Imaging strategies for patients with suspicion of uncomplicated colic pain: diagnostic accuracy and management assessment.

OBJECTIVE: Compare different imaging scenarios in the diagnosis of uncomplicated renal colic due to urolithiasis (URCU). MATERIALS AND METHODS: A total of 206 prospectively included patients had been admitted with suspected URCU and had undergone abdominal plain film (APF), US and unenhanced CT after clinical STONE score evaluation. CT was the reference standard. We assessed sensitivity (Se), specificity (Spe) and Youden index for colic pain diagnosis, percentage of patients managed by urologic treatment with stone identified, percentage of alternative diagnoses (AD) and exposure to radiation, according to single imaging approaches, strategies driven by patient characteristics and conditional imaging strategies after APF and US. RESULTS: One hundred (48.5%) patients had a final diagnosis of URCU and 19 underwent urologic treatment. The conditional strategy, i.e. CT in patients who had no stone identified at US, had a perfect sensitivity and specificity. This enabled diagnosis of all stones requiring urology management while decreasing the number of CT exams by 22%. The strategy whereby CT was used when there was neither direct or indirect APF + US finding of colic pain nor alternative diagnoses in patients with a STONE score ≥ 10 had a sensitivity of 0.95 and a specificity of 0.99, identified 84% of stones managed by urologic treatment and decreased the number of CT examinations by 76%. CONCLUSION: In patients with clinical findings consistent with URCU, the use of ultrasound as first-line imaging modality, with CT restricted to patients with negative US and a STONE score ≥ 10, led to a sensitivity and specificity of above 95%, identified 84% of stones requiring urological management and reduced the number of CT scans needed by fourfold. KEY POINTS: • For diagnosis, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, provides both a sensitivity and specificity superior or equal to 95% and reduces the number of CT scans necessary by fourfold. • For management, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, maintains a 84% stone identification rate in urology-treated patients.

Childhood colic management under the optics of mothers and of the family health team.

OBJECTIVE: to unveil the interrelation of childhood colic management by mothers and Family Health Strategy professional. METHODS: a qualitative, exploratory and descriptive research carried out with 4 Family Health Strategy teams and 31 mothers who experienced childhood colic. Data collection included, respectively, focus group and individual unstructured interview. Symbolic Interactionism was adopted as the theoretical framework, and Narrative Research as methodological. RESULTS: two themes emerged: "Colic approach" and "Social support and care". Professional childhood colic management is based on diagnosis and drug interventions. For mothers, the child's suffering and impotence in the face of the disease stand out. FINAL CONSIDERATIONS: childhood colic is socially widespread because it is a physiological and self-limiting event. Mothers felt helpless in the face of childhood colic. Professionals felt the need to expand their care, with a view to achieving maternal suffering and alleviating it.

Assessment of costs and insurance policies for referral treatment of equine colic.

Colic is the most common emergency problem in horses. The aims of this study were to survey costs of different referral treatments and to review insurance policies relevant to horses with colic. Data were collected retrospectively from nine equine hospitals for case costs, categorised into four different outcomes: admitted and euthanased; euthanased during or immediately after surgery; medical treatment and survived more than 24 hours; and surgical treatment and survived more than 24 hours. Data from five UK equine insurance companies were extracted and analysed using a standardised case example. Costs were obtained for 108 cases. The mean cost for horses admitted and euthanased was £873.89 (range £459.72-£1471.51), and for surgical treatment and survival more than 24 hours was £6437.80 (range £3178.87-£9100.00). Insurance cover for veterinary fees ranged from £5000 to £7500, and monthly premium rates for a standardised case ranged from £27.06 to £47.06. The terms and conditions for the insurance policies ranged in length from 2098 to 17,701 words; Flesch Kincaid Reading Ease scores ranged from 21.6 to 57.7, indicating a high degree of complexity and low readability. This study highlights the complexity and challenges for decision-making in critical cases of colic.

Osteopathic Manipulative Treatment in Pediatric and Neonatal Patients and Disorders: Clinical Considerations and Updated Review of the Existing Literature.

