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Real time ultrasonography for the diagnosis of lower extremity deep venous thrombosis
524
The Journal of Emergency
Medicine
2 hours of hyperbaric oxygen plus 4 hours of NBO (Group A 1), and Group B patients to 2 hours of HBO plus NBO (Group B 1) or 4 hours of NBO plus two sessions of HBO 2-12 hours apart (Group B2). Bach HBO treatment was 2 hours in duration, each NBO treatment was with 100% FiO, via facial mask or mechanical ventilation. Patients were followed up at one month by a questionnaire and neurologic examination. Recovery was defined as absence of signs or symptoms; moderate sequelae as the persistence of at least one symptom; severe sequelae as the presence of at least one neurologic sign. The proportion of patients recovering was not significantly different in the 2 pairs of subgroups (66% and 68% in group A, 54% and 5 1% in group B). The authors conclude that HBO has no advantage over NBO in the treatment of patients without loss of consciousness, but caution that there may be subtle alterations of function to which their study was insensitive. [Vincent A. Marino, MD] Editor’s Note: Long-term follow-up will be essential to document the similar outcomes of these two groups.
level. Fifty-three patients brought to the emergency department for examination and evaluation of possible alcohol intoxication had serum alcohol levels drawn and were also tested with the Alto dipstick. This required the dipstick to be placed under the patient’s tongue until it is saturated with saliva and $en held for 2 min before being compared with the color chart. Different shades of green to blue determine levels of 0.0, 0.02, 0.05, 0.1, 0.3 g/dL. The test will react with methanol, but not with isopropanol. The dipstick was found to be 83% correct when the alcohol level was 0. It detected alcohol on all the patients whose level was greater than 0.036 g/dL. The test was 91% sensitive and 71% specific. The authors conclude that the dipstick could be valuable in determining if a patient has ingested alcohol, especially in the presence of altered mental status or coma. [Satish Patel, MD] Editor’s Note: The utility of such a test lies in its ability to screen patients who have not ingested much alcohol pending laboratory confirmation. If alcohol is present, CNS injury cannot be excluded.
0 REAL TIME ULTRASONOGRAPIIY FOR THE DIAGNOSIS OF LOWER EXTREMITY DEEP VENOUS THROMBOSIS. Becker DM, Philbrick JT, Abbitt PL. Arch Intern Med. 1989;149:17314. The authors conducted a systematic critical review of all articles (15) in the English language medical literature since 1977 that compared real-time ultrasonography with venography for the diagnosis of deep venous thrombosis (DVT) of the lower extremity. None of the articles met all of 8 methodologic standards proposed for research on diagnostic tests; only 4 met over half of the standards. Nonetheless, many of the results were consistent. For all sites, the sensitivity varied from 0.78 to 1.OOand specificity from 0.78 to 1.OO,but for femoral and popliteal vein DVT, the mean sensitivity was 0.96 (range 0.92 to 1.00) and the mean specificity was 0.99 (range 0.96 to 1.00). In addition, useful diagnostic information regarding non-DVT diagnoses causing symptoms (eg, Baker’s cyst, calf hematoma) was often provided. The authors conclude that the ultrasonography is not accurate or reliable for calf or iliac thrombi, but is an accurate noninvasive test for femoral and popliteal DVT. Patients with negative studies could still have calf or iliac thrombi, and further evaluation or follow up of these patients is necessary. The authors suggest that just as serial impedance plethysmography has been used for patients with suspected DVT, repeated ultrasonography over 10 to 14 days to look for DVT propagation would be a safe alternative [John McGoldrick, MD] to immediate venography. Editor’s Note: This paper is an example of meta-analysis: it is a study in which the subjects are other studies, and it is an objective method of combining information from the typically disparate literature into a coherent whole.
