1032
Letters
to
the Editor
The right of being wrong in the diagnosis of appendicitis is the only sure means to avoid mortality from an essentially benign disease. ERWIN T. JACOB Department of Surgery B, NATHAN BAR-NATHAN Hillel Yaffe Government Hospital, MIGUEL IUCHTMAN. Hadera, Israel -
ERROR-RATE FACTOR IN THE MANAGEMENT OF APPENDICITIS
SIR,-We read with great interest the paper of Mr Gilmore and his colleagues (Sept. 6, p. 421) on the problem of right lower-abdominal pain misdiagnosed as appendicits. We are reviewing 1000 consecutive appendectomies from our department, which draws patients from a population of similar size (250 000 urban and rural) as their hospitals. The area is serviced by 120 general practitioners who have a high index of suspicion for appendicitis: the 1000 operated cases result from 4677 referred suspected cases. The diagnosis was made on the macroscopical appearence of the appendix during surgery. Acute appendicitis was diagnosed in 750 cases, and in 13-8% ruptured appendicits was found. In 250 cases the diagnosis of acute appendicitis could not be confirmed. However, 16% from this latter group carried other surgical conditions justifying ERROR-RATES AND MORTALITY IN APPENDICECTOMIES
celiotomy. Average length of stay in hospital was 8-9 days (range of 3-127 days). No patients died. In large published series of acute appendicitis from the Western literature, as well as in our series (see table), an inverse correlation between rates of error and rates of rupture could be detected. Furthermore, as expected, a direct correlation becomes apparent between rates of perforation and mortality. In the absence of highly specific clinical and biological methods for accurate preoperative diagnosis of the disease, the diagnosis of acute appendicitis remains mostly a decision made by the surgeon. Mr Gilmore and his colleagues suggest that with a diagnostic error-rate of some 22% in England and Wales, 15 000 emergency appendicectomies may have been unnecessary. However, the real issue is not the unnecessary appendicectomy but the unnecessary mortality deriving from under-
diagnosis. It is
our
belief that the removal of
some
provides additional support to a controlled liberal celiotomy policy in the face of suspected appendicitis. However, removal of innocent appendices in a rate exceeding 25-30% seems to be neither advisable nor necessary for the fall in mortality arising from ruptured appendicitis. tomies
Hobson, T., Rosenman, L. D. Am. J. Surg. 1964, 108, 306. Barnes, B. A., Behringer, G. E., Wheelock, F. C., Wilkins, E. W. J. Am.
med. Ass. 1962, 3. Kazarian, K. k.,
180, 122. Roeder, W. J., Mersheimer,
119, 681. Swink, R. L. Am. Surg. 1969, 35, 149.
W. L.
SIR,-We read with interest studies’-6 and reviews’ 8 which describe the role of -haemolytic streptococci in pyoderma and acute glomerulonephritis, both common in Ghana. In studies in the United States, 12 Panama,3 and Tanzania,4 over 90% of p-haemotytic streptococci isolates were group A. Recently nephritogenic group-A strains have been reported in northern Nigeria.’ Therefore, the finding of non-group-A streptococci in rural patients in southern Ghana should be of interest. From March to April, 1975, we conducted a survey of skin infections among residents of 20 villages within 50 miles of Accra. Cultures were taken from skin lesions in 76 persons who had pyoderma. For 56 subjects who had positive streptococcal cultures, representative colonies of i-ha:mo)ytic streptococci were subcultured and sent to the Streptococcus Reference Laboratory, Public Health Laboratory, Colindale, London. 46 of the 56 strains (82.1 1%) were group-G streptococci, and 10 (17.9%) were group C. There was a complete absence of group-A strains. We thought this distribution was extraordinary, but subsequently we saw a report6 from Lagos, Nigeria, where only 22% of skin streptococcal isolates were found to be group A. 34% were group C, 10% group G, and 34% other streptococcal groups. In the Nigerian patients, two-thirds of nose-and-throat isolates were groups C and G. These preliminary studies suggest that non-group-A streptococci are frequent causes of pyoderma in southern Ghana and Nigeria. Because most studies have investigated only the role of group A in glomerulonephritis, we wonder whether nongroup-A streptococci may not be a factor in pyoderma-nephritis in tropical areas. Group-G streptococci have produced outbreaks of pharyngitis,9 and three group-G strains were found to have M-protein indistinguishable from that of group A, type 12,10 a type often associated with glomerulonephritis. Although post-streptococcal glomerulonephritis has been believed to follow group-A infections only, perhaps the role of non-group-A streptococci has been overlooked. Further studies are in progress here to clarify the relationship of non-group-A to pyoderma and its complications. Danfa
Comprehensive Rural Health
& Family Planning Project, P.O. Box 13 Legon, Accra, Ghana.
