Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Biophysical Semeiotics? What does it mean?
- Sergio Stagnaro (13 December 2002)
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early CT scan; yes but after the evaluation by an experienced clinician
- Paul J. Willemsen (13 December 2002)
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early abdominal CT scan in acute abdominal pain of unknown cause
- jumkur.s nagabhushan, fk2 7ey (15 December 2002)
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Who examined the patients?
- Richard G Fiddian-Green (15 December 2002)
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CT abdo pelvis in abdominal pain
- C S Ripley (15 December 2002)
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Re: Who examined the patients?
- wayne lewis (17 December 2002)
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New roles for GPs in managing patients?
- Richard G Fiddian-Green (18 December 2002)
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Computed Tomography
- Peter F Jones (24 December 2002)
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Early abdominal computed tomography
- Anusha G Edwards, Andrew R Weale (7 January 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 16037 Riva Trigoso (Genoa) Italy.
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Sirs, Ng Chaan S.et al., in order to evaluate the impact of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause on length of hospital stay and accuracy of diagnosis, utilized “early” computed tomography (within 24 hours of admission) in 55 individuals, clearly when “clinical” diagnosis resulted impossible, among 120 patients admitted with acute abdominal pain, for which no immediate surgical intervention or computed tomography was indicated. I think, infact, that all patients underwent, firstly, a physical examination, unfortunately, only by means of old, traditional, orthodox, academic physical semeiotics, since all authors of this article ignore, without any doubt, the recent, paramount progresses, of physical semeiotics, or better speaking, of Biophysical Semeiotics, realised during the last 50 years (See the site, HONCode 233736, http://digilander.libero.it/semeioticabiofisica, the Page, I hold weekly, in www.katamed.it, and italian famous site www.piazzetta.sfera.it) (2, 3, 4, 5). This fact accounts for the reason that “only” 50% (59 of 118) (sic!) of diagnoses on admission, as referred in the paper, were correct at follow up at 6 months (See, Stagnaro S., bmj.com. Rapid Response,”A new physical semeiotics in detecting disorders otherwise undiagnosed”, 25 May 2001). It is well known that computed tomography improves the accuracy of diagnosis of several acute abdominal conditions, but we have to apply it in clinically well-selected patients, for economic as well as practical reasons, and, moreover, such as selection can be obtained exclusively with the aid of an efficacious physical semeiotics, reliable and rapidly to perform, that exists nowadays, although a large number of authors, all around the world, including article’s authors, ignore it, or more precisely speaking, overlook it (2, 3, 4, 5). As far as the need for a more powerful physical semeiotics is concerned, I would put to my colleagues, particularly general practitioners working “at the bed-side”, where Medicine is not certainly ruled by high technology, the following question: ”What is the reason for not becoming involved in an opportunity to broaden your horizon of physical semeiotic science?”. In my opinion, this talk, “clinical” in nature, has never been more strident in a medical world ruled by technology with consequently extreme NHS public expense. However, “Change is simultaneously desired and resisted”. 1)Ng Chaan S.et al. Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomised study. BMJ 2002;325:1387 ( 14 December). 2)Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. letter [PubMed –indexed for MEDLINE]. 3)Stagnaro-Neri M., Stagnaro S., Diagnosi Clinica Precoce dell’Osteoporosi con la Percussione Ascoltata. Clin.Ter. 137, 21-27, 1991 [Pub-Med indexed for MEDLINE]. 4)Stagnaro S., Sindrome percusso-ascoltatoria di Iperfunzione del Sistema Reticolo-IstiocitarioMin. Med. 74, 479, 1983 [Pub-Med indexed for MEDLINE]. 5)Stagnaro S., Rivalutazione e nuovi sviluppi di un fondamentale metodo diagnostico: la percussione ascoltata Atti Accademia Ligure di Scienze e Lettere. Vol. XXXIV, pg. 176-192, 1978. Competing interests: None declared |
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Paul J. Willemsen, consultant surgeon AZ Middelheim Lindendreef 1 B-2020 Antwerpen, Belgium
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This is a very nice study but it needs to be stressed only those patients were included who did not need emergency surgery or other urgent interventions. The mortality in the standard treatment group might be explained by the fact that patients for this study were recruited during weekend hours and that these patients are seen by less experienced staff. So early CT-scan is useful in the diagnosis of acute abdominal pain after evalution of an experienced clinician. Competing interests: None declared |
