Perioperative complications of anterior procedures on the spine

We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.     

Radiological and orthopedic abnormalities in Satoyoshi syndrome

BACKGROUND: The advent of proton-pump inhibitors, and subsequently of the laparoscopic technique, can be assumed to have influenced the use of antireflux surgery in gastro-oesophageal reflux disease. METHODS: Data on antireflux operations carried out in Finland in 1988-93 were obtained from national statistics, and the number of operations performed laparoscopically in 1993 was ascertained by a questionnaire to all relevant units. The rates per 100,000 population in the catchment areas were calculated. RESULTS: Antireflux surgery almost always implied fundoplication. During 1993, 784 fundoplications and 43 other antireflux procedures were performed in Finland (total population around 5 million). The fundoplication rate per 100,000 population rose from 8.8 to 15.4 between 1988 and 1993. The increase was minimal (8.1-8.2) in 1990-91 when the first proton-pump inhibitor, omeprazole, was introduced, but remarkably greater (12.8-15.4) in 1992-93, when the laparoscopic technique became popular. Differences in fundoplication rates were six to tenfold between health service districts and even larger between hospitals. CONCLUSIONS: The numbers of antireflux operations in Finland were almost static when proton-pump inhibitors were introduced, but rapidly increased after the advent of the laparoscopic technique. Remarkable discrepancies were found in the incidence of fundoplication between different areas and hospitals.     

Analysis of geriatric surgical experience in a veterans home

Surgical experience at the hospital of a State Veterans Home is reviewed over a period of two and half years (1973-1975). The average age of the patients was 74 years, and many had severe pulmonary or cardiac disease. Of the operations performed, 283 were major and 301 were minor. For the major operations (including emergencies) the mortality rate was 4.2 percent, for the minor procedures the rate was zero, and for all types of procedures the overall mortality rate was 2 percent. Emergency operations increased the expected mortality tenfold. Colonic and biliary-tract operations bore the highest mortality. The incidence of malignant lesions was high. In the elderly, indicated surgical procedures are justified, provided they are carried out by an organized, highly trained health team.     

Mortality due to acute adverse drug reactions: opiates and cocaine in Barcelona, 1989-93

Drug-related deaths have become a major source of premature mortality. This paper presents an analysis of deaths due to acute adverse drug reactions caused by opiates or cocaine in the city of Barcelona over a 5-year period during which figures were stable. Annual mortality rates due to adverse drug reactions of city residents for the 1989-93 period were estimated to be 15.3 per 100,000 people in the 15-49-year age group. Mortality rates for men (25.0) are consistently higher than mortality rates for women (5.8). Mortality rates by age group show different patterns by gender. Males in the 25-29-year group have the highest mortality rate (62.8), almost doubling the rates for the 20-24 (36.1) and 30-34 (33.3)-year groups. The highest differential in age-specific mortality by gender is seen in the 35-39-year age group, where mortality rates for men (21.5) are eight times higher than for women (2.6 per 100,000). The distribution by place of residence, stratifying data across city neighbourhoods and municipal districts displays wide differences between districts in the mean annual rates, ranking between 77.3 and 8.3 per 100,000, a nine-fold magnitude. Differences are even steeper when we break down data by neighbourhood. Although all areas with high adverse drug reactions mortality are areas of low socio-economic level, a more complex association between deprivation and drug use must exist, as other areas with similarly low socio-economic indicators do not suffer from such high mortality. A cross-tabulation of place of residence and district of death shows that for most adverse drug reaction deaths, death takes place in the district of residence but patterns related to districts who attract drug-related deaths and districts who export them may be observed. These results provide new insights into the epidemiology of substance abuse in Barcelona, where it follows patterns that may be similar to those of other major urban areas in Spain, but also in other Southern European countries.     