Ghana Medical School, P.O. Box 4236, Accra, Ghana.
D. W. BELCHER S. N. AFOAKWA E. OSEI-TUTU F. K. WURAPA L. OSEI
25% of innocent
appendices is bound to lower the rates of perforation and consequently the mortality. The discovery of other unsuspected surgical conditions in about a fifth of unnecessary appendicec-
1. 2.
NON-GROUP-A STREPTOCOCCI IN GHANAIAN PATIENTS WITH PYODERMA
Am. J. Surg. 1970,
4. 5. Egdahl, R. H. Am. J. Surg. 1964, 107, 757. 6. Cantrell, J. R., Stafford, E. S. Ann. Surg. 1955, 141, 749. 7. Babcock, J. R., McKinley, W. M. ibid. 1959, 150, 131.
DIAGNOSIS OF G.-6-P.D. DEFICIENCY
SIR,-Dr Wood and others have suggested (Oct. 4, p. 657) that the tetrazolium-linked cytochemical method may be a useful adjunct to the diagnosis of G.-6-P.D. deficiency once hxmolysis has occurred. To support this view they present the case 1. Dillon, H. C. Am. J. Dis. Child. 1968, 115, 530. 2 Dajani, A S., Ferriert, P., Wannamaker, L. W. Archs Derm. 1973, 108, 517 3. Allen, A. M., Taplin, D. Am. J. trop. Med. Hyg. 1974, 23, 950 4. Mhalu, F. S. E. Afr. med. J. 1973, 50, 272. 5. Whittle, H. C., Abdullahi, F. F., Parry, E. H. O., Rajovic, A. D. Trans R Soc. trop. Med. Hyg. 1973, 67, 349. 6. Ogunbi, O. J Nig. med. Ass. 1971, 1, 159. 7. Wannamaker, L. W. New Engl.J. Med. 1970, 282, 23. 8. See Lancet, 1974, ii, 390. 9. Hill, H. R., Caldwell, G. G., Wilson, F., Hager, D, Zimmerman, R A ibid
1969, ii, 371. 10. Maxted, W R., Potter, E.
V. J. gen. Microbiol. 1967, 49, 119
Letters
to
the Editor
The right of being wrong in the diagnosis of appendicitis is the only sure means to avoid mortality from an essentially benign disease. ERWIN T. JACOB Department of Surgery B, NATHAN BAR-NATHAN Hillel Yaffe Government Hospital, MIGUEL IUCHTMAN. Hadera, Israel -
ERROR-RATE FACTOR IN THE MANAGEMENT OF APPENDICITIS
SIR,-We read with great interest the paper of Mr Gilmore and his colleagues (Sept. 6, p. 421) on the problem of right lower-abdominal pain misdiagnosed as appendicits. We are reviewing 1000 consecutive appendectomies from our department, which draws patients from a population of similar size (250 000 urban and rural) as their hospitals. The area is serviced by 120 general practitioners who have a high index of suspicion for appendicitis: the 1000 operated cases result from 4677 referred suspected cases. The diagnosis was made on the macroscopical appearence of the appendix during surgery. Acute appendicitis was diagnosed in 750 cases, and in 13-8% ruptured appendicits was found. In 250 cases the diagnosis of acute appendicitis could not be confirmed. However, 16% from this latter group carried other surgical conditions justifying ERROR-RATES AND MORTALITY IN APPENDICECTOMIES
celiotomy. Average length of stay in hospital was 8-9 days (range of 3-127 days). No patients died. In large published series of acute appendicitis from the Western literature, as well as in our series (see table), an inverse correlation between rates of error and rates of rupture could be detected. Furthermore, as expected, a direct correlation becomes apparent between rates of perforation and mortality. In the absence of highly specific clinical and biological methods for accurate preoperative diagnosis of the disease, the diagnosis of acute appendicitis remains mostly a decision made by the surgeon. Mr Gilmore and his colleagues suggest that with a diagnostic error-rate of some 22% in England and Wales, 15 000 emergency appendicectomies may have been unnecessary. However, the real issue is not the unnecessary appendicectomy but the unnecessary mortality deriving from under-
diagnosis. It is
our
belief that the removal of
some
provides additional support to a controlled liberal celiotomy policy in the face of suspected appendicitis. However, removal of innocent appendices in a rate exceeding 25-30% seems to be neither advisable nor necessary for the fall in mortality arising from ruptured appendicitis. tomies
Hobson, T., Rosenman, L. D. Am. J. Surg. 1964, 108, 306. Barnes, B. A., Behringer, G. E., Wheelock, F. C., Wilkins, E. W. J. Am.
med. Ass. 1962, 3. Kazarian, K. k.,
180, 122. Roeder, W. J., Mersheimer,
119, 681. Swink, R. L. Am. Surg. 1969, 35, 149.