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jumkur.s nagabhushan, SHO-3 in surgery falkirk royal infirmary, falkirk, fk2 7ey
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I read with interest the authors study about Abdominal CT for the diagnosis of acute abdominal pain of unknown cause. It would be much easier if we could use this vauable tool for the diagnosis of nonspecific abdominal pain in most of the patients. But unfortunately with limited resources, and people in the waiting list to undergo this procedure electively means that this cannot happen realistically. Some times even though the CT scan has been done the reporting takes time which will add on for the stay of the patient in the hospital. Certain proportion of patients will settle on their own without much active intervention. Abdominal ultrasound would be an easier first option if the plain X rays are inconclusive. Investigations should be tailored to the individual patient needs and we should not be dictated by the availability of resources. Although certain patients definitely benefit from this investigation it would be unlikely that this could be used as an initial tool in the diagnosis of acute abdominal pain of unknown cause. In the DGHS setting to get a CT scan the radiologist and the surgeon should be in concurrence otherwise things could be delayed add on top the difference of opinions. In the end I agree with the authors that CT is not infalliable and clinical examination and review remain crucial. Competing interests: None declared |
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Richard G Fiddian-Green, None None
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In the US, and I suspect in the UK, acute abdominal pain is first assessed by a junior ER doctor. This is a major problem especially in the US where students do not get into the operating room and medical interns and residents do not do a surgical house job as in the UK. The attendings whpo train them, be they ER doctors, internists or even gastroenterologists, are notoriously bad in evaluating patients with acute abdominal pain. This is dramatically revealed in watching patients yelp with pain when "tested for rebound tenderness". I further suspect that few if any ER doctor in the US has heard of let alone read a good book on the diagnosis of the acute abdomen, such as Zachary Cope's classic. In the absence of the experience surgeon's gain from evaluating a succession of patients with an acute abdomen, examining them again after induction of anesthesia and then seeing the pathology in vivo, these deficiencies are understandable. The problem in the US is compounded by the surgical residents complaining when they are called to see patients without significant pathology. This is possibly the primary reason for most patients having a host of unnecessary blood tests and imaging studies before the surgical residents are even called to see patients with an acute abdomen. To make matters worse the progress in evaluting patients is often so slow that the ER doctor who examined the patient in the first place is often replaced by a second doctor and so the benefit of repeated examinations by the same observor is lost. One problem, certainly in the UK, is that no senior clinician of any discription is ever in hosptial in the evenings and weekends unless called to see an emergency. It would be a lot cheaper in addition to being better for patient care if the first person to evaluate a patient with an acute abdomen were an experienced surgeon. That is incompatible with part time appointments in the NHS and with the miserable salaries surgeons are paid for their NHS services. I suspect an NHS solution to this might be to have nurses be the first to evaluate patients with an acute absomen because their time is the cheapest. The only people who benefit from such an arrangement would be those selling disposables and imaging equipment to the NHS who already get far more more business than they should. Competing interests: None declared |
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C S Ripley, SPR radiology Ninewells Hospital, Dindee, DD1 9SY
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"Evaluation of early abdominopelvic computed CT in patients with acute abdominal pain of unknown cause: prospective randomised study", was an interesting, well performed study, but the results do not justify the headline "Early CT improves diagnosis in abdominal pain" when there was no statistically siginficant difference at 24 hours between the two groups in terms of accuracy of diagnoses. Furthermore the length of stay was not reduced by a statistically significant degree and there was no statistically significant change in the number of operations performed. It is claimed "Early computed tomography did, however, identify significantly more of the serious diagnoses than standard practice and it was probably this aspect that affected mortality." However the standard parctice group shows that the mortality from surgical causes, was related to perforated viscus and ruptured abdominal aortic aneurysms. There were no ruptured abdominal aortic aneurysms detected by early CT and only one perforated viscus which was treated conservatively. Or put another way CT was not shown to have any effect on mortality. In conclusion this was an interesting study, which is unfortunately underpowered and from which no definite conclusions as to the usefulness of CT can be drawn and which does not merit the editors choice of headline. Competing interests: None declared |