0 EXTREME I-IYPERI’YREXLA IN CHILD,HOOD: PRESENTATION SIMILAR TO HEMORRHAGIC SHOCK AND ENCEPHALOPATHY. Caspe WB, Nucci AT, Sangho
0 EVALUATIONOFCOLORIMETRICDIPSTICKTEST TO DETECT ALCOHOL IN SALIVA: A PILOT STUDY. Schwartz RI-I, O’Domiell RM, Thome MM, et al. Ann Emerg Med. 1989;18:1001-3. This study was done to determine the accuracy of a dipstick test for detection of alcohol compared to actual serum alcohol
C. Clin Pediatr. 1989;28:76-80. The authors report 5 cases of previously well children, 8 to 33 months of age, presenting with temperatures greater than 42°C (107.6 “F) over a 14year period. Hyperpyrexia of severity may cause lethal injmy itself and is rare. It has been reported in association with heatstroke, anesthesia, psychotropic agents, or trauma, but not with bacterial infection. These cases had none of these associations, and blood, stool, and spinal fluid cultures were uniformly negative. In 1983 a new syndrome of hemorrhagic shock and encephalopathy (HSES) was described in Britain with 49 young children (median age 5 months) presenting with abrupt onset encephalopathy, shock, coagulopathy, diarrhea, azotemia, metabolic acidosis, and negative cultures. Elevated temperatures were present (38.0 “C to 41.5 “C), but were not considered significant in the genesis of HSES. These 5 cases all fit the criteria for HSES, but the terminal event appears related to a sudden catastrophic rise in temperature. The authors believe a significant role of hyperpyrexia itself should be examined more carefully in this newly recognized lethal entity of young children. [Peter Pruett, MD]
0 ACCURACY OF RADIOGRAPHIC DIFFERENTIATION OF BACTERIAL FROM NONBACTERIAL PNEUMOMA. Courtoy I, Lande AB, Turner RB. Clin Pediatr.
1989;28:2614. Chest x-ray study has been considered the gold standard in the diagnosis of lower respiratory tract disease. This study investigates. the ability of 5 pediatricians (2 of whom were pediatric radiologists) to differentiate bacterial from nonbacterial pneumonia in 36 cases of culture- or antigen-proven pneumonia. ‘Ihe sensitivity of film interpretation for detection of bacterial pneumonia varied from 42% to 58%. Sensitivity improved to 42% to 92% when clinical and laboratory information was supplied to observers. The positive predictive value of the presence of bacterial pneumonia ranged 35% to 64% and
The Journal of Emergency
Medicine
2 hours of hyperbaric oxygen plus 4 hours of NBO (Group A 1), and Group B patients to 2 hours of HBO plus NBO (Group B 1) or 4 hours of NBO plus two sessions of HBO 2-12 hours apart (Group B2). Bach HBO treatment was 2 hours in duration, each NBO treatment was with 100% FiO, via facial mask or mechanical ventilation. Patients were followed up at one month by a questionnaire and neurologic examination. Recovery was defined as absence of signs or symptoms; moderate sequelae as the persistence of at least one symptom; severe sequelae as the presence of at least one neurologic sign. The proportion of patients recovering was not significantly different in the 2 pairs of subgroups (66% and 68% in group A, 54% and 5 1% in group B). The authors conclude that HBO has no advantage over NBO in the treatment of patients without loss of consciousness, but caution that there may be subtle alterations of function to which their study was insensitive. [Vincent A. Marino, MD] Editor’s Note: Long-term follow-up will be essential to document the similar outcomes of these two groups.
level. Fifty-three patients brought to the emergency department for examination and evaluation of possible alcohol intoxication had serum alcohol levels drawn and were also tested with the Alto dipstick. This required the dipstick to be placed under the patient’s tongue until it is saturated with saliva and $en held for 2 min before being compared with the color chart. Different shades of green to blue determine levels of 0.0, 0.02, 0.05, 0.1, 0.3 g/dL. The test will react with methanol, but not with isopropanol. The dipstick was found to be 83% correct when the alcohol level was 0. It detected alcohol on all the patients whose level was greater than 0.036 g/dL. The test was 91% sensitive and 71% specific. The authors conclude that the dipstick could be valuable in determining if a patient has ingested alcohol, especially in the presence of altered mental status or coma. [Satish Patel, MD] Editor’s Note: The utility of such a test lies in its ability to screen patients who have not ingested much alcohol pending laboratory confirmation. If alcohol is present, CNS injury cannot be excluded.
