External validation of the CHOKAI score for the prediction of ureteral stones: A multicenter prospective observational study

Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location

BACKGROUND

The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates.

PURPOSE

To identify predictors of revisits among patients with ureteral calculi in the ED.

DESIGN, SETTING, AND PARTICIPANTS

Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit.

RESULTS

Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021).

CONCLUSIONS

Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

CT Use Reduction In Ostensive Ureteral Stone (CURIOUS)

INTRODUCTION

Computed tomography (CT) is performed in over 90% of patients diagnosed with ureteral stones, but only 10% of patients presenting to the emergency department (ED) with acute flank pain are hospitalized for a clinically important stone or non-stone diagnosis. Hydronephrosis can be accurately detected using point-of-care ultrasound and is a key predictor of ureteral stone and risk of subsequent complications. The absence of hydronephrosis is insufficient to exclude a stone. We created a sensitive clinical decision rule to predict clinically important ureteral stones. We hypothesized that this rule could identify patients at low risk for this outcome.

METHODS

We conducted a retrospective cohort study in a random sample of 4000 adults who presented to one of 21 Kaiser Permanente Northern California EDs and underwent a CT for suspected ureteral stone from 1/1/2016 to 12/31/2020. The primary outcome was clinically important stone, defined as stone resulting in hospitalization or urologic procedure within 60 days. We used recursive partition analysis to generate a clinical decision rule predicting the outcome. We estimated the C-statistic (area under the curve), plotted the receiver operating characteristic (ROC) curve for the model, and calculated sensitivity, specificity, and predictive values of the model based on a risk threshold of 2%.

RESULTS

Among 4000 patients, 354 (8.9%) had a clinically important stone. Our partition model resulted in four terminal nodes with risks ranging from 0.4% to 21.8%. The area under the ROC curve was 0.81 (95% CI 0.80, 0.83). Using a 2% risk cut point, a clinical decision tree including hydronephrosis, hematuria, and a history of prior stones predicted complicated stones with sensitivity 95.5% (95% CI 92.8%-97.4%), specificity 59.9% (95% CI 58.3%-61.5%), positive predictive value 18.8% (95% CI 18.1%-19.5%), and negative predictive value 99.3% (95% CI 98.8%-99.6%).

CONCLUSIONS

Application of this clinical decision rule to imaging decisions would have led to 63% fewer CT scans with a miss rate of 0.4%. A limitation was the application of our decision rule only to patients who underwent CT for suspected ureteral stone. Thus, this rule would not apply to patients who were thought to have ureteral colic but did not receive a CT because ultrasound or history were sufficient for diagnosis. These results could inform future prospective validation studies.

The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments

INTRODUCTION

The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs.

METHODS

All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated.

RESULTS

NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3 mg/L, and 1 mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95 mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95 mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%.

CONCLUSIONS

WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting.

A systematic review and meta-analysis of clinical signs, symptoms, and imaging findings in patients with suspected renal colic

Study Objective

The objective of this study was to conduct a systematic review and meta-analysis of the diagnostic accuracy of the clinical signs, symptoms, laboratory investigations, and imaging modalities commonly used in patients with clinically suspected renal colic.

Methods

We conducted this systematic review and meta-analysis according to an a priori, registered protocol (PROSPERO CRD42017055153). A literature search was performed using MEDLINE and EMBASE from inception to July 2, 2020. We assessed the risk of bias using Quality Assessment of Diagnostic Accuracy Studies-2, calculated likelihood ratios (LRs), and applied a random-effects model for meta-analysis.

Results

Among 7641 references screened, 76 were included in the systematic review and 53 were included in the meta-analyis. The overall pooled prevalence for ureteral stones was 63% (95% confidence interval [CI], 58%-67%). No individual demographic feature, symptom, or sign when present had an LR+ ≥2.0 for identifying ureterolithiasis. A (Sex, Timing and Origin of pain, race, presence or absence of Nausea, and Erythrocytes) STONE score ≥10 increased (sensitivity 0.49, specificity 0.91, LR 5.3 [95% CI, 4.1-6.7]) and a STONE score <6 reduced the likelihood of ureteral stones (sensitivity 0.94, specificity 0.43, LR 0.15 [95% CI, 0.10-0.22]). Standard-dose (sensitivity 0.96, specificity 0.94, LR+ 16 [95% CI, 11-23], LR- 0.05 [95% CI, 0.03-0.07]) and low-dose computed tomography (CT) scanning (sensitivity 0.93, specificity 0.94, LR+ 17 [95% CI, 8.8-31], LR- 0.08 [95% CI, 0.03-0.19]) were the most useful imaging techniques for identifying patients with or without ureteral stones.

