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Berman RB, Villanueva J, Margolin EJ, Balasubramanian A, Lee J, Shah O. Trends in Opioid and Nonsteroidal Anti-Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments from 2015 to 2021. J Endourol 2024; 38:458-465. [PMID: 38308477 DOI: 10.1089/end.2023.0636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.
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Affiliation(s)
- Richard B Berman
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Juliana Villanueva
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ezra J Margolin
- Department of Urology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Justin Lee
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ojas Shah
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
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Orosco E, Terai H, Lotterman S, Baker R, Friedman C, Watt A, Beaubian D, Grady J, Delgado J, Herbst MK. Point-of-care ultrasound associated with shorter length of stay than computed tomography for renal colic. Am J Emerg Med 2024; 79:167-171. [PMID: 38452429 DOI: 10.1016/j.ajem.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Despite similar diagnostic effectiveness for renal colic, computed tomography (CT) is more resource intensive than point-of-care ultrasound (PoCUS). We sought to compare Emergency Department (ED) length of stay (LOS) among patients with renal colic according to imaging modality utilized. We secondarily compared rates of infection, return ED visits, missed significant pathology, and urologic intervention. METHODS This was a 12-month (1/1/22-12/31/22) multi-site retrospective cohort study of all patients diagnosed with renal colic who presented to the ED on days when at least one patient had a billable renal PoCUS examination performed. Patients with a history of genitourinary malignancy, pregnancy, renal transplant, hemodialysis, single kidney, prior visit for renal colic in the previous 30 days, or an incomplete workup were excluded. Median ED LOS was compared using a Wilcoxon rank sum test, and the 95% confidence limits for the difference between medians was calculated. Secondary outcomes were compared using a Fisher's Exact test. RESULTS Of 415 patients screened, 325 were included for analysis: 150 had CT alone, 80 had PoCUS alone, 54 had PoCUS plus CT, and 41 had neither. Median LOS for PoCUS alone was 75.0 (95% CI 39.3-110.7) minutes shorter than CT alone (231.5 vs. 307.0 min, p < 0.0001). Similar rates of infection, return visits, and missed pathology occurred across all groups (p > 0.10). Urologic interventions were higher in the PoCUS plus CT (25.9%) group compared to CT alone (7.3%), PoCUS alone (2.5%), and neither (7.3%), p < 0.0001. CONCLUSION Among patients with renal colic, PoCUS was associated with shorter ED LOS compared to CT, without differences in infection rates, return visits, or missed pathology. Patients with PoCUS plus CT had a higher rate of urologic interventions, suggesting PoCUS may have a role in identifying patients who would most benefit from CT.
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Affiliation(s)
- Emily Orosco
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Hiromi Terai
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Seth Lotterman
- Hartford Hospital, Department of Emergency Medicine, Hartford, CT, United States of America
| | - Riley Baker
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Cade Friedman
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Aren Watt
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Drew Beaubian
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - James Grady
- University of Connecticut School of Medicine, Department of Public Health Sciences, Farmington, CT, United States of America
| | - João Delgado
- Hartford Hospital, Department of Emergency Medicine, Hartford, CT, United States of America
| | - Meghan Kelly Herbst
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America.
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Barton MF, Brower CH, Barton BL, Duggan NM, Baugh CW, Haleblian GE, Goldsmith AJ. POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation. Am J Emerg Med 2023; 74:41-48. [PMID: 37769445 DOI: 10.1016/j.ajem.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/05/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure. METHODS We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure. RESULTS Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually. CONCLUSION If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.
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Affiliation(s)
- Michael F Barton
- Department of Emergency Medicine, University of Chicago Medicine, Chicago, IL, USA.
| | - Charles H Brower
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA.