Anti beta 2glycoprotein I antibodies and lupus anticoagulant in patients with recurrent pregnancy loss: prevalence and clinical significance

Over 2000 electrocution deaths were identified among U.S. construction workers from 1980 to 1991, with the highest mean annual crude mortality rate (2.5 per 100,000 people), and second highest mean age-adjusted rate (2.7 per 100,000 people) of all industries. Although the crude fatality rates showed a downward trend, construction workers are still about four times more likely to be electrocuted at work than are workers in all industries combined. Nearly 40% of the 5083 fatal electrocutions in all industries combined occurred in construction, and 80% were associated with industrial wiring, appliances, and transmission lines. Electrocutions ranked as the second leading cause of death among construction workers, accounting for an average of 15% of traumatic deaths in the industry from 1980 to 1991. The study indicates that the workers most at risk of electrical injury are male, young, nonwhite, and electricians, structural metal workers, and laborers. The most likely time of injury is 11 a.m. to 3 p.m. from June to August. Focusing prevention on these populations and characteristics through better methods of worker and supervisor electrical safety training, use of adequate protective clothing, and compliance with established procedures could minimize the average annual loss of 168 U.S. construction workers.     

Lights and shadows on the molecular diagnosis of hepatitis C

We undertook an epidemiologic study to ascertain the prevalence of multiple sclerosis (MS) in the Sanitary District of Calatayud, in the north-east of Spain. METHODS: The study was performed from October 1990 to July 1996. The total number of residents in the area was 58,591. An extensive search was carried out to identify all cases of known or suspected MS through general practitioners and specialists, sanitary authorities in the area, the reference hospital, the Spanish Multiple Sclerosis Society, the newspaper and radio. RESULTS: April 1, 1995 was chosen as prevalence day. The crude prevalence rate for the area was 58 per 100,000 (95% CI: 39-78). The approximate annual incidence rate was 2.6/100,000 (1980-1989). CONCLUSIONS: This study and others conducted recently in Spain show that MS is more prevalent than was previously thought and afflicts at least 53-65 per 100,000 population.     

How much is the workload of surgeons in Scandinavia?

According to figures presented at the Bianniul General Meeting of the Scandinavian Surgical Society, the mean number of operations performed per surgeon at some clinics of different sizes in Denmark, Finland, Iceland, Norway and Sweden ranged from 90 to 240 in 1996. This corresponds to 2.6 to 8.5 hours actual operating time, though figures are misleading since time spent assisting at operations, or on endoscopies, minor diagnostics and outpatient procedures, and essential pre- and post-operative tasks is not included. This level of operative activity is considered barely sufficient for training surgeons or for maintaining surgical skills. Surgeons could devote more time to surgery if a greater proportion of their non-surgical workload was taken over by other hospital staff, which would also reduce the number of surgeons required.     

An epidemiological study of acute carbon monoxide poisoning in the West Midlands

OBJECTIVES: To describe the epidemiology of carbon monoxide (CO) poisoning in a defined population, identifying those at greatest risk from acute poisoning resulting in admission to hospital or death. METHODS: A retrospective study with routinely collected information, set in the former West Midlands Regional Health Authority; population of 5.2 million. The data comprised 939 deaths and 701 hospital admissions due to CO poisoning between January 1988 to December 1994. The main outcome measures were age and sex standardised incidence rates (SIRs) for non-intentional, suicidal, and undetermined poisonings for health authorities and the linear relation with socioeconomic deprivation. RESULTS: Overall rate of non-intentional poisonings over the 7 year period was 7.6/100,000, an annual rate of 1.1/100,000. The 7 year rates were highest in people > or = 85; men 24.0/100,000 and women 19.7/100,000. For suicides the 7 year rate was 19.6/100,000, an annual rate of 2.8/100,000. The 7 year rates were highest for men of 35-39, 64.1/100,000, and for women aged 45-49, 15.3/100,000. None of the causes of poisoning were related to deprivation. Non-intentional poisonings showed a strong seasonal variation with the highest rates being recorded in the months October to March. Increased rates of poisoning were found in the rural districts of the West Midlands. There seems to have been a decline in suicides coinciding with the introduction of three way catalytic converters on cars. CONCLUSIONS: Elderly people and the very young are at the greatest risk from non-intentional CO poisoning and rates are highest in the winter months. Although deaths from non-intentional CO poisoning are declining nationally, in the West Midlands they have remained stable and hospital admissions are increasing. It is not solely an urban phenomenon with rates for non-intentional CO poisoning and suicides higher in the rural districts. Health authorities need to consider all populations in any prevention programme. Further work is needed to establish the extent of the burden of chronic CO poisoning and the impact of catalytic converters on suicides.     

