Effect of provider experience on clinician-performed ultrasonography for hydronephrosis in patients with suspected renal colic

Renal screening sonography-A comparative study in a Portuguese basic emergency service

INTRODUCTION

Renal Point-of-Care Ultrasound (POCUS) is a screening modality that aids in clinical decision-making for patients with suspected renal colic. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with the imaging findings at the Referral Hospital (RH).

METHODS

Thirty-one patients suspected of having renal pathology underwent initial sonography screening with POCUS at the BES and were subsequently referred to the RH for additional imaging examinations. The results of both examinations were compared to verify whether the findings from the BES were confirmed by the radiologist in the RH and to ensure that the patient referrals from BES to RH were appropriate.

RESULTS

In our sample, the majority of patients (80%) exhibited varying degrees of pyelocaliceal distension, with nearly half (48%) patients presenting obstructions. A strong association between the sonographic findings in the BES and the RH was found in the variables 'Dilatation of pyelocaliceal system' (V = 0.895; P = 0.00), 'Simple cystic formation' (V = 0.878; P = 0.000), respectively. There was a statistically significant correlation between BES and RH findings, indicating a strong association between these two variables, respectively (k = 0.890; P = 0.000) and (k = 0.870; P = 0.000). There was also a strong statistically significant correlation in the ultrasonographic findings between BES and RH performers (k = 0.890; P = 0.000 and k = 0.870; P = 0.000). In this research, an achieved sensitivity of 96% and a specificity of 85% were demonstrated in the identification of pyelocaliceal dilatation.

CONCLUSION

Renal POCUS screening successfully detected abnormalities in the urinary system of patients suspected of having renal colic. The sonographic findings at the BES had a good correlation with the complementary imaging results obtained at the RH in Portugal. These results suggest that Radiographers/Sonographers can have an important role in the preliminary assessment of urgent renal pathology in remote areas, contributing to a correct referral and early treatment.

Point-of-care ultrasound associated with shorter length of stay than computed tomography for renal colic

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.

Reliability of renal point-of-care ultrasound (POCUS) performed by pediatric postgraduates to diagnose hydronephrosis in infants

Purpose

Point-of-care ultrasound (POCUS) has gained prominence in a variety of medical specialties due to advances in ultrasound technology. POCUS has not been fully integrated into pediatric residency training programs despite its widespread use and proven benefits. At our institution, renal POCUS is performed by pediatric residents for the evaluation of hydronephrosis, which is the main pathology for which ultrasound is used in the clinical practice of pediatric nephrology. This study was conducted to evaluate the quality of renal POCUS performed by pediatric residents in infants.

Methods

Four pediatric residents, comprising two first-year and two second-year residents at Konyang University Hospital, participated in the study conducted from May 2021 to May 2022. All participants had completed our Point-of-Care Ultrasound (POCUS) training program. The study focused on infants admitted to the pediatric inpatient unit, identified by attending physicians as requiring renal ultrasound. All infants underwent their initial kidney ultrasound examination. Temporal alignment between renal Point-of-Care Ultrasound (POCUS) performed by pediatric residents and conventional ultrasound (USG) conducted by radiologists was asynchronous. Pediatric residents conducted POCUS sessions during scheduled radiologist appointments throughout the day, occurring either before or after the radiologist's examination. There was no mutual awareness of each other's results. Inter-observer agreement between radiologists and pediatric residents was compared for the presence or absence of hydronephrosis and its grade, which are primary considerations in pediatric renal ultrasound.

Results

Our study found that 53 infants (68.8%) were diagnosed with hydronephrosis using point-of-care ultrasound (POCUS), compared to 48 infants (62.3%) diagnosed with conventional ultrasound (USG). Among the POCUS examinations conducted by pediatric residents, hydronephrosis of SFU grades 1, 2, 3, and 4 were observed in 56.6%, 35.8%, 7.5%, and 0%, respectively. Inter-observer reliability between POCUS and conventional USG showed good agreement, with Cohen's kappa coefficients exceeding 0.8 for sensitivity and 0.6 for grading.