Osteopathic medicine is a form of complementary and alternative medicine. Osteopathic practitioners treat patients of all ages: according to the Osteopathic International Alliance's 2012 survey, about one-third of all treated patients are aged between 31 and 50 years and nearly a quarter (23.4%) are pediatric patients, with 8.7% of them being younger than 2 years. In 2013 a systematic review evaluated the effectiveness of osteopathic manipulative treatment (OMT) in pediatric patients with different underlying disorders, but due to the paucity and low methodological quality of the primary studies the results were inconclusive. The aim of this review is therefore to update the evidence concerning OMT in perinatal and pediatric disorders and to assess its clinical impact. Most published studies favor OMT, but the generally small sample sizes in these studies cannot support ultimate conclusions about the efficacy of osteopathic therapy in pediatric age. In turn, clinical trials of OMT in premature infants might represent an important step in the osteopathic research because they can address both cost-effectiveness issues, and an innovative, multidisciplinary approach to the management of specific pediatric diseases cared for by the same, common health care system. The available studies in neonatal settings provide evidence that OMT is effective in reducing the hospital length of stay of the treated infants, therefore, suggesting that robust cost-effectiveness analyses should be included in the future clinical trials' design to establish new possible OMT-shared strategies within the health care services provided to newborns.

Prospective survey of veterinary practitioners' primary assessment of equine colic: clinical features, diagnoses, and treatment of 120 cases of large colon impaction.

BACKGROUND: Large colon impactions are a common cause of colic in the horse. There are no scientific reports on the clinical presentation, diagnostic tests and treatments used in first opinion practice for large colon impaction cases. The aim of this study was to describe the presentation, diagnostic approach and treatment at the primary assessment of horses with large colon impactions. METHODS: Data were collected prospectively from veterinary practitioners on the primary assessment of equine colic cases over a 12 month period. Inclusion criteria were a diagnosis of primary large colon impaction and positive findings on rectal examination. Data recorded for each case included history, signalment, clinical and diagnostic findings, treatment on primary assessment and final case outcome. Case outcomes were categorised into three groups: simple medical (resolved with single treatment), complicated medical (resolved with multiple medical treatments) and critical (required surgery, were euthanased or died). Univariable analysis using one-way ANOVA and Tukey's post-hoc test, Kruskal Wallis with Dunn's post-hoc test and Chi squared analysis were used to compare between different outcome categories. RESULTS: 1032 colic cases were submitted by veterinary practitioners: 120 cases met the inclusion criteria for large colon impaction. Fifty three percent of cases were categorised as simple medical, 36.6% as complicated medical, and 9.2% as critical. Most cases (42.1%) occurred during the winter. Fifty nine percent of horses had had a recent change in management, 43% of horses were not ridden, and 12.5% had a recent / current musculoskeletal injury. Mean heart rate was 43 bpm (range 26-88) and most cases showed mild signs of pain (67.5%) and reduced gut sounds (76%). Heart rate was significantly increased and gut sounds significantly decreased in critical compared to simple medical cases (p<0.05). Fifty different treatment combinations were used, with NSAIDs (93%) and oral fluids (71%) being administered most often. CONCLUSIONS: Large colon impactions typically presented with mild signs of colic; heart rate and gut sounds were the most useful parameters to distinguish between simple and critical cases at the primary assessment. The findings of seasonal incidence and associated management factors are consistent with other studies. Veterinary practitioners currently use a wide range of different treatment combinations for large colon impactions.

Colic after swimming exercise in racehorses: an investigation of incidence, management, surgical findings and outcome.

