Letters to the Editor

Sir,

Re: Al Mulla A, Purva M and Behbehani A. Fireworks injury: temporal bone penetration and a wooden intra-cranial foreign body. J R Coll Surg Edinb 2001; 46 (4): 249-51.

I read the above article with some interest, as it is rare for neurosurgical material to appear in your journal. Unfortunately, I was concerned that certain aspects of the management of the case reported do not reflect normal practice in this country and warrant some discussion.

The most important issue is the fact that the authors make no reference to pre-operative cerebral angiography for management planning. It is a fundamental concept in the management of penetrating head injuries that significant vascular injuries may have occurred; the embedded fragment may be tamponnading the injured vessel, so that simply ‘easing the fragment out’, as the authors did in this case, may result in rapidly fatal intra-cranial haemorrhage. The closer the foreign body approaches to the basal cisterns of the brain, the more likely it is that such a vascular injury is present. The CT section illustrated in their Figure 1, shows a large foreign body traversing the interpeduncular/ chiasmatic cistern, with a substantial amount of blood in the region of the left Sylvian fissure; there is a significant chance that the left middle cerebral vessels, at least, have been compromised. Cerebral angiography would demonstrate this, and allow the surgeon to plan a left-sided procedure to permit control of any involved vessel(s) before definitive removal of the foreign body. The authors successfully removed the foreign body with a solely right-sided, and essentially blind (in the sense of knowledge about the cerebral vasculature) procedure, which was fortunate but should not serve to recommend this approach. About 24 hours later, the patient suddenly fixed her pupils; with no further imaging, one cannot say why this happened, but it is entirely possible that it was due to a delayed haemorrhage from an occult vascular injury. The ‘perfusion studies’ on day nine referred to by the authors as confirming brainstem death do not form part of the assessment of brainstem death in the UK; even if this is formal cerebral angiography, a vascular injury would probably not be apparent, as at that point there is likely to be little or no cerebral perfusion (intra-cranial pressure [ICP] close to mean arterial pressure) so that the intra-cranial vessels will be poorly delineated, if at all.

The patient’s subsequent management was similar to what would be the norm in the UK, with the exception that such patients virtually always have intra-cranial pressure monitors placed at the time of surgery, or in a separate small procedure if a craniotomy is not planned. This allows treatment with diuretics (Mannitol, frusemide), hyperventilation,hypothermia etc, to be administered with clear evidence of a need for them in our unit, jugular venous saturation monitoring is also routinely used to guide the selection of the most appropriate treatment for episodes of raised ICP. It is not clear whether the authors had these options available to them in their unit.

Finally, I would take issue with the statement that diabetes insipidus is ‘a syndrome of inappropriate vasopressin secretion characteristic of severe head injury’. First of all, the wording is misleading, given that there is a true syndrome of inappropriate vasopressin secretion (the SIADH syndrome), which is the exact opposite of diabetes insipidus both in terms of the biochemical abnormalities produced, and the treatment. Giving such a patient nasal DDAVP would be frankly dangerous. If the authors want to use this form of words, they would have to say ‘a syndrome of inappropriate undersecretion of vasopressin’, but the simple statement that the condition is caused by deficiency of vasopressin is best. Severe head injury is not a particularly common cause of diabetes insipidus, nor is diabetes insipidus a characteristic feature of severe head injury, in my experience occurring only occasionally.

Having said all this, the unfortunate patient in this case was almost certainly doomed from the outset.

Mr R. Price 
Department of Clinical Neurosciences 
Western General Hospital 
Edinburgh, U.K.

The authors of the article have failed to provide a reply despite numerous requests. Mr Price raises a number of important points in patient management. Although long overdue, we believe the letter is of clinical relevance and educational value to our readers.

Sir,

Re: Chan MYP, Tan C, Chiu MT, Ng YY. Alvarado score: an admission criterion in patients with right iliac fossa pain. Surg J R Coll Surg Edinb Irel 2003; 1 (1): 39-41.

The very fact that the Alvarado scoring system is not uniformly applied in the management of suspected acute appendicitis is testimony to the fallibility of the method, which includes a high false-positive rate in women.¹ Even neural networks have not found universal applicability in streamlining the management of patients admitted with right iliac fossa pain.² The Chan et al article re-explores the, as yet, incompletely validated method designed  to aid clinicians in making accurate management decisions.

