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Penetrating renal trauma: CT evaluation
Abstracts
function was followed by measuring hematologic parameters, by spleen scanning, and by labeled autologous erythrocyte clearance over a period of two to five years. The authors found that patients undergoing splenorrhaphy or partial splenectomy had reticuloendothelial function identical to that of the control group. Patients with splenic autotransplantation had less effective improvement in splenic function compared to these groups, but consistently greater function than splenectomized patients without autotransplantation. At 5.8 to 8.3 years after surgery, none of three autotransplantation patients and none of eleven splenectomized patients (with and without subsequent splenosis) reported a serious infection. [Michael Hunt, MD] Editor’s Note: As recognized by the authors, this study fails to answer the question of how much spleen tissue is required (whether by splenosis or autotransplantation) to prevent overwhelming post splenectomy sepsis.
commonly is due to hematogenous seeding of the ascites. Gram’s negative organisms account for 70% of the infections, with E. coli the most common agent; anaerobes and polymicrobial infections are the least common. This entity should be aggressivelysought in patients with ascites and a deteriorating clinical state. Fever and abdominal pain are the most common complaints, but diarrhea. worsening renal function, hypothermia, and unexplained encephalopathy all should raise the concern of SBP. Up to 33%, of cases may be asymptomatic. A polymorphonuclear cell count of greater than 5OOimmxin ascitic fluid is the best single indicator of SBP (sensitivity 87%. specificity 98%). Lactate levels greater than 25 mg/dL or arterial-ascitic pH gradients greater than 0.1 are less sensitive but possibly more specific indicators. Once a presumptive diagnosis of SBP is made, treatment must be promptly initiated based on the Gram’s stain; usually the initial choice of antibiotics will include ampicillin and an aminoglycoside. Mortality is substantial and appears to be related as much to the severity of the underlying liver diseaseas it is to the mfection.
C PENETRATING RENAL TRAUMA: CT EVALUATION. Federle MP, Brown TR, McAninch JW. J Comput
Editor’s Note: Emergency physicians should be alert to this entity, as its clinical presentation may be subtle. Liberal use of paracentesis is necessary to avv~d missing the diagnosis.
Assist Tomagr. 1987; 11: 1026-1030. This retrospective study evaluates 27 patients with stab wounds, primarily of the back and flank, who were clinically stable and thought to be at risk for renal injury. Patients were studied by a combination of computed tomography (CT, n =22), excretory urography (EU, n = 11) and angiography (n =3). No correlation was found between the degree of hematuria and the extent of renal injury. Twelveof the 22 patients having CT showed renal abnormalities; all of these had some abnormality on EU, but the injury was more accurately defined on CT. Only sevenpatients required surgery, including one with lacerations of the renal artery and vein and the inferior vena cava, whose CT and EU were abnormal but nonspecific, but whose CT was suggestive of a major vascular injury. All the patients managed non surgically did well, including seven with identifiable renal lacerations judged to be minor on CT. The authors conclude that CT is the procedure of choice for evaluating penetrating renal injury. [Paul D. O’Brien, MD] Editor’s Note: Since the method of assignment of patients to the various imaging modalities was not controlled, these results must be viewed with some caution. In addition, this study was limited only to stab wounds; extrapolation to gunshot wounds without further study would be unwarranted.
0 SPONTANEOUS BACTERIAL PERITONITIS: A REVIEW OF PATHOGENESIS, DIAGNOSIS, AND TREATMENT. Wilcox CM, Dismukes WE. Medicine.
1987; 66:447-456. Spontaneous bacterial peritonitis (SBP) is an increasingly common entity, seen most often by cirrhotics with ascites. Infection may occur by invasion from the gastrointestinal tract secondary to derangements in lymphatic circulation and transmural migration of bacteria, but most
C TAPERING OF CORTICOSTEROID THERAPY FOLLOWING EXACERBATION OF ASTHMA: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. Lederle FA, Pluhar RE, Joseph AM, et al. Arch Infern Med. 1987; 147:2201-2203.
While systemic corticosteroids are known to be effective in the treatment of acute asthma, little is known about the optimal scheduling of their withdrawal following the attack. This randomized, double-blind, placebo-controlled trial tested the hypothesis that a longer corticosteroid taper reduced the number of exacerbations and hospital readmissions. Forty-three adult male non-steroid-dependent patients admitted for asthma exacerbations during a one-year period were randomly assigned to either a seven-day or seven-week tapering regimen following completion of an eightday inpatient course of high dose steroids. Follow-up at twelve weeks showed no significant differences between the long- and short-taper groups in incidence of relapse or readmission (41% v 52% and 22% v 21, respectively). A significantly greater number of patients in the Long-Taper group reported steroid, side-effects (41% v 14%). The authors conclude that long tapering of steroids does not provide enough benefit to justify its routine use. [Heidi Kapanka, MD] Editor’s Note: This study was conducted on veterans whose average age was about 62; thus, it actually applies to chronic obstructive pulmonary disease rather than asthma. In addition, the power of the study is such that only virtual elimination of relapse was likely to be detected; the chance that this study might miss a reduction in the true rate of relapse to 26% or lessis roughly 60%.