Conclusions

Renal POCUS performed well in diagnosing and grading hydronephrosis in infants when performed by pediatric residents who had completed a two-phase training program.

Impact of Different Training Methods on Daily Use of Point-of-Care Ultrasound: Survey on 515 Physicians

ABSTRACT

Point-of-care ultrasound (POCUS) curriculum varies among countries. However, the length of training required for physicians is still under debate. We investigated the impact of different training methods: short hands-on courses (STS), long academic training sessions (LTS), or both (mixed training [MTS]), for POCUS daily use and self-reported confidence overall and specific to specific clinical situations. This was a descriptive study conducted over a 3-month period through a Web-based survey designed to assess the influence of different methods of POCUS training among physicians and residents on their daily practice. The survey was sent to 1212 emergency physicians with prior POCUS training; 515 answers (42%) could be analyzed. Participants in the STS group performed POCUS less frequently than physicians in the LTS or MTS group. Daily use in the STS group was 51% versus 82% in the LTS group and 83% in the MTS group ( P < 0.01). The overall self-reported confidence in POCUS was lower in the STS group ( P < 0.01) in all studied clinical situations. There was no significant difference between LTS and MTS groups ( P > 0.05). Method of POCUS training significantly influenced POCUS daily use. Physicians who underwent long training sessions used POCUS more frequently in their routine practice and were significantly more confident in their ability to perform and interpret a POCUS examination.

Test characteristics of point-of-care ultrasonography in patients with acute kidney injury

BACKGROUND

Acute kidney injury is a common disorder that is associated with significant morbidity and mortality. Point-of-care ultrasonography (PoCUS) is an imaging modality performed at the bedside and is used to assess for obstructive causes of acute kidney injury. Little is known about the test characteristics of PoCUS in patients with acute kidney injury.

OBJECTIVE

Our primary objective was to describe the test characteristics of PoCUS for the detection of hydronephrosis in patients presenting with acute kidney injury at our centre. Our secondary objective was to describe the current rate of use of PoCUS for this indication.

RESULTS

In total, 7873 patients were identified between June 1, 2019 and April 30, 2021, with 4611 meeting inclusion criteria. Of these, 94 patients (2%) underwent PoCUS, and 65 patients underwent both PoCUS and reference standard, for a total of 124 kidneys included in our diagnostic accuracy analysis. The prevalence of hydronephrosis in our cohort was 33% (95% CI 25-41%). PoCUS had a sensitivity of 85% (95% CI 71-94%) and specificity of 78% (95% CI 68-87%) for the detection of hydronephrosis.

CONCLUSION

We describe the test characteristics of PoCUS for the detection of hydronephrosis in a cohort of patients with acute kidney injury. The low uptake of this test presents an opportunity for quality improvement work to increase its use for this indication.

Ascending with ultrasound: telementored eFAST in flight-a feasibility study

PURPOSE

Teleultrasound uses telecommunication technologies to transmit ultrasound images from a remote location to an expert who guides the acquisition of images and interprets them in real time. Multiple studies have demonstrated the feasibility of teleultrasound. However, its application during helicopter flight using long-term evolution (LTE) for streaming has not been studied. Therefore, we conducted a study to examine the feasibility of teleultrasound in an Airbus H145 helicopter.

METHODS

Four anesthesiologists and one military physician were recruited to perform telementored extended Focused Assessment with Sonography in Trauma (eFAST) during nine helicopter flights, each with a unique healthy volunteer. A radiologist was recruited as a remote expert, guiding the physicians in their examinations. The examining physicians reported the user experience of telementored eFAST on a questionnaire, while the remote expert rated the diagnostic quality of the images on a 1-5 Likert scale. In addition, we measured the duration of the examinations and key LTE network parameters including signal strength, quality, and continuity.

RESULTS

The images were rated to an average of 4.9 by the remote expert, corresponding to good diagnostic quality. The average duration of telementored eFAST was 05:54 min. LTE coverage was negatively affected by proximity to urban areas and ceased above 2000 ft altitude. Occasional audio problems were addressed by using the Voice over LTE network for communication. The examining physicians unanimously reported on the questionnaire that they would use telementored eFAST on patients.