| | - Brenna L Barton
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Nicole M Duggan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - George E Haleblian
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Goldsmith
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Lee S, Park YS, Park B, Lee J, Choi JW, Kim KA, Lee CH. Usefulness of Corticomedullary-Phase CT Urography in Patients with Suspected Acute Renal Colic Visiting the Emergency Department. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:923-933. [PMID: 37559807 PMCID: PMC10407065 DOI: 10.3348/jksr.2022.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/28/2022] [Accepted: 10/02/2022] [Indexed: 08/11/2023]
Abstract
PURPOSE To evaluate the sensitivity of corticomedullary-phase imaging for detecting urinary stones in patients with renal colic who visited the emergency department. MATERIALS AND METHODS This retrospective study included 253 patients with suspected renal colic from two tertiary hospitals in South Korea, who visited the emergency department and underwent CT urography. Two radiologists blinded to the clinical history independently reviewed the corticomedullary-phase images. The sensitivity for identifying urinary stones were evaluated for each reviewer. After the initial evaluation, the images were re-evaluated based on patient history. The sensitivity of re-evaluation were recorded. RESULTS Of 253 patients, 150 (59%) had urinary stones. Among them, significant stones were observed in 138 patients (92%), and obstructive changes on CT in 124 patients (82.7%). For identifying significant urinary stones, the sensitivity was 98.6% (136/138) for both the reviewers. For identifying significant urinary stones with urinary obstruction, the sensitivity was 99.2% (123/124) for reviewer 1, and 100% (124/124) for reviewer 2. The sensitivity for identifying significant stones increased from 98.6% to 100% for reviewer 1, and from 98.6% to 99.3% for reviewer 2 in the re-evaluation session. CONCLUSION The corticomedullary-phase CT urography was sensitive for diagnosing urolithiasis in patients with acute renal colic who visited the emergency department.
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Mantica G, Carrion DM, Antón-Juanilla M, Pang KH, Parodi S, Tappero S, Rodriguez-Serrano A, Crespo-Atín V, Cansino R, Scarpa RM, Nikles S, Balzarini F, Terrone C, Gomez Rivas J, Esperto F. Impact of a delayed presentation to the emergency department for acute renal colic on biochemical and clinical outcomes. Actas Urol Esp 2023; 47:41-46. [PMID: 36503815 DOI: 10.1016/j.acuroe.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVE To verify the impact of delay on biochemical and clinical outcomes for patients presenting to the emergency department (ED) with acute renal colic. MATERIALS AND METHODS Data were retrospectively collected from three institutions of two European countries between 01 January and 30 April 2020. Patients who presented to the ED with unilateral or bilateral renal colic caused by urolithiasis confirmed by imaging tests during the study period were included. A presentation after 24 h since the onset of symptoms was considered a delay. Patients presenting before 24 h from the symptom onset were included in Group A, while the patients presenting after 24 h in Group B. Clinical and biochemical parameters and management were compared. RESULTS A total of 397 patients who presented to ED with confirmed urolithiasis were analyzed (Group A, n = 199; Group B, n = 198. The median (IQR) delay in presentation was 2 days (1,5-4). At presentation, no statistically significant differences were found amongst the two groups of patients regarding presenting symptoms such as fever and flank pain, and the median serum levels of creatinine, C reactive protein and white blood cells. No differences were found in terms of conservative or operative management. CONCLUSION Delay in consultation >24 h is not associated with worsening biochemical parameters and clinical outcomes. Most patients with acute loin pain do not necessarily need urgent attendance to the ED and may be managed in the outpatients.
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Affiliation(s)
- G Mantica
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy; European Society of Residents in Urology (ESRU), Arnhem, The Netherlands
| | - D M Carrion
- European Society of Residents in Urology (ESRU), Arnhem, The Netherlands; Department of Urology, La Paz University Hospital, Madrid, Autonomous University of Madrid, Madrid, Spain
| | - M Antón-Juanilla
- Department of Urology, Cruces University Hospital, Barakaldo, Vizcaya, Spain
| | - K H Pang
- European Society of Residents in Urology (ESRU), Arnhem, The Netherlands; Department of Oncology and Metabolism, Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - S Parodi
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy
| | - S Tappero
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy
| | - A Rodriguez-Serrano
- Department of Urology, La Paz University Hospital, Madrid, Autonomous University of Madrid, Madrid, Spain
| | - V Crespo-Atín
- Department of Urology, Cruces University Hospital, Barakaldo, Vizcaya, Spain
| | - R Cansino
- Department of Urology, La Paz University Hospital, Madrid, Autonomous University of Madrid, Madrid, Spain
| | - R M Scarpa
- Department of Urology, Campus Biomedico, University of Rome, Italy
| | - S Nikles
- European Society of Residents in Urology (ESRU), Arnhem, The Netherlands; Department of Urology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - F Balzarini
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy.
