One thousand consecutive deaths from injury in 11 coroner's districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%).Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment.The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.

Aims-To investigate the role of the matrix metalloproteinases (MMPs) in the connective tissue changes seen in the intestine in Crohn's disease. Methods-Indirect immunofluorescence microscopy using specific antibodies to the MMPs (collagenase, gelatinase A and B, and stromelysin) were used to assess the distribution of these enzymes in normal and diseased intestine. Results-In normal intestine the matrix metalloproteinases were confined to a few isolated inflammatory cells, but in Crohn's disease, the inflammatory infiltrate was associated with increased numbers of polymorphonuclear leucocytes which stained positive for gelatinase B. Stromelysin was also detected extracellularly on the connective tissue matrix in regions of smooth muscle cell proliferation and mucosal degradation. Interestingly, in ulcerative colitis, another inflammatory bowel disease, stromelysin was localised in the lamina propria in regions of mucosal loss. Conclusions-The increased numbers of inflammatory cells containing gelatinase B, and the localisation of extracellular stromelysin in regions of fibrosis and mucosal degradation, suggest that these enzymes have a role in the pathological changes seen in Crohn's disease. In cases of ulcerative colitis stromelysin was also detected on the laIina propria in regions of mucosal loss, and seems to be associated with the connective tissue changes that precede mucosal loss.

Background-A study was performed to measure the quality of life of patients receiving home parenteral nutrition (HPN)

There was major disagreement between the studies on whether use of the drugs in question is of value in preventing postoperative complications. This analysis suggests that, in units where the postoperative fistula rate following pancreaticoduodenectomy for neoplasia and other pancreatic conditions exceeds 10 per cent, somatostatin or octreotide administered before operation may significantly reduce the rate of major postoperative complications, particularly pancreatic fistulas. The identified evidence also suggests that there may be a limited role for such drugs in the treatment of established postoperative enterocutaneous pancreatic fistulas. A major conclusion is that further clarification of the roles of these drugs is still required through large, high-quality, randomized trials.

Two commercially available kits have been used to create 25 percutaneous tracheostomies, 20 using the Cook system and five using the Rapitrac system. The operation time and complication rates of these tracheostomies have been compared with those for 16 conventional tracheostomies performed for similar indications. Median operating times were 60 (range 30-105) min for conventional tracheostomy, 15 (range 8-70) min for Cook and 5 (range 3-15) min for Rapitrac systems (P less than 0.001). A significantly higher proportion of patients in the Rapitrac group had complications compared with the other two groups (P less than 0.05). The complication rate for the Cook group compared favourably with that for the conventional tracheostomy group. The Cook system of percutaneous tracheostomy is a simple, rapid and safe alternative to conventional tracheostomy.