CONCLUSION

Telementored eFAST is feasible in ambulance helicopters and can produce images of good diagnostic quality. However, it relies on stable LTE coverage, which is influenced by many factors, including the helicopter's altitude and flight path. Furthermore, its benefit on patient outcomes remains to be proven.

Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis

Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Identification of Clinically Insignificant Renal Calculi on Sonography

OBJECTIVE

To determine factors predicting if a radiologists... report of a .. stone... on ultrasound (US) was not actually a clinically significant stone, based on subsequent computed tomogram (CT). US often overestimates stone size and various pathologic entities are also hyperechoic;.ßthus, a subsequent CT without a clinically significant stone may represent unnecessary radiation exposure. A decision-tree and nomogram were developed to predict when stones are unlikely on subsequent CT.

METHODS

Retrospective analysis of patients, of any age, receiving CT within 24.ßhours of a sonographic report documenting a single renal stone, during 2019...2020, in any phase of care, at one institution. Novel stone-likelihood-systems for US and CT (US-SLS, CT-SLS) were devised and validated to classify stones as clinically significant or insignificant, with CT as the gold standard. Binomial logistic regression predicting clinically significant stones was performed with sonographic and patient characteristics.

RESULTS

Eight hundred twenty patients had US followed by CT, 228 (27.8%) reported documented stones, 140 (17.1%) reported a single stone. Clinically significant stones were associated with larger stone size (P: .002), location (P: .002), hydronephrosis (P: .04), shadowing-artifact (P: .02) depth.ßto.ßstone (P: .008), and Body mass Index (BMI) (P: .01). US-SLS had higher sensitivity (95.4%) and negative-predictive-value (81.8%) compared to a multivariate model of significant variables.

CONCLUSION

US-SLS appears to exclude clinically irrelevant .. stones... better than established criteria including twinkle or shadow in this retrospective analysis. A diagnostic algorithm and nomogram are presented. US-SLS and the associated decision tree can assist providers in avoiding unnecessary radiation when clinically significant stones are unlikely.

Value of detected hydronephrosis and hydroureter on ultrasound for detecting a ureteral stone: a retrospective study

To investigate the predictive value of hydronephrosis and hydroureter in the detection of ureteral stones using ultrasound, a total of 366 patients suffering from ureteral stones confirmed by ultrasound, computed tomography (CT) and their follow-up treatments were consecutively collected. All the included patients underwent systematic ultrasound scanning of the kidney and ureter. The hydronephrosis and hydroureter in each patient were measured using a digital caliper. Then, receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values for hydronephrosis and hydroureter to predict a ureteral stone's location and size. The hydronephrosis, hydroureter, and stone size measurements showed good interobserver agreement (P < 0.001). Using the lower border of the sacroiliac joint as a demarcation point, we found larger widths of hydronephrosis and hydroureter in the proximal ureteral stone group than in the distal ureteral stone group (P < 0.001). Additionally, 10.9 mm and 5.9 mm were identified as optimal cutoff values for predicting a distal position (P < 0.001), with no significant difference in their predictive value (P > 0.05). Similar comparisons between groups based on size stratification revealed no significant difference in hydronephrosis between the > 5 mm group and the ≤ 5 mm group. However, the hydroureter was larger in the > 5 mm group than in the ≤ 5 mm group after identifying 6 mm as the best cutoff (P =0.004). In summary, the ultrasound measurement of hydronephrosis and hydroureter may predict the position and size of a possible ureteral stone in patients with colic symptoms.

