Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones.

INTRODUCTION: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number. METHODS: This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results. RESULTS: 125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2-85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82-98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65-86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63-100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria. CONCLUSION: In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

Painful ophthalmoplegia of the right eye in a 20-year-old man.

BACKGROUND: Painful ophthalmoplegia is an infrequent but very important presentation in the acute care setting and requires a thorough neurologic evaluation to determine its cause. This clinical sign has a large differential and generally indicates a serious cerebrovascular process. CASE REPORT: We describe a patient with a subacute presentation of painful ophthalmoplegia, ultimately diagnosed as Tolosa-Hunt syndrome, a rare inflammatory process of the cavernous sinus. CONCLUSION: This case highlights the importance for the Emergency Physician to quickly recognize painful ophthalmoplegia and rapidly elucidate the cause to prevent further complications for the patient.

Chorionic villus sampling and risk for hypertensive disorders of pregnancy.

OBJECTIVE: This study was undertaken to evaluate the relationship between chorionic villus sampling at 10-13 weeks' gestational age and hypertensive disorders of pregnancy. STUDY DESIGN: The prevalence of hypertensive disorders of pregnancy in women with singleton gestations, undergoing transcervical or transabdominal chorionic villus sampling between 10 weeks 0 days' and 13 weeks 6 days' gestational age was compared with that of control women with singleton gestations having first-trimester screening with nuchal translucency and biochemistry between 11 weeks 0 days' and 13 weeks 6 days' gestational age. Patients having invasive prenatal diagnosis (chorionic villus sampling or amniocentesis) were excluded from the control group. All patients delivered at Cedars-Sinai Medical Center. RESULTS: There were 1540 women who had chorionic villus sampling and 840 controls. Hypertensive disorders of pregnancy were diagnosed in 76 (4.9%) patients in the chorionic villus sampling group and in 37 (4.4%) of the controls (chi2 = 0.34, P = .31). CONCLUSION: Chorionic villus sampling at 10 to 13 weeks' gestational age does not appear to increase the overall risk for hypertensive disorders of pregnancy. However, there appears to be an association between chorionic villus sampling and severe hypertensive disorders including severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome.