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Diagnosis of acute flank pain: Value of the unenhanced helical CT
The Journal of Emergency Medicine
cardiovascular failure, oliguria, and the need for ventilator support. Too unstable to be transferred to a facility that could offer hemodialysis, the patient was placed on CAVH-D to remove EG and glycolate. Through femoral arterial and venous access,a dialysis flow of 1 L/h and ultrafiltration rates of 250-600 mL/h were achieved. Serum EG level of 9.5 was found at admission, and glycolic acid level was 21.6 mmol/L. At 24 h, this was 2.0 mmol/L and, after 48 h, was not measurable.Acidosis that had been refractory to buffered solution administration was almost fully corrected in 24 h. Ethanol infusion was discontinued on day 2 and dialysis continued for 6 days. The patient was discharged after 13 days and has no sign of neurological sequelae. Although no definite conclusions can be drawn from this case regarding the efficacy of CAVD-H, it may be an appropriate alternative when hemodialysis and 4-methylpyridamole therapy are unavailable. [Terrence L. Jones, MD]
Cl DIAGNOSIS OF ACUTE FLANK PAIN: VALUE OF THE UNENHANCED HELICAL CT. Smith RC, Verga M, McCarthy S, et al. Am J Roentgenology. 1996;166:97101. Previous studies regarding the use of helical computed tomography (CT) in the diagnosis of urolithiasis have been small. This study examined the use of unenhanced helical CT in the diagnosis of acute flank pain in patients with suspected urolithiasis in 292 patients. The study population consisted of 210 patients who had confirmation of the CT diagnosis by other modalities (intravenous pyelogram (IVP) , surgery, lithotrypsy, recovery of stone). One hundred patients had confirmed urolithiasis. One hundred ten patients had a diagnosis other than urolithiasis confirmed. There were 100 CT scans demonstrating stones and 106 that demonstrated no stone. Thirty-one patients had CT findings unrelated to urolithiasis, and one CT scan was a false positive for appendicitis. Of the patients with positive CT findings for urolithiasis, 29 did not have a confirmatory study; however, these patients were contacted and all but four reported passing a stone. The authors count these four patients as false positives, although subsequentreview of these patients’ CT scan clearly demonstrated stones in the ureter of the symptomatic side. Of the 75 patients without a stone on CT, 24 had a negative confirmatory radiological study and the remaining 51 were contacted by telephone. Three patients in this group reported passing a stone, making these studies false negatives. The calculated sensitivity is 97% and speciticity is 96%. The authors conclude that the use of unen-
661
hanced helical CT in acute flank pain patients in whom urolithiasis is suspected is accurate, quick, and can demonstrate other causesof flank pain unrelated to stones. Furthermore, they point out that unenhanced CT cannot demonstrate physiologic information pertaining to degree of obstruction; however, since no contrast is used, it does not interfere with subsequent contrast studies which can delineate degree of obstruction. [Brian Snyder. MD] Editor’s Comment: IVP or ultrasound are less expensive and more readily available.
0 EFFICACY AND TOLERANCE OF ANTIHYPERTENSIVE TREATMENT IN MEN AND WOMEN WITH STAGE 1 DIASTOLIC HYPERTENSION. Lewis CE, Grandits GA, Flack J, et al. Archives of Internal Medicine. 1996; 156:377-85. The benefits of blood pressure (BP) treatment in women has been questioned in the past, and the purpose of this study was to explore the sex specific benefits and risks of treating stage 1 diastolic hypertension (Diastolic BP of 90-99 ) This was a double blind, placebo controlled, randomized trial comparing tive classes of antihypertensive agents for the management of stage 1 hypertension. Patients all underwent lifestyle interventions, and were randomized to acebutolol hydrochloride, amlodipine bosylate, chlorthalidone, doxazosin mesylate, enalapril maleate, or placebo. Patients were followed at 3-month intervals for at least 4% months and had medicine doses increased or second agents added for persistent hypertension. At variable intervals, patients had their weight and BP measured, filled out quality of life surveys, and underwent an electrocardiogram and serum chemistry measurements. All patients randomized to treatment with active medicines had improved BP control and a lower rate of adverse events compared to patients taking placebo. Other than general health category for women, all quality of life indices were better in non-placebo patients. Side effects were minimal, and there were no statistically different changes in serum chemistries between men and women. The authors conclude that antihypertensive medicines are equally effective in both men and women m lowering BP and improving overall quality of life, and are better than lifestyle intervention alone. The authors note. though, that lifestyle intervention is an important adjuncr to medication. All medicines used in the study demonstrated similar efficacy. [Warren Gude, MD 1