| | - C Terrone
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy
| | - J Gomez Rivas
- European Society of Residents in Urology (ESRU), Arnhem, The Netherlands; Department of Urology, Hospital Clinico San Carlos, Madrid, Spain
| | - F Esperto
- European Society of Residents in Urology (ESRU), Arnhem, The Netherlands; Department of Urology, Campus Biomedico, University of Rome, Italy
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Mantica G, Carrion D, Antón-Juanilla M, Pang K, Parodi S, Tappero S, Rodriguez-Serrano A, Crespo-Atín V, Cansino R, Scarpa R, Nikles S, Balzarini F, Terrone C, Rivas JG, Esperto F. Impacto de la presentación tardía al servicio de Urgencias por cólico renal agudo en los resultados bioquímicos y clínicos. Actas Urol Esp 2023. [DOI: 10.1016/j.acuro.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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7
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Vilson FL, Schmidt B, White L, Soerensen SJC, Ganesan C, Pao AC, Enemchukwu E, Chertow GM, Leppert JT. Removing Race from eGFR calculations: Implications for Urologic Care. Urology 2022; 162:42-48. [PMID: 33798557 PMCID: PMC10812382 DOI: 10.1016/j.urology.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/01/2021] [Accepted: 03/18/2021] [Indexed: 12/15/2022]
Abstract
Equations estimating the glomerular filtration rate are important clinical tools in detecting and managing kidney disease. Urologists extensively use these equations in clinical decision making. For example, the estimated glomerular function rate is used when considering the type of urinary diversion following cystectomy, selecting systemic chemotherapy in managing urologic cancers, and deciding the type of cross-sectional imaging in diagnosing or staging urologic conditions. However, these equations, while widely accepted, are imprecise and adjust for race which is a social, not a biologic construct. The recent killings of unarmed Black Americans in the US have amplified the discussion of racism in healthcare and has prompted institutions to reconsider the role of race in estimation of glomerular filtration rate equations and raced-based medicine. Urologist should be aware of the consequences of removing race from these equations, potential alternatives, and how these changes may affect Black patients receiving urologic care.
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Affiliation(s)
| | - Bogdana Schmidt
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Lee White
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | | | - Calyani Ganesan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Alan C Pao
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Ekene Enemchukwu
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA.
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French WW, Scales CD, Viprakasit DP, Sur RL, Friedlander DF. Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non-Index Hospitals. Urology 2022; 164:124-132. [PMID: 35093397 DOI: 10.1016/j.urology.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/27/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease. METHODS All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively. RESULTS Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non-index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p <0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode-based costs were higher in the non-index setting, with a mean difference of $783 (Non-index: $13,672, 95% CI $13,292 - $14,053; Index: $12,889, 95% CI $12,677 - $13,102; p < 0.001). CONCLUSIONS Re-presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode-related health encounters, longer time to definitive surgery, and increased costs.
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Affiliation(s)
- William W French
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
| | - Charles D Scales
- Departments of Surgery (Urology) and Population Health Science, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | - Davis P Viprakasit
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
| | - Roger L Sur
- Department of Urology, University of California San Diego Medical Center, San Diego, CA, USA.
| | - David F Friedlander
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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Bourcier JE, Gallard E, Redonnet JP, Abillard M, Billaut Q, Fauque L, Jouanolou A, Garnier D. Ultrasound at the patient's bedside for the diagnosis and prognostication of a renal colic. Ultrasound J 2021; 13:45. [PMID: 34807330 PMCID: PMC8608963 DOI: 10.1186/s13089-021-00246-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022] Open
Abstract
Background Diagnosing a ureteral colic is sometimes difficult; however, clinicians should not fail to detect a surgical emergency. This is why diagnostic strategies depend on the imaging examinations, especially ultrasound. Prior studies have investigated the accuracy of Point of Care Ultrasound (PoCUS), but there are relatively few. This study aimed to evaluate the performance of the PoCUS in the diagnosis of renal colic. The secondary objective was to evaluate the relationship between the imaging results and the treatment performed. Methods After the clinical evaluation of patients aged > 18 years with suspected ureteral colic, the Emergency Physician (EP) trained in ultrasound performed PoCUS to conclude whether a diagnosis of “renal colic” should be made. A computed tomography (CT) examination was subsequently performed, to determine whether ureteral or bladder lithiasis was present to diagnose a ureteral colic. The patient’s management was decided according to the to degree of urinary tract dilatation, presence of perinephric fluid, size, and localization of stones. Results Of the 12 Eps in our units, seven met the training criteria for the inclusion of patients. A total of 103 patients were analyzed, and the renal colic diagnosis was retained in 85 cases after the CT examination. The accuracy of PoCUS was 91% (86; 95%) for detecting urinary tract dilatation, 83% (76; 90%) for detecting perinephric fluid, and 54% (44; 64%) for detecting lithiasis. Only high urinary tract stones with ≥ 6 mm diameter were surgically managed (p < 0.01). Conversely, distal ureteral stones with a diameter of < 6 mm were managed with medical ambulatory treatment (p < 0.05). Conclusion PoCUS is a good diagnostic tool, for renal colic, and could help reduce the requirement for the CT examinations and, hence, reduce induced radiation exposure.