Changes and results of surgical strategies for hepatocellular carcinoma: results of a 15-year study on 452 consecutive patients

In an attempt to define better surgical strategies for patients with hepatocellular carcinoma (HCC), we conducted a retrospective analysis of 452 patients who underwent hepatic resection at our institute during a period of 15 years. The patients were divided into two groups: group A, comprising 188 patients who underwent hepatic resection before 1988, and group B, comprising 264 patients after 1989. These groups were compared clinicopathologically. The percentage of patients with Child's A disease but without cirrhosis, in group A was lower. The diameter of the resected tumor was larger in group A, and major hepatic resections and curative operations were more frequently performed in group A. In group B, there was less blood loss, the specimen weighed less, and the hospital mortality was lower. Although the tumor-free survival rates were similar between the two groups, the survival rate in group B was significantly better. While even minor hepatic resection accompanied by a lower rate of surgical margin-free surgery has contributed to making hepatic resection safer, it has not improved the tumor-free survival rate. Conversely, recent advances in imaging modalities used during follow-up for the early detection of recurrence and for planning multimodality treatment have contributed to increasing the survival rate.     

The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs

OBJECTIVE: To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs. METHODS: Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured. RESULTS: The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence. Case:fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect. CONCLUSIONS: Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution.     

Salmonella typhimurium DT104 infection in people and animals in Scotland: a collaborative epidemiological study 1993-96

This paper describes a comparative analysis of human and farm animal salmonellosis in Scotland between 1993 and 1996, with particular reference to Salmonella typhimurium definitive type 104 (DT104). Cattle were the main reservoir, accounting for 73.1 per cent of incidents involving all salmonellae and 69.5 per cent of those involving S typhimurium DT104. The annual rates of incidence in people and cattle were recorded in each Health Board area. Dumfries and Galloway had the highest rate of incidence in cattle for all salmonellae (19.0 per 100,000) but people were affected uniformly across mainland Scotland. However, the rate of incidence of S typhimurium DT104 was highest in Dumfries and Galloway for both people (10.1 per 100,000) and cattle (13.0 per 100,000). In Dumfries and Galloway, Wigtownshire had the highest rates for all salmonellae and for S typhimurium DT104 in both people and cattle. In Dumfries and Galloway, 37.8 per cent of the adult cases of S typhimurium DT104 in people were among those known to have had regular contact with animals, and children under six years of age accounted for 36.3 per cent of the human infections in this region.     

Surgery and anesthesia in Ontario

Operative and case-fatality rates in Ontario for eight elective (discretionary) and seven nonelective (nondiscretionary) operations and the proportions of these operations and their anesthetic procedures performed by general practitioners were calculated. Cholecystectomy increased in frequency 32% from 1968 through 1973, tonsillectomy and adenoidectomy decreased 37%, and hysterectomy increased 41%. Except for colectomy the rates for nonelective operations changed only slightly over the 6 years. Case-fatality rates (hospital deaths per 10000 operations) for the discretionary operations in 1973 were as follows: extraction of lens, 23.1; tonsillectomy and adenoidectomy, 0.4 (2 deaths among 52938 operations); varicose vein stripping, 6.1; nonrecurrent inguinal herniorrhaphy, 21.9; cholecystectomy, 61.0; hemorrhoidectomy, 9.8; prostatectomy, 115.9; and hysterectomy, 9.6. In 1973 general practitioners did 32% of tonsillectomies and adenoidectomies (61% in 1971), 10 to 20% of inguinal herniorrhaphies, hemorrhoidectomies and appendectomies and 6% or less of the other operations. However, they performed 35% or more of the anesthetic procedures for these four operations as well as for varicose vein stripping, cholecystectomy and hysterectomy. Rates of general-practice surgery and anesthesia in an urban centre in Ontario were substantially less than those for the province as a whole.     

