Vol. 161. 1992. Suppla'ncnt No.l t

1 STYLE AND SUBSTANCE: AUDIT OF SCIENTIFIC

PAPERS Mary Evans, Alan Pollock

Scarbnrough Hospital YO12 6QL Unread papers are a waste of time, effort, and money, and it is

estimated that half of all published papers are never cited - whether in hard copy or on disk.

It is possible to increase the chances of your paper being noticed, by keeping six simple rules, in mind: the title must be accurate (to aid indexing services); the abstract must summarise the message of the paper; the introduction must whet the appetite; the padents and methods must say what was done and no more; the results set out the raw data succinctly; and the discussion must place the work in context, and say how it may influence clinical practice. All this must be done in clear, unpretentious English without jargon or incompre- hensible abbreviations.

It sounds quite easy -but there are tricks o f this trade as there are of any other, and many pitfalls which - with forewarning - can be avoided.

2

PRE-OPERATIVE STAGING OF FOREGUT CANCER: A PROSPECTIVE CORRELATIVE COMPARISON OF

LAPAROSCOPY AND IMAGING O. O'Sullivan and E. Fitzgerald.

Departments of Surgery and Radiology, Mercy Hospital and Uni- versity College, Cork.

Patients with oesophago-gastric cancer who have metastases outside the field o f resection have a poor prognosis, and rarely bene- fit from resection. To defme the relative merits of era-rent pre- operative staging techniques we prospectively compared the accu- racy of laparoscopy and imaging (computerized tomography - CT, and ultrasound- US) in the same patient group. Findings on laparo- scopy or imaging were unknown to the respective observers. Refer- ence standard was defined histologically from pre-operative biopsy, surgical or post-mortem material. Each patient was fit for major surgery and clinically free of metastases.

84 patients (58 with adanocarcinom a of the distal oesophagus or stomach and 26 with squamoua carcinoma of the lower 10 cms of oesophagus) were studied. 30 had metastases to the liver or perito- neal cavity. Metastases were identified by laparoscopy in 29 of 30 (sensitivity 96%), by CT scan in 15 of 30 (sensitivity 50%), by ultrasound in 10 of 30 (sensitivity 33%), and CT plus US in 15 of 30. There was one false positive on CT scan. Sensitivity of laparoscopy was superior to CT (P<0.01). Clinically and radiographically unde- tected peritoneal metastases were the major error source on imaging.

Conclualon: Whan staging cancer o f stomach or lower extremity of oesophagus laparoscopy is superior to non-invasive imaging and is recommended prior to surgery.

[fish Journal of Medical Science

GENERAL SURGERY of acute appendicitis,

Eighty-eight consecutive patients presenting with right iliac fossa pain underwent PAC in the Accident and Emergency depart- mont. All procedures were carried out and evaluated by one surgical registrax and management decisions were based on the result, Aspi- ration was successful in 86 o f 88 patients, of which 52 were negative and 34 positive.

All positive patients underwent emergency appondicactomy, with 32 having histologically proven acute appendicitis and 2 having peritonitis of other causes. Seven patients with a negative PAC had an appendicectomy - 4 had acute appendicitis and 3 had a normal appendix. PAC was found to be 89% sensitive for acute appendicitis and 92% specific. The positive predictive value of the test was 94% and the negative predictive value 93%. The negative appendicec- tomy rate was 12% overall and 13% in females of reproductive age (taken as 12-40).

We conclude that PAC is a useful investigation in the diagnosis of acute appendicitis. A negative result does not preclude the diag- nosis. In the presence of a negative result end strong clinical suspi- cion of appendicitis, we advocate laparnscopy and if indicated, laparoscopic appendicectomy.

4 EARLY PAIN RELIEF IN THE MANAGEMENT OF THE

ACUTE ABDOMEN IS SAFE A. R. Attard, M. J. Corlett, N. J. Kidner, A. Leslie, I. A. Fraser.

Department of Surgery, Walsgrave Hospital, Coventry. Introduction - Early administration of opiate analgesia to patients

with acute abdominal pain is not conventional teaching since it may mask physical signs and delay diagnosis. We conducted a ran- domised double blind placebo controlled trial to determine whether this is true.

Method- 100 consecutive patients with severe acute abdominal pain were entered" into the study. The admitting house officer assessed their pain and abdominal tenderness using alinear scale and randomised patients who received a blinded intramuscular injection of either saline (n=50) or papaveretum (n=50). This assessment was repeated by the surgical registrar 1 hour post-injection, a diagnosis was made and management decided.

Results - Median pain (PS) and tenderness (TS) scores were lower after papaveretum (PS: 3.1 after papaveretum, 8.1 after saline; TS: 5.1 after papaveretum, 8.1 after saline; p<0.0001, Wilcoxon). 96% of patients were deemed comfortable after papaveretum com- pared to 18% after saline. Incorrect diagnoses were made in 2 patients after papaveretum compared to 9 patients after saline.

Conclusion: Early administration of opiate analgesia in patients with acute abdominal pain can greatly reduce pain. This does not interfere with diagnosis which may even be facilitated despite a reduction in the severity of physical signs. These patients should not be denied early effective pain relief.