cardiovascular failure, oliguria, and the need for ventilator support. Too unstable to be transferred to a facility that could offer hemodialysis, the patient was placed on CAVH-D to remove EG and glycolate. Through femoral arterial and venous access,a dialysis flow of 1 L/h and ultrafiltration rates of 250-600 mL/h were achieved. Serum EG level of 9.5 was found at admission, and glycolic acid level was 21.6 mmol/L. At 24 h, this was 2.0 mmol/L and, after 48 h, was not measurable.Acidosis that had been refractory to buffered solution administration was almost fully corrected in 24 h. Ethanol infusion was discontinued on day 2 and dialysis continued for 6 days. The patient was discharged after 13 days and has no sign of neurological sequelae. Although no definite conclusions can be drawn from this case regarding the efficacy of CAVD-H, it may be an appropriate alternative when hemodialysis and 4-methylpyridamole therapy are unavailable. [Terrence L. Jones, MD]
Cl DIAGNOSIS OF ACUTE FLANK PAIN: VALUE OF THE UNENHANCED HELICAL CT. Smith RC, Verga M, McCarthy S, et al. Am J Roentgenology. 1996;166:97101. Previous studies regarding the use of helical computed tomography (CT) in the diagnosis of urolithiasis have been small. This study examined the use of unenhanced helical CT in the diagnosis of acute flank pain in patients with suspected urolithiasis in 292 patients. The study population consisted of 210 patients who had confirmation of the CT diagnosis by other modalities (intravenous pyelogram (IVP) , surgery, lithotrypsy, recovery of stone). One hundred patients had confirmed urolithiasis. One hundred ten patients had a diagnosis other than urolithiasis confirmed. There were 100 CT scans demonstrating stones and 106 that demonstrated no stone. Thirty-one patients had CT findings unrelated to urolithiasis, and one CT scan was a false positive for appendicitis. Of the patients with positive CT findings for urolithiasis, 29 did not have a confirmatory study; however, these patients were contacted and all but four reported passing a stone. The authors count these four patients as false positives, although subsequentreview of these patients’ CT scan clearly demonstrated stones in the ureter of the symptomatic side. Of the 75 patients without a stone on CT, 24 had a negative confirmatory radiological study and the remaining 51 were contacted by telephone. Three patients in this group reported passing a stone, making these studies false negatives. The calculated sensitivity is 97% and speciticity is 96%. The authors conclude that the use of unen-
661
hanced helical CT in acute flank pain patients in whom urolithiasis is suspected is accurate, quick, and can demonstrate other causesof flank pain unrelated to stones. Furthermore, they point out that unenhanced CT cannot demonstrate physiologic information pertaining to degree of obstruction; however, since no contrast is used, it does not interfere with subsequent contrast studies which can delineate degree of obstruction. [Brian Snyder. MD] Editor’s Comment: IVP or ultrasound are less expensive and more readily available.
0 EFFICACY AND TOLERANCE OF ANTIHYPERTENSIVE TREATMENT IN MEN AND WOMEN WITH STAGE 1 DIASTOLIC HYPERTENSION. Lewis CE, Grandits GA, Flack J, et al. Archives of Internal Medicine. 1996; 156:377-85. The benefits of blood pressure (BP) treatment in women has been questioned in the past, and the purpose of this study was to explore the sex specific benefits and risks of treating stage 1 diastolic hypertension (Diastolic BP of 90-99 ) This was a double blind, placebo controlled, randomized trial comparing tive classes of antihypertensive agents for the management of stage 1 hypertension. Patients all underwent lifestyle interventions, and were randomized to acebutolol hydrochloride, amlodipine bosylate, chlorthalidone, doxazosin mesylate, enalapril maleate, or placebo. Patients were followed at 3-month intervals for at least 4% months and had medicine doses increased or second agents added for persistent hypertension. At variable intervals, patients had their weight and BP measured, filled out quality of life surveys, and underwent an electrocardiogram and serum chemistry measurements. All patients randomized to treatment with active medicines had improved BP control and a lower rate of adverse events compared to patients taking placebo. Other than general health category for women, all quality of life indices were better in non-placebo patients. Side effects were minimal, and there were no statistically different changes in serum chemistries between men and women. The authors conclude that antihypertensive medicines are equally effective in both men and women m lowering BP and improving overall quality of life, and are better than lifestyle intervention alone. The authors note. though, that lifestyle intervention is an important adjuncr to medication. All medicines used in the study demonstrated similar efficacy. [Warren Gude, MD 1