If we look at these figures closely they can be divided into three groups as outlined in Table 1. It would not be unreasonable to assume that the group scoring less than 4 form a cohort (group A) that could probably be discharged on clinical grounds alone. However, above that score they could be divided into two groups as outlined.

There is no statistical difference across the groups B and C in terms of whether the patients had appendicitis or not (p= 0.4106, the sum of small p’s, Fisher’s exact test, SISA statistical software).3 This would imply that the diagnosis alone has no eventual relevance as to what group the patient might fall into and, thereby, also conversely implying that the score itself had statistically little to do with the final diagnosis.

This study, therefore, fails to make a strong case for the Alvarado score on the basis of the numbers. Managing such cases on the basis of active clinical observation would still probably seem to be the optimal way of managing such patients. However, having management algorithms is not a bad idea at all, but perhaps needs some refinement at this stage. It would have been interesting to see a regression analysis of the individual parameters to see their correlation with diagnosis and outcome.

References
1. Malik AA, Wani NA. Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score. ANZ J Surg July 1998; 68(7): 504-5.
2. Ziprin P, Gould SWT, Glazer G. Neural networks as an aid in the diagnosis of acute appendicitis. Br J Surg 1998. 85(1S) (Supplement 1): 37-38.
3. Uitenbroek, Daan G, Binomial. SISA. 1997. http://home.clara.net/sisa/ binomial.htm. (1 Jan. 2002).

Mr A.Chaudhuri 
Department of Surgery 
The Royal Free Hospital 
Rowland Hill Street 
London, U.K.

Sir,

We would like to thank Dr Chaudhuri for his interest and comments on our article. Indeed, we agree that frequent clinical reassessment remains the best method for the management of patients with right iliac fossa pain with equivocal signs. The Alvarado score had been shown to be accurate only in the extremes of the score.^1,2

The purpose of our article was to examine whether one extreme of the score could be used in management of patients with right iliac fossa pain in the outpatient setting. Previous authors had observed that patients with a low score (4 or less) did not have appendicitis.3 We designed our study to look at whether patients could avoid hospitalisation based on the Alvarado score. In our study, admission could have been reduced by 20%, based on a low Alvarado score.

We believe that the Alvarado score may provide objective pointers in the management of patients with right iliac fossa pain. It cannot and should not replace good clinical practice in the managing of patients with suspected appendicitis, especially in the decision to intervene surgically. However, in the outpatient setting, junior doctors or doctors with limited surgical experience may find the Alvarado score a useful guide in their assessment of these patients and deciding on whether patients need hospitalisation or can be observed as outpatients.

References
1. Malik AA, Wani NA. Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score. Aust N Z J Surg 1998; 68 504-5.
2. Chan MYP, Teo BS, Ng BL. The Alvarado score and acute appendicitis. Ann Acad Med Sing 2001; 30: 510-12.
3. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of Alvarado score in acute appendicitis. J R Soc Med 1992; 85: 87-89.

Mr M.Y.P. Chan 
Department of Surgery Tan Tock Seng Hospital 
11 Jalan Tan Tock Seng 
Singapore 30843

Sir,

Re: J.A. Harty, D. Brennan, S. Eustace, J. O’Byrne. Percutaneous cementoplasty of acetabular bony metastasis. Surg J R Coll Surg Edinb Irel 2003. 1 (1): 48-59.

Harty et al describe a novel technique for injection of polymethylmethacrylate into an acetabular bony metastasis.¹ While we agree that such techniques can provide dramatic pain relief in this patient population, they also have the potential to cause significant morbidity.

We note that the patient described by Harty et al received a general anaesthetic while later in the article the procedure is described as requiring ‘only local anaesthesia’. Similarly, the standard femoral cement gun is advanced as a method of overcoming poor pressurisation and injection of larger volumes of cement. However, Figure 4 of the published article shows  a large volume of cement out with the confines of the bony acetabulum. 