The incidence of colic following swimming exercise (SC) in a racehorse population examined over 3 years was 0.08%. Following 167,977 swims, 136 cases were reported. Colic resolved spontaneously in 2 horses, medically in 129 or surgically in 5. In a separate study, 21 horses were subject to exploratory laparotomy for SC. Findings included non-strangulating displacements in 7 horses, strangulating displacements in 7, a combination of non-strangulating and strangulating displacements in 1, prominent gaseous intestinal distension in 5 and no abnormalities in 1 horse. A poor response to analgesia prompted surgery in all cases. Rectal palpation and/or abdominal ultrasound was performed in 16 of 21 cases and abnormalities were found in 14 of these. Of the 21 surgical cases, 20 (95.2%) survived to discharge and 18 (90%) raced postoperatively.

Chiropractic claims in the English-speaking world.

BACKGROUND: Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence). METHODS: A review of 200 chiropractor websites and 9 chiropractic associations' World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment. RESULTS: We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain, CONCLUSIONS: The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

Hospital cost analysis of management of patients with renal colic in the emergency department.

Acute severe colicky pain in the flank region is termed as renal colic (RC), which is commonly diagnosed and treated in the emergency department (ED). The present study is designed to investigate the hospital costs of patients with RC admitted to the ED and factors affecting the figures. Retrospective analysis includes all patients diagnosed with RC following physical examination and X-ray, ultrasound, computed tomography together with laboratory investigations in the university-based ED between February 2007 and February 2009. The study included 574 patients eligible for the predefined criteria. Mean total hospital cost in patients admitted to the ED due to RC was calculated to be 55.77 Euro. The greatest contribution to the total cost was made by radiological investigations in the ED (40.5%) followed by treatment costs (19.7%). Size and location of the stone and stay times in the ED were the independent variables affecting the costs. The costs were higher as the stones were bigger and as they were more distal in the ureter. Renal stones were associated with the lowest hospital costs. Radiological investigations are the greatest contributors in the ED costs in patients with RC. Effective measures need to be undertaken to reduce resultant costs. Preventive measures as well as diagnostic and therapeutic procedures should be standardized in the ED in accordance with technological advances and also cost-effectiveness when appropriate.

Prevalence and management of abdominal cramping and pain: a multinational survey.

BACKGROUND: Though functional gastrointestinal complaints are recognised as being common throughout the world, there have been few comparative studies of prevalence. AIM: To compare the prevalence and management of abdominal cramping/pain in nine countries. METHODS: In a two-stage community survey, approximately 1000 subjects were interviewed in each of nine countries to establish the demographics of individuals with abdominal cramping/pain (stage 1) followed by market research-driven interviews with >or=200 sufferers per country (stage 2). RESULTS: 9042 subjects were interviewed in stage 1. Mexico (46%) and Brazil (43%) had the highest prevalence of abdominal cramping/pain; Japan the lowest (10%). Abdominal cramping/pain was more common in women (12-55%) than in men (7-38%). About 1717 subjects participated in stage 2; 65% were women and the average age at symptom onset was 29 years. The frequency of episodes differed between countries, being highest in the US (61% suffered at least once in a week). Sufferers in the US and Latin America reported a higher usage of medications (around 90%) than those in Europe (around 72%). In most countries over-the-counter drugs were principally used. Antispasmodic drugs were most popular in Latin America and Italy, antacids in Germany and the UK. Drug therapy decreased the duration of episodes (by up to 81% in Brazil). CONCLUSIONS: The community prevalence, severity, healthcare seeking and medication usage related to abdominal cramping/pain are high overall, but vary considerably between countries.

Comparison of surgical versus medical treatment of nephrosplenic entrapment of the large colon in horses: 19 cases (1992-2002).