Tuberculosis notifications in Australia, 1995

This is the fifth annual report of the National Mycobacterial Surveillance System (NMSS), for new and relapsed cases of tuberculosis notified to State and Territory health authorities in 1995. Cases of atypical mycobacterial infection notified to the scheme are also briefly summarised. The notification rate for new cases of tuberculosis was 5.47 per 100,000 population, and for relapsed cases 0.28 per 100,000. These rates have remained stable for a number of years in Australia, and are low compared with rates in other countries. Some identifiable groups in the Australian community continue to experience higher rates of tuberculosis, including members of indigenous communities and some groups born overseas. Surveillance through the NMSS has a major role to play in the control of tuberculosis.     

Attempted suicide in Oxford University students, 1976-1990

During the 14 years between the beginning of academic year 1976-7 and the end of academic year 1989-90, 216 Oxford University students (119 females and 97 males) were referred to the general hospital in Oxford because of suicide attempts (254 in all). The rate of attempted suicide during university term-time (106/100,000) was lower than in other young people of similar age in Oxford City (164/100,000). The difference was particularly marked in females (178/100,000 v. 269/100,000). The lower rate in the students may in part reflect their generally higher socio-economic status. Very few of the attempts by the students appeared to be failed suicides. The most frequent problems faced by the students at the time of their attempts were interpersonal, especially difficulties regarding partners, followed by academic problems. The latter were usually problems with ongoing course work rather than with the Finals examinations. Approximately a quarter of the students had psychiatric problems, with personality disorders and depression being most common. At least 30% had a history of previous attempts. Suggestions are made concerning measures for improving the management and prevention of attempted suicide by students.     

Seven abdominal assessment signs every emergency nurse should know

BACKGROUND: Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations. STUDY DESIGN: The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis. RESULTS: A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively. CONCLUSIONS: Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.     

Complications and surgical indications in 144 cases of nonmetastatic osteosarcoma of the extremities treated with neoadjuvant chemotherapy

From September 1986 to December 1989, 144 patients with osteosarcoma of the extremities were treated with combined surgery and neoadjuvant chemotherapy. The disease-free survival was 79% for good responders (necrosis greater than 90%) and 72% for poor responders (necrosis less than 90%), and the local recurrence rate was low. Improvement in long-term prognosis and the increase of limb-sparing surgery determine a higher rate of immediate and late complications. Most of the complications were observed in limb-salvage procedures; 63% of these procedures presented one or more complications. In nine rotationsplasties, there were four complications, and in 13 amputations no complications were observed. Therefore, 55% of patients were affected by surgical complications. Twenty-eight complications were considered minor (not requiring surgery), whereas 77 complications were major. Functional results, evaluated according to Enneking's new system, were higher than 50% in two thirds of the limb-salvage procedures. Complications in limb-salvage procedures are more influenced by the type of reconstruction than by the surgical procedure used. Probably the most troublesome consequence of surgical complications in osteosarcoma is the deviation or delay in administering postoperative chemotherapy, which jeopardizes survival.     

Retinal stroke. Is the patient at risk?

A follow-up study was performed to determine the general prognosis for health and life in 86 patients with retinal artery occlusion or ophthalmoscopically observed retinal cholesterol emboli, not subjected to surgery. Survivorship rates and incidence of subsequent cerebrovascular disease were calculated and compared to expected survivorship rate of an age-and sex-matched population. Results were as follows: the patient group with retinal stroke as a whole showed a statistically significant diminished survivorship rate from the third year onward; patients with retinal occlusions without visible emboli had a survivorship rate comparable to the matched control; but patients with visible emboli demonstrated a strikingly diminished survivorship rate. In the study group, the combined time corrected annual stroke mortality was 1,695 per 100,000 (four to five times greater than expected), but the largest single cause of death was cardiovascular disease.     

Partial agonists and full antagonists at the human and murine bradykinin B1 receptors

