Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Nifedipine in the management of ureteric stone
- Madhur D Bhattarai (11 June 2004)
-
How could I trust this clinical review ?
- Axel Ellrodt (12 June 2004)
-
Reply to Dr. Bhattarai's comments
- Malvinder S. Parmar (12 June 2004)
-
Cool Down! Dr. Ellrodt
- Malvinder S. Parmar (13 June 2004)
-
Whither spasmolytics?
- Adarsh Mehta (13 June 2004)
-
Renal colic and circadian rhythms.
- Roberto Manfredini, Benedetta Boari, Raffaella Salmi, and Massimo Gallerani (14 June 2004)
-
I.V.U's
- jill E Trevithick (15 June 2004)
-
Augmented Bladders & Stones
- Ian E Willetts (16 June 2004)
-
(Now cold) I apologise, Dr Parmar and BMJ
- Axel Ellrodt (20 June 2004)
-
Author's response to RRs [rapid responses] from June 12-16.
- Malvinder S. Parmar (20 June 2004)
|
|
|||
|
Madhur D Bhattarai, Sr. Consultant Physician Bir Hospital, Post Box: 3245, Kathmandu, Nepal
Send response to journal:
|
Editor -- Parmar (1) has rightly summarized that conservative management is preferred for ureteric stones. But ureteroscopic stone extraction, various forms of lithotripsy, with or without ureteral stent and even invasive surgeries like pyelolithotomy and ureterolithotomy are frequently done, including in developing countries. I had noticed a possible beneficial effect of nifedipine in the passage of a ureteric stone 9 X 10 mm in size (2). Nifedipine has smooth muscle relaxant effect throughout the body as seen by its usefulness in angina, hypertension, Raynaud’s phenomenon, pulmonary hypertension, esophageal motility disorders like achalasia and preterm labour. Thus, in this background, I would like to add that the beneficial effect of nifedipine in the management of the ureteric stones, particularly before submitting the patients to any invasive interventions, also deserves scientific investigation by well-equipped centres. References 1. Parmar MS. Kidney stones. BMJ 2004; 328: 1420-1424. 2. Bhattarai MD. Use of nifedipine in the management of ureteric stones. Case Rep Clin Prac Rev 2003; 4(4): 291-293. Competing interests: None declared |
|||
|
|
|||
|
Axel Ellrodt, Emergency dept, American Hospital of Paris, France France 92202
Send response to journal:
|
I am angry. Isn't it strange that the management of renal colic advocated in this review disregards the "Use NSAIDs for renal colic" title (1) in the same BMJ issue, and the metaanalysis (2) also included in that very issue ? Maybe the author considers NSAIDs as analgesics among others, but the message that has to be conveyed is that of the NSAID treament of renal colic. Desmopressin maybe an elegant treatment, but renal colic has been relieved on a more that daily basis at home, at the office and in the emergency department by the use of NSAIDs in many countries for decades. And not even a word on "the" diagnostic pitfall of the leaking aortic aneurysm that any decent emergency medicine book emphasizes. As this chapter of the review fails to reach the quality expected in my dear BMJ, I have serious doubts about the quality of its other chapters. This is a pity since those were the chapters I wanted to rely on for an update on urolithiasis. And why should they be more seriously written than the "emergency aspect" that I am familiar with ? For once, the review and its reviewing process by the BMJ are disappointing 1-http://bmj.bmjjournals.com/cgi/content/full/328/7453/0 2- http://bmj.bmjjournals.com/cgi/content/full/bmj;328/7453/1401 Competing interests: None declared |
|||
|
|
|||
|
Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
Send response to journal:
|
I thank Dr. Bhattarai for sharing his experience about the use of nifedipine in the management of ureteric colic. Nifedipine - a calcium channel blocker, by relaxing ureteral muscles, is found to be helpful in the management of acute ureteric colic [1] and is mentioned in this review on page 1423. In this study [1], a cocktail containing nifedipine and other agents [prednisone, acetaminophen and antibiotics] were added to conventional therapy [non-steroidal anti-inflammatory agents and opiates] and the cocktail was found to more effective than conventional therapy, and resulted in increased passage of stone rates; less lost work days, emergency room visits and surgical interventions with similar side effect profile. Whether addition of nifedipine alone would be as effective as this cocktail, is not clear, and I agree requires further investigation. References: 1. Cooper JT, Stack GM, Cooper TP. Intensive management of ureteral calculi. Urology 2000; 56:575-578. Competing interests: None declared |
|||
|
|
|||
|
Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
Send response to journal:
|