OBJECTIVE: To compare the outcome of horses with nephrosplenic entrapment of the large colon (NSELC) treated surgically or medically by rolling, administration of phenylephrine hydrochloride (or both), and exercise. DESIGN: Retrospective study. ANIMALS: 11 medically treated horses and 8 surgically treated horses with NSELC. PROCEDURE: Medical records of horses with nephrosplenic entrapment between 1992 and 2002 were reviewed. Medically treated horses were included if diagnosis and outcome of treatment of nephrosplenic entrapment were confirmed via transrectal examination and ultrasonographic examination. Surgically treated horses were included if the diagnosis was confirmed by exploratory laparotomy. Horses in which the large colon was entrapped between the spleen and body wall were not included. RESULTS: Significant differences in mean age, heart rate, and duration of colic prior to treatment were not detected between horses treated surgically or medically. Ten medically treated horses recovered without complications, and 1 died. In the surgically treated group, 6 of 8 horses recovered without complications and 2 died. Mortality rate did not differ between treatments. Duration of hospitalization for medically treated horses was significantly shorter and the cost significantly less than for surgically treated horses. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that medical treatment of horses with NSELC via administration of phenylephrine hydro-chloride, rolling during general anesthesia, or both appears to be as effective as and less expensive than surgical treatment.

[Infantile colic--an assessment of possible risk factors]. / Tremånederskolik--en vurdering af mulige risikofaktorer.

Infantile colic is defined as crying or fussing for more than three hours a day for more than three days a week. The aetiology is unknown, although many hypotheses have been examined: allergy, type of feeding, the development of the gastrointestinal tract, the development of the central nervous system, and the mother/infant relationship. The frequency varies between 8% and 40% in industrialised countries. We found that education, parity, age, obstetric factors, and gender were not important risk factors. There are no unambiguous results on psychosocial risk factors and infantile colic. Giving parents advice and education in parenting were more effective than changing diets. Elimination of cow's milk or the diet of the mother had some effect. This review comprises studies where infantile colic is defined quantitatively. Despite this, no unambiguous results, which are consistent with a multifactorial aetiology were found.

Valoración de la seguridad, tolerancia y eficacia de la combinación de N-butil bromuro de hioscina + ibuprofeno en el tratamiento sintomático del cólico abdominal (no sugestivo de abdomen agudo) en niños de 6 a 12 años / Assessment of safety, tolerance and effectiveness of the combination of N-butil bromide of hioscine + ibuprofen in symptomatic treatment of abdominal colic (not suggestive of acute abdomen) in children from 6-12 years

El cólico abdominal en niños, es un padecimiento bastante frecuente, que se caracteriza por dolor de intensidad variable que reclama alivio inmediato y que ocasiona estado de angustia tanto en el pequeño paciente como en sus familiares. El tratamiento del dolor abdominal es generalmente sintomático, y se emplea con elevada frecuencia para su alivio los espasmolíticos y analgésicos independientemente del tratamiento etiológico que se requiera. El presente estudio se desarrolló para evaluar la tolerabilidad y eficacia de la combinación de Buscapina + Ibuprofén en suspensión administrada vía oral, en niños con cólico abdominal. Fueron incluidos 69 pacientes de ambos sexos entre los 6 y 12 años de edad procedentes de la consulta externa con diagnóstico de cólico abdominal. Todos los pacientes recibieron como medicación de estudio N-butil bromuro de hioscina (5mg/5ml) + Ibuprofeno (100 mg/5ml) en suspensión oral. El esquema de dosificación fue de 1,5 ml/kg/día, divididos en 3 tomas. El medicamento se administró durante tres días consecutivos. Se consideró un analgésico alternativo o de rescate (clorhidrato de pargeverina) en caso de que el dolor persistiera. La valoración de la eficacia y tolerancia fue evaluada empleando la escala visual análoga (EVA). Los resultados demostraron que la combinación de Buscapina + Ibuprofeno fue efectiva en el 95 por ciento de los pacientes, y solo 3 pacientes requirieron medicación de rescate. Mientras que la tolerancia fue muy satisfactoria alcanzando valores en la EVA superiores a 8,5 puntos. No se reportaron efectos adversos durante el estudio. Se puede concluir que la combinación de Buscapina + Ibuprofeno, es eficaz, bien tolerada y segura en pacientes pediátricos que cursan con cólico abdominal.

Emergency intravenous pyelography in the setting of possible renal colic: is it indicated?