Point-of-Care Ultrasound (POCUS) Literature Primer: Key Papers on Renal and Biliary POCUS

Objective The objective of this study is to identify the top five influential papers published on renal point-of-care ultrasound (POCUS) and the top five influential papers on biliary POCUS in adult patients. Methods A 14-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. All panel members have had ultrasound fellowship training or equivalent, are actively engaged in POCUS scholarship, and are involved with POCUS at their local site and nationally in Canada. We used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five influential papers for renal POCUS and biliary POCUS. Results The panel identified 27 relevant papers on renal POCUS and 30 relevant papers on biliary POCUS. All panel members participated in all three rounds of the modified Delphi process, and after completing this process, we identified the five most influential papers on renal POCUS and the five most influential papers on biliary POCUS. Conclusion We have developed a list, based on expert opinion, of the top five influential papers on renal and biliary POCUS to better inform all trainees and clinicians on how to use these applications in a more evidence-based manner. This list will also be of interest to clinicians and researchers who strive to further advance the field of POCUS.

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.

Point‐of‐care renal ultrasound: Are longitudinal views of the kidney alone sufficient to rule out hydronephrosis?

Objective

Point‐of‐care ultrasound for the detection of hydronephrosis is frequently used by emergency physicians. The aim of this study was to assess the accuracy of longitudinal views of the kidney compared with a combination of longitudinal and transverse views of the kidney on emergency physician–performed renal point‐of‐care ultrasound to detect hydronephrosis.

Methods

This was a retrospective case‐control study of patients who received a renal point‐of‐care ultrasound examination performed and interpreted as hydronephrosis in the emergency department (ED). These were then matched with a cohort of kidneys from different patients without hydronephrosis. Longitudinal ultrasound views and transverse ultrasound views were reviewed for the presence of hydronephrosis by ultrasound‐trained emergency physicians. The gold standard of hydronephrosis was an overall interpretation based on the complete ultrasound examination consisting of both transverse and longitudinal views by ultrasound‐trained emergency physicians.

Results

Renal point‐of‐care ultrasound exams from 140 kidneys performed in the ED were enrolled in the study. The sensitivity and specificity of longitudinal ultrasound views compared with a combination of longitudinal and transverse ultrasound views of the kidney as a gold standard were 84.3% (95% confidence interval [CI], 77.2–89.9) and 92.9% (95% CI, 87.3–96.5), the positive predictive value was 92.2% (95% CI, 86.1–96.2), and the negative predictive value was 85.5% (95% CI, 78.9–90.7). The positive and negative likelihood ratios were 11.8 (95% CI, 6.5–21.5) and 0.2 (95% CI, 0.1–0.2), respectively.

Conclusions

Longitudinal views of the kidney on ultrasound showed good sensitivity and specificity to detect the presence of hydronephrosis compared with a combination of longitudinal and transverse ultrasound views of the kidney. However, a combination of longitudinal and transverse ultrasound views may still be warranted in high‐risk patients or in those with inadequate visualization of the upper pole of the kidney.

PAs and point-of-care ultrasound: A scoping review

OBJECTIVE

Point-of-care ultrasound (POCUS) has rapidly emerged as a valuable tool in the bedside assessment of patients. This scoping review summarizes existing literature covering clinical use and educational integration of POCUS by physician assistants (PAs), with the overall goal of identifying gaps in POCUS research involving the PA profession.

METHODS

Keyword searches of PubMed, EMBASE, Medline, and Google Scholar were conducted. Studies assessing PA POCUS use or accuracy; those evaluating extent, method, or value of POCUS educational integration; and those assessing the effect of POCUS training interventions were included.

RESULTS

Of the 717 studies retrieved, 30 met inclusion criteria. Studies generally demonstrated that PAs can use a fairly wide range of POCUS applications with high accuracy, but that POCUS integration into PA programs remains limited because of a number of identified barriers.

CONCLUSIONS

Machine availability and insufficient POCUS training and education opportunities limit widespread clinical use of POCUS by PAs.

Head to toe ultrasound: a narrative review of experts’ recommendations of methodological approaches

Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills.

Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications.

Ultrasound at the patient's bedside for the diagnosis and prognostication of a renal colic

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.

Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock

Despite decades of research, the mortality rate of sepsis and septic shock remains unacceptably high. Delays in diagnosis, identification of an infectious source, and the challenge of providing patient-tailored resuscitation measures routinely result in suboptimal patient outcomes. Bedside ultrasound improves a clinician's ability to both diagnose and manage the patient with sepsis. Indeed, multiple point-of-care ultrasound (POCUS) protocols have been developed to evaluate and treat various subsets of critically ill patients. These protocols mostly target patients with undifferentiated shock and have been shown to improve clinical outcomes. Other studies have shown that POCUS can improve a clinician's ability to identify a source of infection. Once a diagnosis of septic shock has been made, serial POCUS exams can be used to continuously guide resuscitative efforts. In this review, we advocate that the patient with suspected sepsis or septic shock undergo a comprehensive POCUS exam in which sonographic information across organ systems is synthesized and used in conjunction with traditional data gleaned from the patient's history, physical exam, and laboratory studies. This harmonization of information will hasten an accurate diagnosis and assist with hemodynamic management.

Can plain film radiography improve the emergency department detection of clinically important urinary stones?

OBJECTIVE

Physicians frequently use ultrasound to assess hydronephrosis in patients with suspected renal colic, but ultrasound has limited diagnostic sensitivity and rarely clarifies stone size or location. Consequently, up to 80% of emergency department (ED) renal colic patients undergo confirmatory CT imaging. Our goal was to estimate x-ray sensitivity for urinary stones and determine whether x-ray substantially improves stone detection (sensitivity) compared to hydronephrosis assessment alone.

METHODS

We reviewed imaging reports from all renal colic patients who underwent x-ray and CT at four EDs. For each patient, we documented stone size, location and hydronephrosis severity on CT and whether stones were identified on x-ray. We considered moderate and severe hydronephrosis (MS-Hydro) as significant positive findings, then calculated the sensitivity (detection rate) of MS-Hydro and x-ray for large stones ≥5 mm and for stones likely to require intervention (all ureteral stones >7 mm and proximal or middle stones >5 mm). We then tested a diagnostic algorithm adding x-ray to hydronephrosis assessment.

RESULTS

Among 1026 patients with 1527 stones, MS-Hydro sensitivity was 39% for large stones and 60% for interventional stones. X-ray sensitivity was 46% for large stones and 52% for interventional stones. Adding x-ray to hydronephrosis assessment increased sensitivity in all stone categories, specifically from 39% to 68% for large stones (gain = 29%; 95%CI, 23% to 35%) and from 60% to 82% for interventional stones (gain = 22%; 95%CI, 13% to 30%). Because CT and ultrasound show strong agreement for MS-Hydro identification, physicians who depend on ultrasound-based hydronephrosis assessment could achieve similar gains by adding x-ray.

CONCLUSIONS

Adding x-ray to hydronephrosis assessment substantially improves diagnostic sensitivity, enabling the detection of nearly 70% of large stones and over 80% of interventional stones. This level of sensitivity may be sufficient to reassure physicians about a renal colic diagnosis without CT imaging for many patients.

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic

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.

POCUS Evaluation in Acute Kidney Injury

Acute kidney injury is a common clinical problem encountered in general internal medicine. The evaluation of acute kidney injury is mainly driven by the patient's clinical history, physical exam, and laboratory investigation including urinalysis and urine sediment examination. Point of care ultrasound (POCUS) may be a useful tool to help clinicians to narrow and/or prioritize differential diagnosis in patients presenting with acute kidney injury. Here we present a case of a 67-year-old male presenting with dysuria, fevers, and flank pain along with elevation in serum creatinine who was admitted with concern for acute kidney injury secondary to complicated urinary tract infection. Subsequent kidney POCUS of the kidneys and bladder showed bilateral anechoic fluid collection within the kidney sinus with dilated calyces suggestive of bilateral hydronephrosis, most likely due to a new diagnosis of benign prostatic hyperplasia. This case demonstrates the use of POCUS-obtained valuable diagnostic information and subsequent therapeutic management for this patient presenting with suspected acute kidney injury.