I thank Dr. Ellrodt for his comments and slanderous remarks. Dr. Ellrodt, you have opened a pandora box by making such a statement that in fact was discussed recently in ‘Joy of rapid responses[1].’ Let’s change this negative energy to positive one. First of all, I suggest that you cool down and review the paper again and then you would realize that what you want to say is already mentioned in the paper. We all make mistakes and at times a short statement goes unnoticed. There is no need to be angry as someone has said, “Every minute you are angry, you loose sixty seconds of happiness.” You mentioned that non-steroidal anti-inflammatory agents have been used for decades in the management of acute ureteric colic and I agree with that and that is, in fact, what constitutes "conventional treatment" and is already mentioned in this review [2]. It is understood that the "conventional treatment" includes use of non-steroidal inflammatory agents and opiates in the management of acute ureteric colic. I should clarify that this is not a review on the management strategies of acute ureteric colic; instead is focused on the causes and prevention of recurrent kidney stones. The topic by itself is a large topic and when one is trying to cover a vast topic and trying to maintain a balance, one may at times unintentionally miss highlighting important fact(s). I am sorry and accept responsibility if you feel that I fail to highlight the use of anti-inflammatory agents that I felt was covered when using the term "conventional treatment." This is the positive impact of ‘rapid responses’ that I like and enjoy[1]. In fact, in my first version of the paper, I included a table [see below] containing the cocktail [3] that included various agents helpful in the management of acute ureteric colic. However, this table was deleted at the suggestion of the reviewer(s) and later to meet the space and table requirements of the journal. Cocktail for acute renal colic (reference [3]) Extended release nifedipine 30 mg a day for 7 days Prednisone 20 mg twice a day for 5 days Trimethoprim/sulphamethoxazole 160mg/800mg once daily for 7 days Acetaminophen 325 mg every 6 hours for 7 days Toradol 10 mg every 6-hours for 5 days Oxycodone/acetaminophen as required for breakthrough pain Prochlorperazine 25 mg as required - for nausea In response to you comments about the diagnostic pitfall of leaking aortic aneurysm I agree with you that this diagnosis should be considered in a patient presenting with acute abdomen. Again as stated above that this was not a review on the management of acute ureteric colic and the differential diagnosis of acute ureteric colic was specifically not included and the focus was more so on the prevention and management of kidney stones in general. Your point is well taken! In the end, it is atimes importan to know the history of paper and I submitted my paper in late December 2003 and the Cochrane review [4] was not published then and interestingly both papers [2,5] were accepted on the same date and I was not aware of the metanalysis until its publication. References: 1. Parmar MS, Vasenwala M, Colquitt PJ, Wharfield L. Joy of rapid responses. BMJ 2004; 328(7440):644-5. 2. Parmar MS. Kidney stones. BMJ 2004; 328(7453):1420-24 3. Cooper JT, Stack GM, Cooper TP. Intensive management of ureteral calculi. Urology 2000; 56:575-578. 4. Holdgate A, Pollock T. Non-steroidal anti-inflammatory drugs versus opioids for acute renal colic. Cochrane Database Sys Rev 2004;(1):CD004137 5. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ, doi:10.1136/bmj.38119.581991.55 (published 3 June 2004) Competing interests: None declared |
|||
|
|
|||
|
Adarsh Mehta, Assciate Professor (Surgery) Mumbai 400005
Send response to journal:
|
Nifedipine relaxes the ureteral smooth muscle. Would'nt the resultant lack of peristalsis hinder the ureteral calculus to be pushed downwards and thus allow the colic to be relieved. To my mind, the appropriate treatment would be a non-spasmolytic NSAID. Competing interests: None declared |
|||
|
|
|||
|
Roberto Manfredini, Assistant professor of Internal Medicine Internal Medicine, Gerontology and Geriatrics; University of Ferrara, Italy., Benedetta Boari, Raffaella Salmi, and Massimo Gallerani
Send response to journal:
|
We appreciated the exhaustive clinical review by dr Parmar (1). Although the existence of a seasonal variation has been reported, no mention was made on the circadian aspects of renal colic. Acute renal colic, in fact, shows a circadian pattern in occurrence, with an early morning peak and a minimum in the afternoon (2). The renal system is organized according to a specific temporal order, that is oscillatory in nature. Most renal functions, eg, glomerular filtration rate (GFR), urine production, and renal excretion of solutes, show temporal variations with higher values during daytime and lower ones at night (3). Circadian changes are not negligible, since GFR day-night variation in amplitude is 33% (4). Low urinary volume increases urinary supersaturation (1), a risk factor for nephrolithiasis, and night and early morning hours are characterized by a higher lithogenic risk, at least for calcium oxalate stones (5). An easy measure for prevention of recurrent stone formation is increasing fluid intake. Thus, contrary to normal habits, fluid intake should be particularly increased in the evening and prior to bedtime, with the exclusion of those conditions, eg, congestive heart failure and hypertension, in which volume increase is harmful. 1) Parmar MS. Kidney stones. Br Med J 2004;328:14020-4. 2) Manfredini R, Gallerani M, la Cecilia O, Boari B, Fersini C, Portaluppi F. Circadian pattern in occurrence of renal colic in an emergency department: analysis of patients’ notes. Br Med J 2002;324;767. 3) Cambar J, Cal JC, Tranchot J. Renal excretion: rhythms in physiology and pathology. In: Touitou Y, Haus E, eds. Biologic Rhythm in Clinical and Laboratory Medicine, Berlin, Germany: Springer Verlag;1992:470-82. 4) Koopman MG, Koomen GC, Krediet RT, de Moor EA, Hoek FJ, Arisz L. Circadian rhythm of glomerular filtration rate in normal individuals. Clin Sci 1989;77:105-11. 5) Robert M, Roux JO, Bourelly F, Boularan AM, Guiter J, Monnier L. Circadian variations in the risk of urinary calcium oxalate stone formation. Br J Urol 1994;74:294-7. Competing interests: None declared |