3 PERITONEAL ASPIRATION CYTOLOGY - A USEFUL AID TO THE DIAGNOSIS OF ACUTE APPENDICITIS.

M. T. P. Caldwell, R. G. K. Watson Dept. of Surgery, Waterford Regional Hospital, Waterford, Ire-

land. The diagnosis of acute appendicitis remains difficult with most

series showing negative appendicectomy rates of 15-30%. This rate i.s up to 50% in females of reproductive age and I aparo scopy has been recommended in this gre up. The aim o f this study was to evaluate the role of peritoneal aspiration cytology (PAC) in aiding the diagnosis

5 THE IDEAL POST-OPERATIVE DONOR SITE DRESS-

ING; BUPIVACAINE AND KALTOSTAT| P E. M. Butler, P. A. Eadie, D. Lawlor, G. Edwards, M. McHugh. Deparmlent of Plastic and Reconstructive Surgery, Saint James's

Hospital, Dublin. Postoperative pain is soil inadequately treated. Following the

harvesting of a split skin gralt the donor site is inevitably painful and can even be more painful than the recipient site. Kaltostat| (Brit- cait:), a calcium alginate dressing, has been shown to hasten donor site healing and also results in less post operative patier!t discomfort

Vol. 161, 1992. Supplement No. 1 t

when compared to a Jelonot dressing. This prospective study exam- ined the differences in post-operative donor site pain between split thickness donor sites dressed with three different types of dressing; group 1, a dry Kaltostat| dressing; group 2, Kaltostat| moistened with 20 mls of normal saiine; and group 3, Kaltnstat| wetted with 20 mls of 0_5% bopivaealne (along acting local anaesthetic). 30 patients had split thickness skin grafts harvested from a thigh donor site and were assigned to one of tlTee groups. Donor site pain was estimated at 24, 48 end 72 hours using a linear pain analogue scale. Ease of removal and quality of wound healing at 7 days was also assessed. It was found that there was a significant reduction in post-operative pain in the Kaltostat| and bupivasalne group (group 3) at 24 and 48 boors when comp~ed to the other two groups.

24 Hours 48 Hours 72 Hours Group 1 4.5 3.2 1.3 Group 2 4.1 3.7 1.1 Group 3 1.1" 1.2" 0.7 p<0.02*.

No difference was seen in ease of removal of &essings or the quality of wound healing at day 7 between the three groups. This study demonstrates a significant reduction in post-operative pain by bupivacaine soaked Kaltostat without reducing the beneficial effects of Kaltostat on donor site healing and we recommend its routine use in clinical practice.

6 CIMETIDINE: A NOVEL TREATMENT FOR HIDRAN-

DENITIS SUPPURATIVA. D. B. Hocken

North Middlesex Hospital NHS Trust and St. Bartholomew's Hospital

Hidredenitis suppurativa is a chronic condition affecting skin containing apeerine sweat #ands. Treatment is generally unsatisfac- tory and may require wide local excision.

Cimetidine, an H2 receptor antagonist, has previously been reported to affect sweat gland function. Following a clinical obser- vation an open cross over pilot study was performed on 15 patients with axill~a'y end perineal hidradenitis. 12 females and 3 males; me an

Irish Journal of Medical ScienCe

age 29 (22-38) were recruited. TreaWaent was by Cimctidine 400rag bd and response was assessed as recorded disease activity and number of courses of antibiotics in the three months before and on treatment.

All patients reported benefit. Active disease settled end relapse in quiescent patients did not occur during the observation period. Mean (SD) weeks of active inflammation fell from 9.66 (2.19) to 4.20 (2.80) (p<0.001; Wilcoxenn); end courses of antibiotics fell from 2.86 (3.22) to 0.2 (0,42) (p<0.001).

A double blind placebo controlled study of Cimetidine is indi- cated for the control and treatment of hidradenitis suppurativa; on the basis of the results of this study.

7 1NSULINOMA: LOCALISATION AND SURGICAL

MANAGEMENT I. G. Geeghegart, M. P. N. Lewis, E. R. T. C. Owen, J. A. Lynn,

R. C. N. Williamson. Departments of Endocrine and Hepatobiliary Surgery, Ham-

mersmith Hospital, London. Lecalisation of an insulinorna remains the key to successful

surgical managemem. In the fourteen year period 1978-1992 we have treated 31 patients with a mean age of 42 years (17 females, 14 male) with suspected insulinoma. The diagnosis was conf'trmed by deanonsttation of hypoglycaeraia with inappropriate hyperinsulin- ism during supervised fasting. One patient refused operation. Twenty - six patients had an adenoma, 2 had islet call hyperpiasia, one had carcinoma, and one tmderwent negative exploration. Selective vis- ceral angingraphy (SVA) correctly localised all 26 adenomas and the carcinoma, with one false positive. In both patients with hyperplasia SVA demonstrated a sditmy lesion only. CT scan identified the lesion in only 5 of 22 (22%). Endoscopic nltrasonography has been used recently with moderate success (3 of 6 positive). Nineteen ttononrs were enucleated and 10, including 2 patients with hyperpla- sia, were managed by distal penereatectomy (with splenic preserva- tion in 2). There were no operative deaths. Nine patients (30%) had complications (2 subphrenie collections, 5 wound infections, 1 acute penereatitis, 1 pulmonary eanbolus).

SVA localised 100% of iusulinomas but did not identify islet cell hyperplasia. Operation successfully relieved symptoms in 96% of patients with no mortality and low morbidity.