Significance of nuclear medicine scan in comparison with diethylenetriamine pentaacetic acid and ultrasound imaging in diagnosing renal disorders: An observational study

The effectiveness of diethylenetriamine pentaacetic acid scan is regularly monitored for the assessment of any potential modifications in treatment responses or kidney functions in the pediatric population.This study attempts to compare the usefulness of diethylenetriamine pentaacetic acid and ultrasound imaging of renal disorders among paediatric patients.A retrospective observational study was conducted by enrolling 106 children. The demographic details such as: participant's age, gender, and the history of renal disease of each patient were recorded. Patients were administered radiopharmaceuticals in a fixed dose and were later subjected to computed tomography (CT) scan. The obtained data was analysed using descriptive statistics.Findings indicated increased sensitivity for CT (61.20%); whereas, a major decrease in specificity (23.68%) was observed. Comparison of Single-photon emission CT (SPECT) and CT findings revealed the increased sensitivity (90.90%) for ultrasound; whereas, there was a slight decrease in the specificity (40%) for SPECT. However, SPECT findings show 91% sensitivity among patients with 71.42% positive predictive value. Moreover, an increase in sensitivity for CT (61.20%), followed by a major decrease in specificity (23.68%) was observed.Ultrasonography has been proved to be the safest and the most effective method for the diagnosis and the treatment of most renal disorders, due to the higher predictive value of SPECT scans. It is thus suggested that patients with ureteral calculi should be diagnosed with renal scintigraphy and unenhanced helical computerized tomography.

Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic

Background

Point-of-care ultrasound (PoCUS) by emergency physicians for renal colic has been proposed as an alternative to computed tomography (CT) to avoid ionizing radiation exposure and shorten emergency department length of stay. Previous studies have employed experienced or credentialed ultrasonographers or required advanced ultrasound skills. We sought to measure the diagnostic accuracy of PoCUS by physicians with varied experience using a simplified binary outcome of presence or absence of hydronephrosis. Secondary outcomes include assessment as to whether the presence of hydronephrosis on PoCUS is predictive of complications, and to evaluate possible causes for the reduced diagnostic accuracy such as body mass index (BMI) and time between PoCUS and formal imaging, and scanner experience.

Results

413 patients were enrolled in the study. PoCUS showed a specificity of 71.8% [95% CI 65.0, 77.9] and sensitivity of 77.1% [95% CI 70.9, 82.6]. Hydronephrosis on PoCUS was predictive of complications (relative risk 3.13; [95% CI 1.30, 7.53]). The time interval between PoCUS and formal imaging, BMI, and scanner experience did not influence the accuracy of PoCUS.

Conclusions

PoCUS for hydronephrosis in suspected renal colic has moderate accuracy when performed by providers with varied experience for the binary outcome of presence or absence of hydronephrosis. Hydronephrosis on PoCUS is associated with increased rates of complications. PoCUS for hydronephrosis is limited in its utility as a stand-alone test, however this inexpensive, readily available test may be useful in conjunction with clinical course to determine which patients would benefit from formal imaging or urologic consultation.

ClinicalTrials.gov Identifier NCT01323842

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus

BACKGROUND

Renal colic is common, and CT is frequently utilized when the diagnosis of kidney stones is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting.

METHODS

In conjunction with the American College of Emergency Physicians (ACEP) eQual network, we formed a nine-member panel with three physician representatives each from ACEP, the ACR, and the American Urology Association. A systematic literature review was used as the basis for a three-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios.

RESULTS

From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasound in 9 (31%) and no further imaging needed in 12 (45%).

SUMMARY

Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus

STUDY OBJECTIVE

Renal colic is common and computed tomography (CT) is frequently used when the diagnosis of kidney stone is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multiorganizational transdisciplinary collaboration seeks evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting.

METHODS

In conjunction with the American College of Emergency Physicians (ACEP) Emergency Quality Network, we formed a 9-member panel with 3 physician representatives each from ACEP, the American College of Radiology, and the American Urology Association. A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios.

RESULTS

From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, out of the 29 scenarios agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%). There were no scenarios in which at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasonography in 9 (31%) and no further imaging needed in 12 (45%).

CONCLUSION

Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic.

Suspected appendicitis pathway continues to lower CT rates in children two years after implementation

BACKGROUND

We implemented a protocol to evaluate pediatric patients with suspected appendicitis using ultrasound as the initial imaging modality. CT utilization rates and diagnostic accuracy were evaluated two years after pathway implementation.