W. L.
SIR,-We read with interest studies’-6 and reviews’ 8 which describe the role of -haemolytic streptococci in pyoderma and acute glomerulonephritis, both common in Ghana. In studies in the United States, 12 Panama,3 and Tanzania,4 over 90% of p-haemotytic streptococci isolates were group A. Recently nephritogenic group-A strains have been reported in northern Nigeria.’ Therefore, the finding of non-group-A streptococci in rural patients in southern Ghana should be of interest. From March to April, 1975, we conducted a survey of skin infections among residents of 20 villages within 50 miles of Accra. Cultures were taken from skin lesions in 76 persons who had pyoderma. For 56 subjects who had positive streptococcal cultures, representative colonies of i-ha:mo)ytic streptococci were subcultured and sent to the Streptococcus Reference Laboratory, Public Health Laboratory, Colindale, London. 46 of the 56 strains (82.1 1%) were group-G streptococci, and 10 (17.9%) were group C. There was a complete absence of group-A strains. We thought this distribution was extraordinary, but subsequently we saw a report6 from Lagos, Nigeria, where only 22% of skin streptococcal isolates were found to be group A. 34% were group C, 10% group G, and 34% other streptococcal groups. In the Nigerian patients, two-thirds of nose-and-throat isolates were groups C and G. These preliminary studies suggest that non-group-A streptococci are frequent causes of pyoderma in southern Ghana and Nigeria. Because most studies have investigated only the role of group A in glomerulonephritis, we wonder whether nongroup-A streptococci may not be a factor in pyoderma-nephritis in tropical areas. Group-G streptococci have produced outbreaks of pharyngitis,9 and three group-G strains were found to have M-protein indistinguishable from that of group A, type 12,10 a type often associated with glomerulonephritis. Although post-streptococcal glomerulonephritis has been believed to follow group-A infections only, perhaps the role of non-group-A streptococci has been overlooked. Further studies are in progress here to clarify the relationship of non-group-A to pyoderma and its complications. Danfa
Comprehensive Rural Health
& Family Planning Project, P.O. Box 13 Legon, Accra, Ghana.
Ghana Medical School, P.O. Box 4236, Accra, Ghana.
D. W. BELCHER S. N. AFOAKWA E. OSEI-TUTU F. K. WURAPA L. OSEI
25% of innocent
appendices is bound to lower the rates of perforation and consequently the mortality. The discovery of other unsuspected surgical conditions in about a fifth of unnecessary appendicec-
1. 2.
NON-GROUP-A STREPTOCOCCI IN GHANAIAN PATIENTS WITH PYODERMA
Am. J. Surg. 1970,
4. 5. Egdahl, R. H. Am. J. Surg. 1964, 107, 757. 6. Cantrell, J. R., Stafford, E. S. Ann. Surg. 1955, 141, 749. 7. Babcock, J. R., McKinley, W. M. ibid. 1959, 150, 131.
DIAGNOSIS OF G.-6-P.D. DEFICIENCY
SIR,-Dr Wood and others have suggested (Oct. 4, p. 657) that the tetrazolium-linked cytochemical method may be a useful adjunct to the diagnosis of G.-6-P.D. deficiency once hxmolysis has occurred. To support this view they present the case 1. Dillon, H. C. Am. J. Dis. Child. 1968, 115, 530. 2 Dajani, A S., Ferriert, P., Wannamaker, L. W. Archs Derm. 1973, 108, 517 3. Allen, A. M., Taplin, D. Am. J. trop. Med. Hyg. 1974, 23, 950 4. Mhalu, F. S. E. Afr. med. J. 1973, 50, 272. 5. Whittle, H. C., Abdullahi, F. F., Parry, E. H. O., Rajovic, A. D. Trans R Soc. trop. Med. Hyg. 1973, 67, 349. 6. Ogunbi, O. J Nig. med. Ass. 1971, 1, 159. 7. Wannamaker, L. W. New Engl.J. Med. 1970, 282, 23. 8. See Lancet, 1974, ii, 390. 9. Hill, H. R., Caldwell, G. G., Wilson, F., Hager, D, Zimmerman, R A ibid
1969, ii, 371. 10. Maxted, W R., Potter, E.
V. J. gen. Microbiol. 1967, 49, 119