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wayne lewis, general practitioner carreg wen surgery, blaenavon, wales
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Richard G Fiddian-Green makes some interesting points about this study. However, I suspect he is incorrect in asserting that "acute abdominal pain is first assessed by a junior ER doctor" in the UK. Many, perhaps most, of the patients entered into this study would have been assesed by an experienced clinician before getting anywhere near the hospital: namely, a General Practitoner. Competing interests: None declared |
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Richard G Fiddian-Green, None None
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If a patient with an acute abdomen is first assessed by a GP in the UK, and in my experience was almost unheard of in the US, how does that translate into the efficiency and cost-effectiveness of management(1)? I assume that in private practice the GP would call a consultant surgeon who would be the next person to see the patient but if referred to the local NHS Accident and Emergency department it would still be a SHO or junior registrar would it not? In encouraging patients to see a GP first the treatment of serious conditions can be seriously compromised. There is only an hour in which to reverse an impairment of the adequacy of systemic tissue oxygenation if costly organ dysfunctions and failures, nosocomial infections and deaths are to be avoided (2). In the case of acute coronary artery syndromes, strokes and severe hypovolaemia that requires the assistance of an expert team. Hence my argument that the NHS might be better off investing in having specialist teams go to seriously ill patients by ground or air ambulance rather than the reverse (3). The key to more efficient and cost-effective management lies in identifying those who need to be seen by these teams as soon after the onset of their serious illness, that is those with a syntemic inadequcy of tissue oxygenation, as is humanly possible. There are now the simple and reliable means of accomplishing this. GPs and district nurses might, therefore, be profitably employed providing selected patients at risk with the means and skills to establish for themselves at work or home the presence of a systemic inadequacy of tissue oxygenation within minutes of its onset, and establishing effective systems for them summoning specialist teams in a timely manner. Perhaps the GP will be required to take a history over a cell phone and co-ordinate this process to avoid unnecessary calls upon the speialist teams. If in addition most chronic diseases are also the result of an impairment of the adequacy of tissue oxygenation, as would seem likely, then GPs and/or district nurses might end up spending the remainder of their time detecting and reversing any inadequacy of endothelial tissue oxygenation that might develop years before it causes chronic diseases (4). In other words they would in effect be running vascular or rather endothelial wellness clinics. This would require not only a major change in the organisation of their practices but also a major change in the pharmacological management of their patients. I foresee, therefore, a pharmaceutical industry that is greatly contracted and more specialised with far fewer medical subspecialties and accompanying hospital-based physicians(internists). That would certainly constitute a revolution in healthcare (5). Who knows what the place of experienced GPs might become if, as I anticipate, this revolution comes to fruition. There should remain a place for experienced clinicians, be they Dr Wayne Lewis, other GPs, gastroenterologists or surgeons, to evaluate patients with acute and chronic abdominal pain. Those who evaluate these patients would, however, have to have access to the appropriate imaging techniques and to dialogue with those able to provide expert interpretations of the images. 1. Re: Who examined the patients? wayne lewis (17 December 2002) 2. GPs and district nurses in the hot seat? Richard G Fiddian-Green bmj.com/cgi/eletters/320/7240/0/a#7353, 10 Apr 2000 3. Buildings or ambulances? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7375/1290#27694, 9 Dec 2002 4. Iatrogenic diseases with a common cause? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7370/913#26512, 25 Oct 2002 5. Preparing for the coming healthcare revolution Richard G Fiddian-Green bmj.com/cgi/eletters/325/7375/1290#27463, 29 Nov Competing interests: None declared |