METHODS

This was a retrospective observational study of patients <18 years evaluated for suspected appendicitis. CT rates were compared before and after implementation of the protocol, and monthly CT rates were calculated to assess trends in CT utilization.

RESULTS

CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.5% (78/284; p < 0.001). Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation. Adherence to the pathway was 89.8% (255/284). Negative appendectomy rate was 2.4% (2/85) in the post-pathway period.

CONCLUSIONS

Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in CT use without compromising diagnostic accuracy.

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

OBJECTIVE

The CHOKAI and STONE scores are clinical prediction rules to predict ureteral stones in patients presenting with renal colic. Both systems contribute to reducing diagnostic radiation exposure; however, few studies have compared the two scoring systems. Therefore, we aimed to compare these systems and assess their diagnostic accuracy for ureteral stones.

METHODS

This was a multicenter prospective observational study performed between 2017 and 2018, including patients aged >15 years with renal colic and suspected with ureteral stones. We calculated the CHOKAI and STONE scores of each patient based on their medical interviews and physical and laboratory findings. Primary outcome was differences in the area under the receiver operating characteristic curve in each model, and secondary outcome was diagnostic accuracy at the optimal cut-off point.

RESULTS

Of the 124 patients included, 84 were diagnosed with ureteral stones. The area under the curve of the CHOKAI score was 0.95, showing a sensitivity of 0.93, specificity of 0.90, positive likelihood ratio of 9.3, and negative likelihood ratio of 0.079, at an optimal cut-off point of 6. The area under the curve of the STONE score was 0.88, showing a sensitivity of 0.68, specificity of 0.90, positive likelihood ratio of 6.8, and negative likelihood ratio of 0.36, at an optimal cut-off point of 9. Thus, the area under the curve was significantly higher for the CHOKAI score than for the STONE score (p = 0.0028).

CONCLUSIONS

The CHOKAI score has a diagnostic performance superior to that of the STONE score in this population.

PA use of point-of-care ultrasound: A pilot survey

Limited research exists on PAs and use of point-of-care (POC) ultrasound. This pilot survey sought to determine current views on and use of POC ultrasound in a small group of PAs.

METHODS

The authors developed an anonymous voluntary survey on PA views and use of POC ultrasound. The survey was entered into Qualtrics and e-mailed three times.

RESULTS

Nearly 27% of the subjects use ultrasound with 62% feeling confident in their ability to use ultrasound. The top reason for not using ultrasound was lack of access to a machine (50%). Only 35.3% of those without access to a machine were interested in bringing ultrasound into their practices. Sixty-seven percent of respondents felt that PAs should have standardized ultrasound training.

CONCLUSIONS

Results demonstrate that more research is needed into the applicability of POC ultrasound to all PA practice areas as well as how PAs should be trained in POC ultrasound.

Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists

OBJECTIVE

The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard.

METHODS

The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp).

RESULTS

A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73).

CONCLUSIONS

Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.

Limited sensitivity and size over measurements of ultrasound affect medical decisions for ureteral stone compared to non-contrasted computed tomography

PURPOSE

To evaluate the limited sensitivity and size over measurements of ultrasound (US) for ureteral stone, and demonstrate how this influenced medical decisions.

PATIENTS AND METHODS

Retrospectively, we analyzed the data of patients with ureterolithiasis estimated by US and non-contrasted computed tomography (NCCT) within 48 h at our institution from January 1st 2014 to June 1st 2017. Stone size was grouped by the longest axis diameter on NCCT: < 5, 5-10, and > 10 mm. Then, US and NCCT results were compared for the sensitivity and measurements.