Patients with lytic deposits outside the pelvis should theoretically gain a similar benefit from percutaneous cementoplasty. We have recently treated a patient in our unit who sustained a subtrochanteric femoral fracture three days after percutaneous injection of cement into a metastatic femoral neck lesion. The presence of cement in the femoral neck significantly increased the technical difficulty of the operative procedure and undoubtedly contributed to an increased hospital stay.

In our opinion percutaneous cementoplasty has a delicate risk/ benefit profile, particularly for lesions outwith the pelvis. Patients may experience dramatic pain relief after this procedure but must also be aware of the potential for significant complications.

Reference
1. Harty J A, Brennan D, Eustace S, O’Byrne J. Percutaneous cementoplasty of acetabular bony metastasis. Surg J R Coll Surg Edinb Irel 2003. 1 (1): 48-59.

Mr D.Cairns & Mr I. Ritchie 
Department of Orthopaedic Surgery 
Stirling Royal Infirmary 
Livilands 
Stirling, U.K.

Dear Sir,

Many thanks for your interest in our article, Percutaneous cementoplasty of acetabular bony metatasis. With regard to the anaesthetic administered during the procedure, the patient was given a general anaesthetic and a local anaesthetic was administered at the incision site, and also infiltrated into the periosteum to help improve postoperative analgesia. This procedure in certain circumstances may be amenable of local anaesthesia, such as in percutaneous vertebral cementoplasty. The use of a femoral cement gun we felt improved the ease with which pressure was maintained during the insertion of the cement. We realise that it is not a foolproof method, however, it did allow us to inject large volumes of cement at a high pressure.

It is difficult to control the oozing of cement around the gun at the entry point, whilst still maintining pressurisation. Hence, the cement seen outside the acetabulum. We are also aware of the potential injury to the sciatic nerve in this region, however, we did not encounter this problem.

The correspondents referred to the treatment of femoral neck metastasis with a similar treatment regimen. We feel that a long bone metastasis is best managed by internal fixation of some form and, if necessary, supplemented by cement stabilisation.

References

1. Favorito PJ, McGrath BE. Impending or completed pathologic femur fractures treated with intramedullary hip screws. Orthopedics 2001 Apr; 24 (4): 359-63.
2. Habermann ET, Sachs R, Stern RE, Hirsh DM, Anderson WJ Jr. The pathology and treatment of metastatic disease of the femur. Clin Orthop 1982 Sep; (169): 70-82.
3. Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG. Methylmethacrylate as an adjunct in internal fixation of pathological fractures. Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976 Dec; 58 (8): 1047-55.

Mr J. Harty 
Misericordiae Hospital 
Ireland

Sir,

Re: H.A. Vohra Laboratory research during training. Surg J R Coll Surg Edinb Irel 2003; 1 (1): 60-61.

As Mr Vohra stated in his letter of 02/03 (Vol. 1, No. 1), there is no doubt that research plays an important part in the education of today’s surgical trainees. Despite the beneficial experiences that research offers, many still view it as a necessary hurdle to negotiate before commencing registrar training. As few can afford to work unpaid while they pursue a two-year higher degree, the issue of funding often gains paramount importance. As a result, research that has already attracted funding (frequently the continuation of someone else’s work) appears very alluring to the SHO at the end of his basic training. Care must be taken however, to ensure that any research undertaken over a long period of time is stimulating and personally fulfilling.

At York District Hospital we have developed a strategy for overcoming the issue of wage funding, to allow research fellows more time to develop and personalise their research projects. The solution arose following the need to reduce on-call hours at the SHO level (ensuring new deal rota compliance), whilst wanting to develop a programme of postgraduate training and research to co-inside with the opening of the Hull-York medical school in October 2003. Three research fellows were appointed, alongside the five basic surgical trainees to bolster on call numbers. The research fellows cover a large proportion of out of hours work during the week, whilst being free to pursue research during the day. This has the advantage of providing both wages and clinical experience for research fellows, whilst they pursue their research. The existing SHOs also benefit, as time gained from not having to cover night shifts is more usefully employed working and receiving education as part of a clinical firm. All three research fellows are granted the freedom to develop research ideas alongside clinical and academic supervisors before applying for funding to cover research expenses, without worrying about a salary. It could be argued that this practice might delay the onset of any practical research, but time spent at the start of any piece of research is usually spent searching the literature and refining the study proposal rather than engaging in practical work.