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Peter F Jones, Emeritus Clinical Professor of Surgery University of Aberdeen
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7, Park Road, Cults, Aberdeen. AB15 9HR The Editor BMJ BMA House, Tavistock Square, 21 December 02 London. WC1H 9JR Use of CT on the acute abdomen Editor - Although there have been many papers in the North American journals about the early use of computed tomography in the diagnosis of patients with acute abdominal pain who do not require immediate operation, I believe there is a good reason why the paper of Ng et al is one of the few published in the UK.1 It is now generally recognised that at least one-third of patients in this category have a self-limiting condition, known as Acute Non-Specific Abdominal Pain, which settles without treatment in 24-48 hours. 2 To submit all these patients, mostly young, to a substantial dose of ionising radiation, before allowing time for observation, is questionable practice. It is difficult to draw conclusions from the outcome in the two groups of Ng et al because they are dissimilar. The computed tomography series contains 4 patients in the high-risk groups (malignancy and perforated viscus) compared to the12 patients receiving “standard practice” who suffered 6 deaths: more information is needed before we can conclude that it was delay in applying computed tomography which so prejudiced their outcome. I am sure that Ng et al are correct to advise that “computed tomography should be used with caution”, and be reserved for difficult cases. In a prospective series of 625 comparable patients in New York, Weyant et al found that “there was no correlation between computed tomography findings and pathologically proved disease”: they advised “more precise patient selection by clinical criteria”. 3 Before any extension of the use of early computed tomography in patients with an undiagnosed acute abdomen, consideration should be given to the use of a disciplined regime of clinical observation (with blood tests and plain radiography as required). In over 2000 patients scrutiny of results showed that this regime was safe (1 death) and allowed patients with a perforated viscus , or other active surgical condition, to receive timely recognition and operative treatment. 4 Peter F Jones Emeritus Clinical Professor of Surgery, University of Aberdeen. Competing interests: None declared 1. Ng CS, Watson CJE, Palmer CR, See TC, Beharry NA, Housden BA et al. Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospectiuve randomised study. BMJ 2002;325: 1387-9. (14 December) 2. de Dombal FT. The OMGE Acute Abdominal Pain Survey. Progress Report, 1986. Scand J Gastroent 1988: 23 (Suppl 144): 35-42. 3. Weyant MJ, Eachempati SRE, Maluccio MA, Rivadeneira DE, Grobmeyer SR, Hydo LJ et al. Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis. Surgery 2000: 128: 145-52. 4. Jones PF. Suspected acute appendicitis: trends in management over 30 years. Br J Surg 2001; 88: 1570-77. Competing interests: None declared |
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Anusha G Edwards, research registrar Southmead Hospital, Westbury on Trym, Bristol BS10 5NB, Andrew R Weale
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Editor-We welcome any study that provides evidence for improved patient care with out of hours radiological investigation. However, we have the following concerns about the methodology of the study by Ng et al: 1. The CONSORT method of presenting randomised controlled studies encourages transparency. The authors have not given the grade of surgeon or radiologist involved in patient assessment and reporting of the scans respectively. 2. The hospital stay data, log transformed to account for skewness, shows a 1.1 day shorter stay in patients undergoing early CT. Although not statistically significant the authors conclude that this early investigation may reduce the length of hospital stay. An alternative explanation is based on the fact that the study was carried out during an out of hours period to ensure access to CT within 24 hours. However, the standard practice group did not have any of their investigations expedited as part of the study. Therefore, this apparent increased length of stay in the standard practice group may be due to longer waiting times for investigations and their subsequent reporting. 3. The difference in mortality between the two groups may perhaps be explained by the difference in case mix. The standard practice group included 5 patients with a perforated viscus and one with a ruptured abdominal aortic aneurysm. These patients would not necessarily have had improved survival as a result of early CT. This study, as the authors point out, was not designed to investigate mortality and such chance findings are perhaps to be expected with such numbers of patients. Competing interests: None declared |
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