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Affiliation(s)
- Jean-Eudes Bourcier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France. .,Pôle Anesthésie-Réanimation-Urgences, Hôpital de Lourdes, 2 Avenue Alexandre Marqui, 65100, Lourdes, France.
| | - Emeric Gallard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Jean-Philippe Redonnet
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Morgan Abillard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Quentin Billaut
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Laura Fauque
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Anna Jouanolou
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
| | - Didier Garnier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, Lourdes, France
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10
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Innes GD, Scheuermeyer FX, McRae AD, Teichman JMH, Lane DJ. Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic. CAN J EMERG MED 2021; 23:687-695. [PMID: 34304393 DOI: 10.1007/s43678-021-00168-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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Affiliation(s)
- Grant D Innes
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joel M H Teichman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Daniel J Lane
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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11
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Schoenfeld EM, Poronsky KE, Westafer LM, DiFronzo BM, Visintainer P, Scales CD, Hess EP, Lindenauer PK. Feasibility and efficacy of a decision aid for emergency department patients with suspected ureterolithiasis: protocol for an adaptive randomized controlled trial. Trials 2021; 22:201. [PMID: 33691760 PMCID: PMC7944622 DOI: 10.1186/s13063-021-05140-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 12/23/2022] Open
Abstract
Background Approximately 2 million patients present to emergency departments in the USA annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization. Methods This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention—a decision aid (“Kidney Stone Choice”)—on patient-centered outcomes, compared with usual care. Patients age 18–55 presenting to the emergency department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization. Discussion We hypothesize that this study will demonstrate that “Kidney Stone Choice,” the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy. Trial registration ClinicalTrials.gov NCT04234035. Registered on 21 January 2020 – Retrospectively Registered Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05140-9.
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Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - Kye E Poronsky
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Lauren M Westafer
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Brianna M DiFronzo
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Paul Visintainer
- Department of Medicine, and Institute for Healthcare Delivery and Population Science Epidemiology and Biostatistics Research Core, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Charles D Scales
- Duke Clinical Research Institute and Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, TN, Memphis, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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12
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Gourlay K, Splinter G, Hayward J, Innes G. Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic? Am J Emerg Med 2021; 45:37-41. [PMID: 33647760 DOI: 10.1016/j.ajem.2021.02.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/27/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes. METHODS We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8-10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention. RESULTS We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days. CONCLUSIONS Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.
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Affiliation(s)
- Katie Gourlay
- The University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3, Canada
| | - Graeme Splinter
- The University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, 790 University Terrace Building, 8303 112 street, Edmonton T6G 2T4, Canada
| | - Grant Innes
- Departments of Emergency Medicine and Community Health Services, University of Calgary, 2500 University Drive NW, Calgary T2N 1N4, Canada.
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13
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Antonucci M, Recupero SM, Marzio V, De Dominicis M, Pinto F, Foschi N, Di Gianfrancesco L, Bassi P, Ragonese M. The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis. ACTAS UROLÓGICAS ESPAÑOLAS (ENGLISH EDITION) 2020. [PMCID: PMC7598308 DOI: 10.1016/j.acuroe.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction and objectives Patients and methods Results Conclusions
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14
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Antonucci M, Recupero SM, Marzio V, De Dominicis M, Pinto F, Foschi N, Di Gianfrancesco L, Bassi P, Ragonese M. The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis. Actas Urol Esp 2020; 44:611-616. [PMID: 32713658 PMCID: PMC7332912 DOI: 10.1016/j.acuro.2020.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/07/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES We aimed to evaluate how the corona virus disease of 2019 (COVID-19) outbreak influenced emergency department (ED) admissions for urolithiasis, hospitalizations and clinical management of the hospitalized patients. PATIENTS AND METHODS We conducted a multicentric retrospective analysis of ED admissions in three high volume urology departments (one directly involved in COVID-19 patients management and two not involved) in Rome - Italy between March and April 2020 and in the same period of 2019. Statistical analysis was conducted on the number of admissions for urolithiasis, rate of complications, hospitalization and the type of treatment received. RESULTS 304 patients were included in the analysis. A significant reduction in the global number of patients admitted to ED for urolithiasis between 2019 and 2020 (48.8%) was noted. Moreover, regarding the choice of treatment of hospitalized patients, a statistically significant increase of stone removal procedures versus urinary drainage was reported in 2020 (p = 0.015). CONCLUSIONS During the COVID-19 pandemic in Rome there has been a significant reduction of emergency admissions for urolithiasis. Patients admitted to ED had more complications, more frequently need hospitalization and regarding clinical management early stone removal was preferred over urinary drainage only. All the urologists should be aware that in the next months they could face an increased number of admissions for urolithiasis and manage more complicated cases.