OBJECTIVE: To examine the incidence of first diagnosis of invasive squamous cell carcinoma (SCC) of the skin over time. DESIGN: Retrospective, population-based incidence study. SETTING: Enumerated, geographically isolated, semiurban population served by the Mayo Clinic and its affiliated hospitals and the Olmsted Medical Center, including its affiliated hospital in Rochester, Minn. METHODS: Using the Rochester Epidemiology Project databases that capture virtually all medical care provided to the residents of Rochester, we identified and reviewed records of all documented residents in whom histologically proven, invasive SCC of the skin was first diagnosed between 1984 and 1992. Age and sex stratum-specific rates were calculated, and age-adjusted rates observed over time for individuals aged 35 years or older were analyzed using Poisson regression. Adjusted rates were compared with the results of other studies. RESULTS: Review of 1630 records identified 511 incidence cases of SCC. Tumors located on the head and neck accounted for 66.4% of tumors in females and 72.9% in males. The annual age- and sex-specific incidence rates per 100,000 increased from 0 cases among males aged 0 to 14 years to 1286.0 cases among males aged 85 years or older. Over time, the annual age-adjusted incidence rates per 100,000 females rose from 46.5 (95% confidence interval [CI], 32.4-60.6) for the 1984 to 1986 period to 99.6 (95% CI, 80.4-118.7) for the 1990 to 1992 period and were 71.2 (95% CI, 61.7-80.8) overall. The corresponding rates for males were 125.9 (95% CI, 95.3-156.4), 191.0 (95% CI, 156.9-225.0), and 155.5 (95% CI, 137.0-174.0). The age- and sex-adjusted SCC incidence rates for the period from 1987 to 1989 and 1990 to 1992 exceeded those for the period from 1984 to 1986 (P = .03 and P < .001, respectively). Our age-adjusted rates for SCC were within the ranges seen in other white populations from temperate climates. CONCLUSION: The frequencies of first diagnosis of SCC are increasing at rates beyond those explainable by demographic shifts alone.     

Significant regional differences in the frequency of vascular surgery

The six health care regions of Sweden were compared with regard to the frequency of vascular surgery for three diagnoses: chronic lower extremity ischaemia, abdominal aorta aneurysm, and carotid stenosis. In 1995, the frequency of intervention for chronic lower extremity ischaemia varied from 26/100,000 of the population in northern Sweden to 68/100,000 in the southern region, the variation being greater for critical limb ischaemia than for intermittent claudication. In the country as a whole, the frequency of abdominal aorta aneurysm surgery increased five-fold from 1987-89 to 1993-95. During 1995, regional figures varied from 4.7 to 8.4 per 100,000 for elective procedures, and from 3.8 to 5.5 per 100,000 for emergency procedures. Overall surgical mortality varied regionally, and emergency surgery mortality differed between regional and county hospitals. Carotid surgery manifested the greatest regional difference in frequency, which was 7-fold greater in the southern than in the northern region, while its overall mean frequency was 6/100,000.     

Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality, 1979-94. The Scottish Melanoma Group

OBJECTIVE: To determine the changing incidence of and mortality from cutaneous malignant melanoma in Scotland from 1979 to 1994. DESIGN: Detailed registration of clinical and pathological features, surgical and other treatment, and follow up of all cases of cutaneous malignant melanoma diagnosed from 1979 to 1994 and registered with specialist database for Scotland. SETTING: Scotland. SUBJECTS: 6288 patients with invasive primary cutaneous malignant melanoma diagnosed between 1 January 1979 and 31 December 1994. RESULTS: The annual age standardised incidence of cutaneous malignant melanoma rose significantly from 3.5 to 7.8 per 100,000 per year in men and from 6.8 to 12.3 per 100,000 per year in women (P < 0.001 for both). World standardised rates increased from 2.7 to 6.0 per 100,000 per year in men and 4.6 to 8.50 per 100,000 in women. The incidence of melanoma continued to increase significantly in men of all ages during the study, but the rate stabilised in women after 1986. Mortality from cutaneous malignant melanoma was 1.3 per million per annum in men in 1979, rising to 2.3 per million per annum in 1994 (P < 0.01); it was 2.4 per million per annum in women in 1979, falling to 1.9 per million per annum in 1994 (P = 0.09). The underlying mortality trends showed a continuing rise for men but a downward trend for women that was not significant (P = 0.09). In men, melanoma free survival was 69% at 5 years and 61% at 10 years; in women the corresponding rates were 82% and 75%. Younger patients had higher survival rates, which were not entirely explained by thinner tumours. Over the 15 year period, survival rates improved by 12% overall, only partly owing to thinner tumours. CONCLUSIONS: In Scotland the incidence of melanoma in women has stabilised, while mortality associated with melanoma in women shows a downward trend.