Conclusions

Individual signs, symptoms, or the presence of microscopic hematuria do not substantially impact the likelihood of ureteral stones in patients with clinically suspected renal colic. The STONE score at high and low thresholds and a modified STONE score at a high threshold may sufficiently guide physicians' decisions to obtain imaging. Low-dose, non-contrast CT imaging provides superior diagnostic accuracy compared with all other imaging index tests that are comparable with standard CT imaging. Limitations of the evidence include methodological shortcomings and considerable heterogeneity of the included studies.

Investigation of the CHOKAI score used to predict ureteral stones in patients presenting to the emergency department with renal colic

Aim: To investigate the adequacy of the CHOKAI score in the prediction of ureteral stones in patients presenting to the emergency department with renal colic. Material and Method: The data of all patients aged over 18 years, who presented to the emergency department with the complaint of renal colic and were diagnosed with ureteral stones during the study period were retrospectively analyzed using the electronic-based hospital information system. The area under the receiver operating characteristic curve and the area under the curve were used to assess for each patient to determine the cut-off value of the CHOKAI score in the prediction of ureteral stones. Results: The study was completed with 219 patients, of whom 146 were men, and the mean age was 39.4±16.1 years. When the cut-off value of the CHOKAI score was >6, its sensitivity was 84.1%, specificity was 96.7%, positive likelihood ratio was 25.2, negative likelihood ratio was 0.2, positive predictive value was 99.4%, and negative predictive value was 49.2%. Conclusion: In this study, it was concluded that the CHOKAI score had high accuracy in terms of diagnostic power in detecting ureteral stones. However, further studies are needed to demonstrate the broader applicability of the score.

The Use of Visual Analogue Scale Score as a Predicting Tool in Differentiating Renal Colic From Lumbar Back Pain

Introduction

Renal colic is often confused with low back pain (LBP) and other pathologies. Computed tomography (CT) is frequently used to reach a definitive diagnosis, but its use increases the exposure to radiation. Researchers have tried to predict urinary stones in patients presenting with flank pain. Several scoring systems have been introduced; however, none of them provide a prediction based on the physical examination of the patient upon initial presentation to the outpatient clinic. In this study, we aimed to investigate whether we can predict the presence of stone with visual analogue scale (VAS) questionnaire during the first admission.

Materials and methods

Patients with complaints of flank pain were started to be followed for three months in our urology clinic. After the definitive diagnosis was made the patients were classified into two groups: renal colic group (group 1; n=36) and the LBP group (group 2; n=30).

Results

In logistic regression analysis, the possibility of renal colic increased 5.4 times more per one-unit increase in the VAS score. In receiver operating characteristic (ROC) analyses, when the VAS was 4.5, the diagnosis of renal colic could be made with 88% sensitivity and 71% specificity.

Conclusion

If the VAS score is ≤ 4 in patients that have flank pain without limitation of movement, it is more likely to manage these patients with a simple medical treatment plan. In these patients, unnecessary ultrasonography (US) scans be reduced by 86.3% and unnecessary CT scans by 88.8%. A VAS score of ≥5 should warn the clinician about the necessity of routine urinary stone examinations.

The prospective evaluation of the effectiveness of scoring systems in the emergency department in cases with suspected ureteral stones: STONE? CHOKAI?

INTRODUCTION

This study evaluates the effectiveness of CHOKAI and STONE scores in patients presenting to the emergency department with ureteral stones.

METHODS

Patients over the age of 18 who were admitted to the emergency department with flank pain, groin pain, scrotal pain, and hematuria and who were performed non-contrast abdominal computed tomography (CT) for diagnostic imaging were included. The numeric pain, CHOKAI, and STONE scores of the patients were calculated. The effectiveness of these scoring systems in the presence of stones was examined.

RESULTS

A total of 105 patients were included in the study. In the analysis performed to investigate whether there was a difference between the numeric pain, STONE, and CHOKAI scores in terms of the presence of stones on CT, it was seen that the CHOKAI score was significantly different from the others (p < 0.001). A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).When the cut-off value of the CHOKAI score was >7, the sensitivity was found to be 60.49%, and specificity was 83.33%. The cut-off value for the STONE score was >8 with a sensitivity of 70.37% and specificity of 58.33%. The corresponding area under curve values for the CHOHAI and STONE scores was 0.788 (p < 0.0001) and 0.615 (p = 0.087). Male sex, the CHOKAI, and STONE scores were the independent risk factors for ureteral stone. A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).