|||
|
|
|||
|
jill E Trevithick, GP stockton heath medical centre, Warrington, WA4 6HJ
Send response to journal:
|
What about I.V.U's ( intravenous urography) in the management of acute renal colic,is it not indicated in everybody to exclude acute obstruction? Competing interests: None declared |
|||
|
|
|||
|
Ian E Willetts, Consultant Paediatric Surgeon John Radcliffe Hospital, Oxford, UK, OX3 9DU
Send response to journal:
|
Just to correct an omission from the paper. We manage a large number of children who undergo bladder augmentation procedures for various pathologies. Subsequently a number develop bladder calculi probably secondary to stasis and mucous production by the augment bowel segment. These children are now becoming adults. An awareness of this diagnostic possibility in the previously augmented child is necessary. Mr I E Willetts BSc, DM, FRCS(Paed Surg) Competing interests: None declared |
|||
|
|
|||
|
Axel Ellrodt, Emergency Dpt American Hospital of Paris Neuilly sur Seine 92202
Send response to journal:
|
Thank you for this detailed reply. I agree my e-letter was close to offensive both to Dr Parmar and the BMJ and I'd like to markedly soften its tone. It is unfortunately too late, and as you stated, why lose 60 seconds of happiness in an unnecessary anger? I think some emphasis should have been given to NSAID treatment, but 1- I understand why you did not; 2- The scope of the review was too wide to allow for that ; 3- there is a misunderstanding about "conventional" treatment. I do see many patients with renal colic who never received NSAIDs for their previous episodes. This is why my feeling is that "conventional" treatment may not be the same for all. Conversely, for some physicians and sometimes authorities, conventional treatment has for long excluded opiates, in fear of masking another diagnosis, or leading to addiction. Thanks again and I will end with a question I feel too lazy to try and answer through a literature screen (well, I tried but gave up early): do you know what in the pain of renal colic pertains to cavity distension on the one hand and ureteral spasms, if any, on the other hand ? After all, your answer might help me catch up the minute of "anger" I wasted. Competing interests: None declared |
|||
|
|
|||
|
Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
Send response to journal:
|
I thank Drs. Mehta, Manfredini et al, Trevithick, and Willetts for their comments. Dr Mehta raise an interesting but theoretical concern regarding the use of nifedipine in the treatment of acute ureteric colic. Calcium channel blockers (e.g. nifedipine) selectively inhibits the quick phasic contractions [present during hyperstimulation] without influencing the tonic [baseline] activity of the ureter.[1] . Therefore, nifedipine by relaxing smooth muscles relieves the pain but doesn’t appear to inhibit the ‘normal’ peristalsis. However, nifedipine alone was not found to be better than placebo in relieving the pain of acute ureteric colic. [2] I agree with Manfredini and colleagues about the circadian variation in the incidence of acute renal colic, however, this review was on kidney stones in general and circadian changes, I agree affect the incidence of acute renal colic or crystalluria but not the incidence of kidney stones, as stones takes weeks to months to develop. This circadian variation is more so dependent on the human nature of poor oral intake during fasting states – sleeping hours. I am not sure if we should classify it as a ‘real circadian variation’ – as this pattern is affected by more so external than internal factors. Academics aside, I agree that increasing fluid intake, especially during fasting states [sleeping hours (night for day time workers and day for night time workers)] is important to prevent urinary concentration of solutes to prevent supersaturation and recurrent stone formation. In response to Dr. Trevithick’s question about the role of intravenous pyelography - Although intravenous pyelography or urography has been considered the standard for many years, non-contrast helical CT scanning has replaced it and has significant advantages in the setting of acute renal colic. Helical CT scans can be performed rapidly, without the use of intravenous contrast [no risk of reaction to contrast agent], has high accuracy for stone disease [99%], can confirm or exclude obstruction and can identify other causes of acute abdomen masquerading as renal colic. I welcome Dr. Willetts addition to the list of anatomical abnormalities that may predispose to urinary tract stone formation. This is another example of a positive impact of rapid response(s). References: 1. Hannappel J, Rohrmann D, Lutzeyer W. [Pharmacologic modification of ureteral activity] Urologe A. 1986 Sep;25(5):246-51. 2. Caravati EM, Runge JW, Bossart PJ, Martinez JC, Hartsell SC, Williamson SG. Nifedipine for the relief of renal colic: a double-blind, placebo- controlled clinical trial. Ann Emerg Med. 1989 Apr;18(4):352-4. Competing interests: None declared |
|||