A study was set up to review the effectiveness of primary
prevention strategies aimed at delaying sexual intercourse, improving use of
birth control, and reducing incidence of unintended pregnancy in adolescents.
The authors looked at 12 electronic bibliographic databases,
10 key journals, citations of relevant articles, and contact with authors. 26
trials described in 22 published and unpublished reports that randomised
adolescents to an intervention or a control group were found. Interventions did
not delay initiation of sexual intercourse in young women or young men; did not
improve the use of birth control by young women at every intercourse or by young
men at every intercourse and did not reduce pregnancy rates in young women.
Four abstinence programmes and one school based sex education
programme were associated with an increase in number of pregnancies among
partners of young male participants. There were significantly fewer pregnancies
in young women who received a multifaceted programme, though baseline
differences in this study favoured the intervention.
Overall, primary prevention strategies evaluated to date do
not delay the initiation of sexual intercourse, improve use of birth control
among young men and women, or reduce the number of pregnancies in young women.to
examine the availability of measures across specialties.
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Early appendicectomy was first recommended and performed for non-perforated
acute appendicitis in the 1880s. The operation remains the most common in the
Western world, accounting for a million hospital days per year in the United
States. Despite more than 100 years’ experience, accurate diagnosis still evades the surgeon, and avoiding perforation
and subsequent complications must be weighed against removal of a normal
appendix in patients with other causes of abdominal pain - a “negative”
appendicectomy - which has a rate as high as 20%.
This is not a trivial problem. Flum and Kepsell assessed its
impact in the United States – length of stay, rate of complications, and
mortality (1.5%
0.2%) were all significantly higher in the negative appendicectomy group, and
the annual cost of a negative appendicectomy was calculated at $742m.
The use of an objective scoring system such as the Alvarado
System can reduce the negative appendicectomy rate to 0-5%. The simple expedient
of close observation and repeated re-evaluation has in itself been shown in
several studies to reduce the unnecessary exploration rate. It is inevitable in
a climate that values high tech investigations above clinical skills that other
modalities (and expensively) evaluated in the past decade.
A systematic review for the Cochrane Library identified 39
randomised controlled trials of laparoscopic versus open appendicectomy in
adults, recruiting more than 4000 patients.
Laparoscopic appendicectomy halved the number of wound
infections, and reduced pain on the first postoperative day, duration of
hospital stay, and time to return to work, but at the cost of a threefold
increase in the number of postoperative intra-abdominal abscesses.
The results in a much smaller number of trails in children
were less clear cut. Possibly the increase in abscesses may be obviated if
laparoscopic appendicectomy is avoided in patients with probable perforated
appendicitis unless done by an experienced laparoscopist.
Laparoscopic appendicectomy comes into its own when there is
diagnostic doubt – a special case is that of young women, in whom the
diagnostic dilemma is often greatest and in whom endoscopic surgery can be
performed if tubo-ovarian pathology is found at laparoscopy.
One non-randomised study of parallel groups used the Alvarado
score to select young women with suspected acute appendicitis for laparoscopy.
Ten per cent were found to have normal appendixes and were spared a surgical
incision, and the normal appendicectomy rate was 0%, compared with 18% in the
control group treated on a different surgical unit. This effect in your women
was borne out by the systematic review.
What should now be recommended for the diagnosis and
management of acute appendicitis? Clinical judgment still has a place,
especially if an experienced clinician is prepared to re-evaluate doubtful cases
at regular intervals: rapid, unexpected perforation is uncommon, and there is no
case for rushing to operate in marginal cases.
Scoring systems may help, if only by formalising assessment
and ensuring attention to detail. Ultrasound has no place as a screening tool
but may help in some patients where the diagnosis is doubtful, but computed
tomography should be reserved for patients in whom there is suspicion of an
alternative diagnosis, especially in elderly or unfit patients.
Laparoscopy has a definite place in women, and in others
where there is diagnostic uncertainty, although perhaps it is best avoided where
the suspicion of perforation is strong.
The challenge now is to provide a sufficient number of
surgeons skilled in diagnostic and therapeutic laparoscopy on demand, able to
deal not only with proved acute appendicitis but also with occasional unexpected
findings. Perhaps new approaches to this old common problem will bring us a step
closer to a truly consultant based, specialised, acute surgical service in our
hospitals.