function was followed by measuring hematologic parameters, by spleen scanning, and by labeled autologous erythrocyte clearance over a period of two to five years. The authors found that patients undergoing splenorrhaphy or partial splenectomy had reticuloendothelial function identical to that of the control group. Patients with splenic autotransplantation had less effective improvement in splenic function compared to these groups, but consistently greater function than splenectomized patients without autotransplantation. At 5.8 to 8.3 years after surgery, none of three autotransplantation patients and none of eleven splenectomized patients (with and without subsequent splenosis) reported a serious infection. [Michael Hunt, MD] Editor’s Note: As recognized by the authors, this study fails to answer the question of how much spleen tissue is required (whether by splenosis or autotransplantation) to prevent overwhelming post splenectomy sepsis.
commonly is due to hematogenous seeding of the ascites. Gram’s negative organisms account for 70% of the infections, with E. coli the most common agent; anaerobes and polymicrobial infections are the least common. This entity should be aggressivelysought in patients with ascites and a deteriorating clinical state. Fever and abdominal pain are the most common complaints, but diarrhea. worsening renal function, hypothermia, and unexplained encephalopathy all should raise the concern of SBP. Up to 33%, of cases may be asymptomatic. A polymorphonuclear cell count of greater than 5OOimmxin ascitic fluid is the best single indicator of SBP (sensitivity 87%. specificity 98%). Lactate levels greater than 25 mg/dL or arterial-ascitic pH gradients greater than 0.1 are less sensitive but possibly more specific indicators. Once a presumptive diagnosis of SBP is made, treatment must be promptly initiated based on the Gram’s stain; usually the initial choice of antibiotics will include ampicillin and an aminoglycoside. Mortality is substantial and appears to be related as much to the severity of the underlying liver diseaseas it is to the mfection.
C PENETRATING RENAL TRAUMA: CT EVALUATION. Federle MP, Brown TR, McAninch JW. J Comput
Editor’s Note: Emergency physicians should be alert to this entity, as its clinical presentation may be subtle. Liberal use of paracentesis is necessary to avv~d missing the diagnosis.
Assist Tomagr. 1987; 11: 1026-1030. This retrospective study evaluates 27 patients with stab wounds, primarily of the back and flank, who were clinically stable and thought to be at risk for renal injury. Patients were studied by a combination of computed tomography (CT, n =22), excretory urography (EU, n = 11) and angiography (n =3). No correlation was found between the degree of hematuria and the extent of renal injury. Twelveof the 22 patients having CT showed renal abnormalities; all of these had some abnormality on EU, but the injury was more accurately defined on CT. Only sevenpatients required surgery, including one with lacerations of the renal artery and vein and the inferior vena cava, whose CT and EU were abnormal but nonspecific, but whose CT was suggestive of a major vascular injury. All the patients managed non surgically did well, including seven with identifiable renal lacerations judged to be minor on CT. The authors conclude that CT is the procedure of choice for evaluating penetrating renal injury. [Paul D. O’Brien, MD] Editor’s Note: Since the method of assignment of patients to the various imaging modalities was not controlled, these results must be viewed with some caution. In addition, this study was limited only to stab wounds; extrapolation to gunshot wounds without further study would be unwarranted.
0 SPONTANEOUS BACTERIAL PERITONITIS: A REVIEW OF PATHOGENESIS, DIAGNOSIS, AND TREATMENT. Wilcox CM, Dismukes WE. Medicine.
1987; 66:447-456. Spontaneous bacterial peritonitis (SBP) is an increasingly common entity, seen most often by cirrhotics with ascites. Infection may occur by invasion from the gastrointestinal tract secondary to derangements in lymphatic circulation and transmural migration of bacteria, but most
C TAPERING OF CORTICOSTEROID THERAPY FOLLOWING EXACERBATION OF ASTHMA: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. Lederle FA, Pluhar RE, Joseph AM, et al. Arch Infern Med. 1987; 147:2201-2203.
While systemic corticosteroids are known to be effective in the treatment of acute asthma, little is known about the optimal scheduling of their withdrawal following the attack. This randomized, double-blind, placebo-controlled trial tested the hypothesis that a longer corticosteroid taper reduced the number of exacerbations and hospital readmissions. Forty-three adult male non-steroid-dependent patients admitted for asthma exacerbations during a one-year period were randomly assigned to either a seven-day or seven-week tapering regimen following completion of an eightday inpatient course of high dose steroids. Follow-up at twelve weeks showed no significant differences between the long- and short-taper groups in incidence of relapse or readmission (41% v 52% and 22% v 21, respectively). A significantly greater number of patients in the Long-Taper group reported steroid, side-effects (41% v 14%). The authors conclude that long tapering of steroids does not provide enough benefit to justify its routine use. [Heidi Kapanka, MD] Editor’s Note: This study was conducted on veterans whose average age was about 62; thus, it actually applies to chronic obstructive pulmonary disease rather than asthma. In addition, the power of the study is such that only virtual elimination of relapse was likely to be detected; the chance that this study might miss a reduction in the true rate of relapse to 26% or lessis roughly 60%.