We feel that this solution benefits everyone and allows more time and flexibility for research fellows to plan their research. However surgical trainees decide to fund their research, it is important that they consider whether they will still find it interesting and stimulating at the end of two years.

Mr J.I. Wilson & Mr T. Wilson 
Clinical Research Fellows 
York District General Hospital 
Wigginton Road 
York U.K.

Sir,

I read with interest the correspondence from Wilson et al regarding issues surrounding funding in research in general in response to my letter emphasising the value of laboratorybased research. There is indeed no doubt that the issue of funding is pivotal to any research. This becomes even more important in the context of laboratory-based research where besides salary, expenditures need to be met for equipment, assay kits, etc. Clinical research fellow jobs advertised as funded by project or programme grants from charitable organisations are very few in the field of surgery. Research fellowships (one to two years) are more common but it would generally take at least four to six months from the time of writing of a grant application before a decision is reached. Thus, to start with, research fellows funded by carrying out on-call SHO commitments may seem to be an attractive option. This seems to be the route adopted by many trusts within the United Kingdom. However, as these research fellows have already spent 24-36 months at the SHO level, perhaps it would be more beneficial for their clinical training to perform registrar on-call duties instead. In the context of laboratory-based research, results generally take longer to obtain and get published than clinical research. It would thus seem reasonable to apply for a fellowship before starting a two-year research project. This allows more focus on experimental work as preliminary literature searches have been carried out and study proposal decided.

To ensure that the research proposed to be undertaken by a surgical trainee is appealing from the ‘beginning’, it is important that visits to the department are made beforehand and a literature search carried out to assess the nature and quality of work expected to be undertaken. As surgical trainees are frequently less inclined towards laboratory research, this becomes even more important to avoid poor progress. I would also agree that a new fellow in a research department generally follows a previous theme. However, to justify inclusion in a MD or PhD thesis, a novel hypothesis is tested with each study.

It can be argued that there is no single ‘ideal’ strategy to overcome the problem of funding surgical trainees in research. It will vary with the nature/ period of work to be undertaken, the clinical and research training needs of the prospective candidate and the resources available.

Mr H.A. Vohra & Mr T.N.F. Chowdhry 
Clinical Research Fellows Department of Surgery 
University of Leicester 
Leicester, U.K.

The Royal College of Surgeons of Edinburgh

Advanced Ilizarov Course

6-8 October 2003

Convenor - Professor Hamish Simpson
University of Edinburgh

Registration Fee = £495.00

To book a place and for further information, please contact:

Mrs Maureen Lowrie, 
Education Section
RCSEd. 
Tel: 44 (0) 131 668 9209. Fax: 44 (0) 131 9241

Email: m.lowrie@rcsed.ac.uk

The Faculty of Dentistry

Royal College of Surgeons in Ireland

‘Implants - The Current Status’

Wednesday, October 29th - Saturday, November 1st , 2003 

Dublin

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

SPEAKERS:

                                                                            Dr. Crawford A. Bain                         Prof. Klaus Lang
                                                                            Prof. Per-Inguar Brånemark             Dr. Richard Lazzara
                                                                            Dr. Frank Celenza                             Prof. Jan Lindhe
                                                                            Dr. Christer Dahlin                            Prof. Regina Mericske-Stern
                                                                            Prof. John Davies                              Dr. Patrick Palacci
                                                                            Dr. Klaus Gotfredsen                        Dr. Lloyd Searson
                                                                            Prof. Hans-Göran Gröndahl              Prof. Massimo Simion
                                                                            Prof. Kerstin Gröndahl                      Prof. Maurizio Tonetti
                                                                            Dr. David Harris                                Dr. Ned Van Roekel
                                                                            Dr. Kenji Higuchi                               Prof. Daniel van Steenberghe

For further information and programme details, please contact:

Faculty of Dentistry, Royal College of Surgeons in Ireland
123, St. Stephen’s Green, Dublin 2, Ireland
Telephone: +353 1 402 2239 or +353 1 402 2256
Fax: +353 1 402 2125 / Email: facdentistry@rcsi.ie

Further information is available on the College website at: www.rcsi.ie