ABSTRACTS

evaluation." The latter consists of a 24-hour urinalysis performed after a week of dietary restriction of calcium, oxalate, sodium, and pufine, with a subsequent calcium load test. The authors conclude that there was no sig- nificant difference in sensitivity between the strategies. However, they argue that if the patients with a diagnosis of low urine volume (the most common diagnosis) are excluded, then the comprehensive evalua- tion is significantly more sensitive than a single urinalysis (but not significantly more sensitive than the 2 serial urinalyses). They conclude by arguing that despite the appar- ent lack of a significantly higher sensitivity, a comprehensive evaluation should be per- formed on all patients with recurrent kidney stones.

[Editor's note: This article offers little with respect to emergency department manage- ment of patients with recurrent stones other than to find out if a patient has had any form of workup, as this might direct follow-up to urology rather than a primary care physician. The authors also do not de fine "recurrent stone former, " so it is unclear who should fol- Iow up at a "stone clinic. " The analysis was performed on patients being seen in a refer- ral center, a group more likely to have a sig- nificant disorder than the average EO patient who has had 1 or2 episodes of stones in the past.]

Eric Bryant, MD

Follow-up imaging studies in children with splenic injuries

Shaft S, Gilbert JC, Irish MS, et al Clin Pediatr 38.273-277 May 1999

Pediatric patients with splenic injuries typi- cally undergo serial computed tomography (CT) scans, with recommended intervals varying widely. This retrospective chart and radiograph review examines whether serial CT scans actually affect outcome in patients who are being managed nonoperatively, it is argued that the role of seriat scans is to look for worsening injury or increasing free fluid, to rule out possible missed injuries or delayed ruptures, and to assess healing

with respect to resuming normal activity. In this review of 72 children, the median num- ber of scans was 3, occurring on average on days 12, 54, and 99. Only one child subse- quently underwent splenectomy. The authors point out that this was for clinical reasons, not radiographic changes. They also found that parenchymal healing was only seen in 31 (42%) of the children at a median time of 57 days. In conclusion, they argue that serial scans did not change the management of any patient, and that serial scanning does not need to be part of the rou- tine management of all patients with splenic injuries who are managed nonopera- tively.

[Editor's note: This small study makes a compelling argument that more is not neces- sarily better, and that the routine use of serial CTscans in pediatric patients with splenic injury is unnecessary and costly. A larger study would be necessary to confirm these findings if there is to be a widespread change in current practices. Although this would not affect initial emergency depart- ment evaluation of these patients, such a change could benefit the entire system in terms of cost and resource utilization.]

Eric Bryant, MD

Pulmonary contusions: Quantifying the lesions on chest x-ray films and the factors affecting prognosis

Tyburski JG, Collinge JD, Wilson RE et al J Trauma 46:833-838 May 1999

This retrospective chart and radiograph review describes a scoring system for quan- tifying pulmonary contusions based on chest radiograph (CXR)findings. The authors assess this pulmonary contusion score (PCS) and its changes within the first 24 hours along with several other parameters to see how they correlate with the need for ventila- tory assistance and mortality. The PCS is derived by dividing the image of each lung into thirds and giving each a score of 0 to 3 from no opacification to completely opaci- fled, thus yielding a total score of 0 (no con- tusion) to 18 (complete involvement of both

lungs). The article also focuses on a value called the PFR, which the authors do not define in the text, nor describe, but which appears to refer to the ratio of Pao 2 to Fie 2. The authors found that the PCS does not cor- relate significantly to mortality, but that high score (>lg categorized as "very severe") does correlate significantly with the need for ventilatory assistance. They also point out that lower PFFIs correlate sig- nificantly with both ventilatory support and mortality.

[Editor's note: The PCS could be a useful shorthand for describing pulmonary contu- sions, but it does not seem much more con- venient than simply describing the CXR findings. It would be interesting to see how much agreement there would be between different reviewers in applying the score. It seems intuitive that more involvement of a lung, or particularly involvement of both lungs would bode poorly. Similarly, it seems intuitive that patients who are difficult to oxygenate (Iow PFR) would need more sup- port and would have higher mortality, This article suffers from trying to compare too many factors without controlling for many other variables (associated injuries to the head or abdomen, age, comorbid condi- tions). Finally, it would ha ve benefited from more editorial attention to detail.]

Eric Bryant, MD

Admission risk assessment by cardiac troponin T in unstable coronary artery disease: Additional prog- nostic information from continuous ST segment monitoring

Norgaard BL, Andersen K, De//borg M, et al J Am Coil Cardiol 33.1519-1527 May 1999

This study sought to determine whether the addition of cardiac monitoring to measure- ments of cardiac troponin T (cTnT) could improve risk stratification of patients with unstable coronary artery disease (U CAD). Patients between the ages of 25 and 80 years who had new-onset ischemic chest

5 7 0 ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 1