CONCLUSION

The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones.

NEW KNOWLEDGE ADDED BY THIS STUDY

The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones. Especially in countries such as Turkey, where there are no specific racial differences, the STONE score may be diagnostically insufficient. The CHOKAI score shows the presence of the patient's stone and positively correlates with the size of the stone and the stone location.

IMPLICATION FOR CLINICAL PRACTICE OR POLICY

In the functioning of the emergency department, it is important to make the differential diagnosis of patients quickly and provide effective treatment. The use of diagnostic scoring systems saves time for the emergency physician in the differential diagnosis phase and guides in terms of applying for possible additional imaging methods.

What are the clinical effects of the different emergency department imaging options for suspected renal colic? A scoping review

OBJECTIVES

Clinicians have minimal guidance regarding the clinical consequences of each radiologic imaging option for suspected renal colic in the emergency department (ED), particularly in relation to patient-centered outcomes. In this scoping review, we sought to identify studies addressing the impact of imaging options on patient-centered aspects of ED renal colic care to help clinicians engage in informed shared decision making. Specifically, we sought to answer questions regarding the effect of obtaining computed tomography (CT; compared with an ultrasound or delayed imaging) on safety outcomes, accuracy, prognosis, and cost (financial and length of stay [LOS]).

METHODS

We conducted a comprehensive search using Pubmed, EMBASE, Web of Science conference proceedings index, and Google Scholar, identifying studies pertaining to renal colic, urolithiasis, and ureterolithiasis. In a prior qualitative study, stakeholders identified 14 key questions regarding renal colic care in the domains of safety, accuracy, prognosis, and cost. We systematically screened studies and reviewed the full text of articles based on their ability to address the 14 key questions.

RESULTS

Our search yielded 2570 titles, and 68 met the inclusion criteria. Substantial evidence informed questions regarding test accuracy and radiation exposure, but less evidence was available regarding the effect of imaging modality on patient-oriented outcomes such as cost and prognosis (admissions, ED revisits, and procedures). Reviewed studies demonstrated that both standard renal protocol CT and low-dose CT are highly accurate, with ultrasound having lower accuracy. Several studies found that ureterolithiasis diagnosed by ultrasound was associated with overall reduced radiation exposure. Existing studies did not suggest choice of imaging influences prognosis. Several studies found no substantial differences in monetary cost, but LOS was found to be shorter if a diagnosis was made with point-of-care ultrasound.

CONCLUSION

There is a plethora of data related to imaging accuracy. However, there is minimal data regarding the effect of CT on many patient-centered outcomes. Further research could improve the patient-centeredness of ED care.

Derivation of a clinical predicting rule for obstructive urolithiasis and alternative diagnosis requiring urgent intervention: the CLAD score

Most patients with renal colic are discharged from the emergency department (ED) after evaluation and pain alleviation. These patients may not require urgent imaging by computed tomography. We derived a clinical prediction score in patients with renal colic to identify those at very low risk for complications and alternative diagnoses requiring urgent intervention. This retrospective chart review was carried out in 2 ED at an urban university hospital from January to December 2015. All patients with a diagnosis of renal colic were included. The primary outcome was an intervention required for renal colic or alternative diagnoses within 7 days of ED presentation. A stepwise logistic regression was used to assess factors associated with the outcome. A score was derived as a weighted sum of these predictors and its performance was calculated. The database was submitted to the French National Commission for Data Protection and Liberties (CNIL): declaration n°2164898v0 (03/22/2018). 871 with complete data were analyzed. In 94 (11%) patients, an intervention was performed for obstructive urolithiasis or alternative diagnosis. Five factors were most predictive of intervention: age > 45 years (1 point), a history of urologic surgery (1 point), pulse > 100 bpm (1 point), temperature > 37.8 °C (2 point), and urine dipstick negative for blood (1 point), yielding a score of 0-6 points (the Complicated uroLithiasis and Alternative Diagnosis (CLAD) score). The area under the curve of the receiver operating characteristic curve was 0.82 (95% CI 0.77-0.87). We derived a clinical score for renal colic that predicted the presence of obstructive urolithiasis and acute alternative diagnoses requiring intervention.