0 REAL TIME ULTRASONOGRAPIIY FOR THE DIAGNOSIS OF LOWER EXTREMITY DEEP VENOUS THROMBOSIS. Becker DM, Philbrick JT, Abbitt PL. Arch Intern Med. 1989;149:17314. The authors conducted a systematic critical review of all articles (15) in the English language medical literature since 1977 that compared real-time ultrasonography with venography for the diagnosis of deep venous thrombosis (DVT) of the lower extremity. None of the articles met all of 8 methodologic standards proposed for research on diagnostic tests; only 4 met over half of the standards. Nonetheless, many of the results were consistent. For all sites, the sensitivity varied from 0.78 to 1.OOand specificity from 0.78 to 1.OO,but for femoral and popliteal vein DVT, the mean sensitivity was 0.96 (range 0.92 to 1.00) and the mean specificity was 0.99 (range 0.96 to 1.00). In addition, useful diagnostic information regarding non-DVT diagnoses causing symptoms (eg, Baker’s cyst, calf hematoma) was often provided. The authors conclude that the ultrasonography is not accurate or reliable for calf or iliac thrombi, but is an accurate noninvasive test for femoral and popliteal DVT. Patients with negative studies could still have calf or iliac thrombi, and further evaluation or follow up of these patients is necessary. The authors suggest that just as serial impedance plethysmography has been used for patients with suspected DVT, repeated ultrasonography over 10 to 14 days to look for DVT propagation would be a safe alternative [John McGoldrick, MD] to immediate venography. Editor’s Note: This paper is an example of meta-analysis: it is a study in which the subjects are other studies, and it is an objective method of combining information from the typically disparate literature into a coherent whole.
0 EXTREME I-IYPERI’YREXLA IN CHILD,HOOD: PRESENTATION SIMILAR TO HEMORRHAGIC SHOCK AND ENCEPHALOPATHY. Caspe WB, Nucci AT, Sangho
0 EVALUATIONOFCOLORIMETRICDIPSTICKTEST TO DETECT ALCOHOL IN SALIVA: A PILOT STUDY. Schwartz RI-I, O’Domiell RM, Thome MM, et al. Ann Emerg Med. 1989;18:1001-3. This study was done to determine the accuracy of a dipstick test for detection of alcohol compared to actual serum alcohol
C. Clin Pediatr. 1989;28:76-80. The authors report 5 cases of previously well children, 8 to 33 months of age, presenting with temperatures greater than 42°C (107.6 “F) over a 14year period. Hyperpyrexia of severity may cause lethal injmy itself and is rare. It has been reported in association with heatstroke, anesthesia, psychotropic agents, or trauma, but not with bacterial infection. These cases had none of these associations, and blood, stool, and spinal fluid cultures were uniformly negative. In 1983 a new syndrome of hemorrhagic shock and encephalopathy (HSES) was described in Britain with 49 young children (median age 5 months) presenting with abrupt onset encephalopathy, shock, coagulopathy, diarrhea, azotemia, metabolic acidosis, and negative cultures. Elevated temperatures were present (38.0 “C to 41.5 “C), but were not considered significant in the genesis of HSES. These 5 cases all fit the criteria for HSES, but the terminal event appears related to a sudden catastrophic rise in temperature. The authors believe a significant role of hyperpyrexia itself should be examined more carefully in this newly recognized lethal entity of young children. [Peter Pruett, MD]
0 ACCURACY OF RADIOGRAPHIC DIFFERENTIATION OF BACTERIAL FROM NONBACTERIAL PNEUMOMA. Courtoy I, Lande AB, Turner RB. Clin Pediatr.
1989;28:2614. Chest x-ray study has been considered the gold standard in the diagnosis of lower respiratory tract disease. This study investigates. the ability of 5 pediatricians (2 of whom were pediatric radiologists) to differentiate bacterial from nonbacterial pneumonia in 36 cases of culture- or antigen-proven pneumonia. ‘Ihe sensitivity of film interpretation for detection of bacterial pneumonia varied from 42% to 58%. Sensitivity improved to 42% to 92% when clinical and laboratory information was supplied to observers. The positive predictive value of the presence of bacterial pneumonia ranged 35% to 64% and