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Affiliation(s)
- M Antonucci
- Departamento de Urología, Ospedale Cristo Re, Roma, Italia.
| | - S M Recupero
- Departamento de Urología, Ospedale Fatebenefratelli San Giovanni Calibita, Roma, Italia
| | - V Marzio
- Residente de Urología, Sapienza Università di Roma, Roma, Italia
| | - M De Dominicis
- Departamento de Urología, Ospedale Cristo Re, Roma, Italia
| | - F Pinto
- Departamento de Urología, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italia
| | - N Foschi
- Departamento de Urología, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italia
| | - L Di Gianfrancesco
- Departamento de Urología, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italia
| | - P Bassi
- Departamento de Urología, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italia
| | - M Ragonese
- Departamento de Urología, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italia
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15
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Rana RS, Nazim SM, Ather MH. Predicting emergency interventions in patients with acute ureteral colic using acute renal colic scoring system in a Pakistani cohort. Int Urol Nephrol 2020; 53:21-26. [PMID: 32813207 DOI: 10.1007/s11255-020-02607-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the acute renal colic score (ARC) in predicting the need of emergency intervention (EI) in patients with ureteric colic secondary to a ureteral stone. PATIENT AND METHODS In an emergency room (ER) of a university hospital, we conducted a prospective cohort study over a period of 6 months. ARC score was calculated using four parameters, i.e., serum creatinine, total white cell count (TLC), stone length and level. Primary outcome measure was EI, which was defined as the need of endourological intervention within 48 h of presentation. ARC was calculated for each patient against the two possible outcomes, i.e., EI vs. no EI. The need of intervention was based on patient-related clinical factors and the decision of the attending urologist. RESULTS The study included 132 patients. EI was performed in 85 patients (64.4%). URS was the most common intervention performed in 81 (95.3%) patients, followed by the a insertion of a double J stent in two (2.4%) patients for forniceal rupture and high TLC count and percutaneous nephrostomy in two (2.4%) patients for raised creatinine and TLC. All four variables in ARC score including serum creatinine (p < 0.001), TLC (p < 0.001), stone size (p < 0.001) and stone level (p < 0.001) were found to be significantly associated with need for EI. Using ROC the sensitivity and specificity of the score was 92.9% and 87.5%, respectively, with AUC of 0.93. CONCLUSIONS ARC score is highly sensitive and specific in determining the need of EI in patients with uncomplicated ureteric colic within 48 h of initial presentation.
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Affiliation(s)
| | - Syed M Nazim
- Aga Khan University, Stadium Road, P O Box 3500, Karachi, 75290, Pakistan
| | - M Hammad Ather
- Aga Khan University, Stadium Road, P O Box 3500, Karachi, 75290, Pakistan.
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16
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Schoenfeld EM, Houghton C, Patel PM, Merwin LW, Poronsky KP, Caroll AL, Sánchez Santana C, Breslin M, Scales CD, Lindenauer PK, Mazor KM, Hess EP. Shared Decision Making in Patients With Suspected Uncomplicated Ureterolithiasis: A Decision Aid Development Study. Acad Emerg Med 2020; 27:554-565. [PMID: 32064724 DOI: 10.1111/acem.13917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis. METHODS We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time. RESULTS From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested. CONCLUSIONS Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
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Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Connor Houghton
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Pooja M. Patel
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Leanora W. Merwin
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Kye P. Poronsky
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | | | | | - Maggie Breslin
- Design for Social Innovation Program School of Visual Arts (SVA) New York NY
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery Duke University School of Medicine Durham NC
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical Schooland the Meyers Primary Care Institute Worcester MA
| | - Erik P. Hess
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham AL
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