Trauma training in Australia and New Zealand: results of a survey of advanced surgical trainees.

BACKGROUND: The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training. METHODS: A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons. RESULTS: Two hundred and seventy-two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations. CONCLUSIONS: Regional rotations may need to be developed to even out trainees' experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.

Effect of breast surgery on serum levels of insulin-like growth factors (IGF-I, IGF-II, and IGF binding protein-3) in women with benign and malignant breast lesions.

BACKGROUND: There is evidence that insulin-like growth factors play a role in the development of breast cancer. Antiestrogens reduce circulating levels of IGF-I, but the influence of other breast cancer treatments, including surgery, is unknown and is investigated in this study. METHODS: Circulating serum concentrations of IGF-I, IGF-II, and IGF binding protein-3 (IGFBP-3) were measured before and after breast surgery in 31 patients with breast cancer and 12 controls with benign breast lesions. Serum albumin was measured as a marker of the nonspecific metabolic effect of surgery. RESULTS: Serum IGF-I, IGF-II, IGFBP-3, and albumin fell 24 hours after surgery for breast cancer but largely normalized again over the next 7 days. The fall in IGF-I and IGFBP-3 was not significant when the change in serum albumin was used as a covariate, suggesting a nonspecific effect of surgery. However, the reduction in IGF-II remained significant when adjusted for albumin and was greater after lumpectomy of malignant tumors (-8 +/- 2%) compared with benign disease (2 +/- 2%, P = .001). The fall in IGF-II was significantly related to the size of the removed tumor. CONCLUSIONS: Breast cancer may directly influence the serum concentration of IGF-II, possibly by direct tumor production.

Surgery in New Zealand.

Surgery in New Zealand is performed by more than 500 surgeons who serve a population of 3.8 million people. Most of the surgeons are trained in New Zealand under the auspices of the Royal Australasian College of Surgeons. Surgical services are consistent with the highest standards of Western countries.

Lumbar transverse process fractures--a sentinel marker of abdominal organ injuries.

Fractures of lumbar vertebrae may be associated with abdominal organ injuries. Lumbar transverse process fractures are commonly thought of as minor injuries compared with body, pedicle and lamina fractures. To determine the significance of transverse process fractures as opposed to other lumbar vertebral fractures in relation to abdominal organ injury, a retrospective study was performed. One hundred and ninety-one patients with lumbar spine fractures were reviewed. One hundred and thirty-five (71%) of these had non-transverse process (NTP) fractures only (including vertebral body, pedicle, or spinous process fractures). Fourty-two patients (22%) had transverse process fractures only. Fourteen patients (7%) had both transverse process and NTP fractures. Twenty (48%) of the 42 patients with transverse process fractures had abdominal organ injuries identified. This was a significantly (P<0.05) higher rate than for the patients with NTP fractures, eight of 135 (6%). Patients with transverse process fractures and abdominal organ injuries had a median injury severity score (ISS) of 29 compared with a median ISS of 17 for patients with NTP fractures and abdominal organ injuries. If a transverse process has been fractured, there is likely to have been very large forces involved in the incident. The data strongly suggest that lumbar transverse process fractures should not be thought of as minor injuries but regarded as a significant marker for abdominal organ injuries and should alert the doctor caring for the injured patient of the high probability of these injuries.

Serum levels of insulin-like growth factor binding protein-3 in benign and malignant breast disease.

BACKGROUND: The insulin-like growth factors IGF-I and IGF-II and their major binding protein IGFBP-3 influence the growth of breast cancer cells in vitro. Some benign non-breast tumours appear to be associated with increased serum IGFBP-3 levels which would tend to reduce bioactive-free IGF concentrations. The present study investigates whether this pattern also occurs in neoplastic breast disease. METHODS: Serum IGF-I, IGF-II and IGFBP-3 were measured by specific radioassay in 12 women with benign breast disease, 31 patients with breast cancer and in age-matched controls. RESULTS: The mean (+/-SD) serum IGFBP-3 concentration was higher in benign breast disease (3.6+/-0.7 mg/L) than in controls (2.7+/-0.6 mg/L) or in breast cancer patients (2.7+/-0.5 mg/L) (P = 0.001). Serum IGF-I and IGF-II levels were not significantly different among the groups. However, the index of free unbound IGF measured as the molar ratio of IGF-I plus IGF-II divided by IGFBP-3 was significantly lower in benign breast disease than in the other subjects. CONCLUSIONS: Either the production or clearance of IGFBP-3 is altered in benign breast disease so that there is less free IGF available to cells. This may serve to protect against malignant transformation in patients with benign breast disorders.

Penetrating trauma in Auckland: 12 years on.

BACKGROUND: The current spectrum of penetrating trauma presenting to Auckland Hospital is described and whether this differs from the situation in 1983 is determined. METHODS: Prospectively collected trauma registry data were used to describe the characteristics of penetrating trauma cases presenting to Auckland Hospital during the 1995 calendar year. Using data collected from a previous study in 1983, comparisons were made of the incidence, severity, and outcome of penetrating trauma cases between these two cohorts. RESULTS: In 1995, 96 patients, representing 7.3% of total trauma admissions, presented to Auckland Hospital following penetrating trauma. Of these, 32 patients were admitted by the trauma team via the resuscitation room, 13 were admitted to the intensive care unit (ICU) and four died. The median age of these patients was 30 years and median Injury Severity Score, 4. In comparison with the 1983 patients there was no demonstrable change in the numbers of patients or their length of stay. Although injury severity was similar in the 1995 cohort, fewer patients were admitted to the ICU. Mortality of the 'trauma team' group was 4/32 in 1995 compared with 7/33 in 1983. CONCLUSIONS: Despite public concerns, the frequency of penetrating trauma cases presenting to Auckland Hospital was similar in 1995 and 1983. There is a non-significant decrease in length of stay and mortality in the 1995 cohort.

Resuscitation following injury: an end or a means?

It is known that a successful outcome after injury requires haemostasis and replacement of intra- and extracellular fluid losses. In situations of controlled haemorrhage rapid replacement of these fluid losses is likely to be associated with the least morbidity. When considering uncontrolled haemorrhage, however, there is good evidence that effective resuscitative devices and strategies have proven to be associated with a worse outcome when used initially than when their use follows surgical control of bleeding. Despite newer developments in resuscitative technique, surgeons must continue to be involved in the early management of the severely injured so that they are in the best position to employ their skills and provide surgical haemostasis when and where it is required. The 'end' therefore in resuscitation of the injured is a normovolaemic, normotensive patient who is physiologically stable and able to have definitive management of his/her anatomic injuries. The 'means' are good prehospital care, accurate initial assessment and resuscitation that employs temporary and definitive haemostasis combined with adequate volumes of appropriately chosen and delivered resuscitation fluid.

Severe blunt assault injuries at Auckland Hospital.

The incidence and nature of severe blunt assault injury in the Auckland region was assessed by a retrospective review over a 2-year period. Approximately 14,000 charges of assault (excluding paediatric and sexual assault) were laid during this period. A total of 1035 people were admitted to hospital. Of 331 patients admitted to one hospital, 35 patients were admitted via the resuscitation room after severe assault; of these, two died. Of these patients, 33 were male and 19 of 21 ethanol levels measured were greater than 17 mmol/l. Head and facial injuries were the most frequent.