STUDY OBJECTIVE: To determine whether emergency IV pyelography (IVP) adds significant information to clinical judgment in the setting of possible renal colic. DESIGN: A prospective voluntary survey of a convenience sample of physicians at the time of patient encounter. SETTING: The emergency department of a university hospital, annual census 50,000 visits. PARTICIPANTS: Emergency medicine faculty physicians. INTERVENTION: Physicians were surveyed before and after IVP was performed on patients with possible renal colic. RESULTS: Over the course of 12 months, 62 patients with possible kidney stones were evaluated by 14 different faculty ED physicians, who filled out surveys. Before IVP results were obtained, 63% of patients were thought to have a high (more than 75%) probability of ureteral obstruction. In 59% of these patients, the IVP results showed ureteral obstruction. The IVP revealed unexpected findings in 42% of all patients, including normal results in 19%, ureteral stones in 5%, higher than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 5%. Management was reported to have been changed in 60% of all patients for a wide variety of reasons, but consideration of alternative diagnosis was the most common reason, occurring in 23%. Management changes included unexpected hospital admission in five patients (9%) and emergency urologic consultation in five patients (9%). CONCLUSION: Emergency IVPs are useful in the evaluation of patients with suspected renal colic, primarily when they rule out ureteral obstruction and allow consideration of alternative diagnoses. Not uncommonly, emergency urologic consultation or hospitalization occurs on the basis of IVP findings.

[Infants who cry a lot: incidence and management of this problem in family practice]. / Zuigelingen die vaak huilen: frequentie en aanpak van dit probleem in de huisartspraktijk.

OBJECTIVE: To determine how frequently general practitioners (GPs) are consulted because of excessively crying infants and how such infants are managed. SETTING: A stratified sample of 103 GP practices throughout The Netherlands. DESIGN: Descriptive. METHOD: 161 GPs from 103 practices for one year (in four groups, each for three months) recorded all their contacts with patients as a part of the National Study of Diseases and Items of Service in General Practice, conducted by the Netherlands Institute for Primary Health Care Research. An inventory was made of the infants who fulfilled the criteria of the 'colic syndrome' as to age, symptomatology and diagnosis. RESULTS: Of the infants seen by the GPs, 10% displayed symptoms of excessive crying, colic or restlessness. In over one-third of this group a colic-like diagnosis was made; of the children from zero to four months this proportion was two-thirds. The probability of a child in the age group of 0 to 4 months being seen by the GP with colic-like symptoms and diagnosis amounted to 7.1% (cumulative incidence). The majority of the GPs were certain of their (mostly somatic) diagnoses. The GPs were consulted more often about these children, apart from the colic problem, than about their contemporaries, the difference being statistically significant. In only 30% of the cases did the GPs prescribe medication or a diet, or made a referral.

Randomised controlled trial of cost-effectiveness of lithotripsy and open cholecystectomy as treatments for gallbladder stones.

Inpatient extracorporeal shockwave lithotripsy for treatment of gallbladder stones has not previously been compared with open cholecystectomy in terms of cost-effectiveness. In a randomised controlled trial, 163 patients, stratified by gallstone bulk (over 4 cm3 or not), were randomised to lithotripsy or cholecystectomy (38 large-bulk and 27 small-bulk cholecystectomy; 37 large-bulk and 61 small-bulk lithotripsy) and followed up for 1 year. Both treatments gave significant health gains in terms of a reduction in episodes of biliary pain, improved perceived health status, and symptom relief, but few differences between treatments were found. There was some evidence that biliary-pain episodes were less severe after cholecystectomy. Cholecystectomy patients also had greater improvements in mean health gain for three related symptoms: vomiting, feeling sick, and fatty-food upset. However, there were no differences between groups in perceived health status. Among lithotripsy patients, health gain was not related to stone clearance. Lithotripsy was more expensive than cholecystectomy, principally because of the costs of the inpatient stay and adjuvant bile-salt therapy. Conventional lithotripsy appears at least as cost-effective as cholecystectomy for patients with small-bulk stones but less cost-effective for those with large-bulk stones. To some extent treatment choice can be guided by patient preference.