracranial bleeding, may be reduced by earlier and better first aid and by speedier neurosurgical consultation. There is a need for more complete coronial autopsy examinations in all cases of violent death, and for the application of standardised diagnostic criteria.