RESULTS

A total of 614 cases of ureterolithiasis were visible on NCCT. The sensitivity of US for ureterolithiasis < 5, 5-10, and > 10 mm were 63.49, 79.06, and 84.67%, respectively (P = 0.001). US overestimated the size in 63.49 and 50.54% of patients with ureterolithiasis < 5 and 5-10 mm compared to NCCT, respectively (P < 0.001). Under the assumptions that patients with ureteral stone < 5, 5-10, and > 10 mm would be simply observed, received medical expulsive therapy (MET), and surgical interventions, 20.94 and 15.33% of patients with stone sized 5-10 and > 10 mm might be improperly observed due to negative US reports. Besides, 63.49 and 50.54% of cases with stone < 5 and 5-10 mm might receive more aggressive interventions ascribed to over measurements of US.

CONCLUSIONS

Limited sensitivity and size over measurements of US might significantly influence medical decisions for ureteral stone. Inaccurate evaluation of US should be taken in consideration for appropriate counseling options.

The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis

INTRODUCTION

Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic value in the management of renal colic.

METHODS

The review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, Embase, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were computed tomography evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer. Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary.

RESULTS

The electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full-text review, and nine articles met all inclusion criteria. Of these, five high-quality studies (N = 1,773) were included in the meta-analysis for diagnostic accuracy and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% confidence interval [CI] = 67.1%-73.2%) and 75.4% (95% CI = 72.5%-78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta-analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI = 92.7%-95.8%). Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation.

CONCLUSION

Point-of-care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5 mm) stone in those presenting with renal colic.

Bilateral ureterolithiasis: A true positive and false negative PoCUS exam in a patient with renal colic

Acute flank pain from suspected urolithiasis is a common presenting complaint in the Emergency Department. Multiple computed tomography (CT) has traditionally been the standard imaging modality used to diagnose obstructive kidney stones, however point of care ultrasound (PoCUS) can play an important role in the diagnostic algorithm and risk stratification of acute flank pain. Here, we present the case of a 29-year-old female with suspected urolithiasis, who underwent PoCUS that revealed right-sided hydronephrosis and normal left kidney, bladder, and aorta. A subsequent KUB was negative. As the clinical course failed to improve with therapy, an abdominal and pelvic CT was ordered revealing a 5 mm distal obstructing ureteric calculus at the right vesico-ureteric junction and another 5 mm left mid ureteric calculus. To the best of our knowledge, this is the first case in which a patient presenting with acute right-sided flank pain demonstrated unilateral hydronephrosis on PoCUS, but had clinically significant bilateral ureteric stones on CT. Emergency physicians who employ PoCUS for evaluation of flank pain must be aware of its benefits and drawbacks and how they apply to each patient. As such, we have developed a script emergency physicians can use for shared decision-making with renal colic patients when deciding on the appropriate imaging modality.

Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation

BACKGROUND

Patients presenting to the ED with suspected renal colic are frequently imaged with CT urography (CTU), which rarely alters diagnosis or management. To reduce use of CTU in this population, we instigated a new imaging and management guideline in our ED.

METHODS

This was a quasi-experimental prospective study, whereby a new guideline was commenced at the intervention site (Monash Medical Centre) and the existing guideline continued at the control site (Dandenong Hospital). The new guideline promotes focused ultrasound for diagnosing renal colic and restricts CT to those with poor response to analgesia or 'red flags'. A consecutive series of patients with suspected renal colic were prospectively enrolled and outcomes compared between the sites. The primary outcome was CTU utilisation and secondary outcomes were radiation exposure, stone rate on CTU, admission, ED length of stay and rates of urological intervention and returns to ED at 4-week follow-up.

RESULTS

Preintervention CTU rates were 76.7% at Monash and 72.1% at Dandenong. 324 patients were enrolled; 148 at Monash and 176 at Dandenong. Median age 47 years vs 49 years, males 76.4% vs 66.5% and medianSex, Timing, Origin, Nausea, Erythrocytes (STONE) score 10 vs 10 for Monash and Dandenong, respectively. CTU was performed in 54.1% vs 75.0% (p<0.001), median radiation exposure 2.8 vs 4.0 mSv (p<0.001) and urological intervention occurred in 16.4% vs 15.7% for Monash and Dandenong, respectively.

CONCLUSIONS

We found that use of CTU for renal colic was significantly reduced by introduction of a guideline promoting ultrasound and encouraging selective CTU. Although intervention rates were similar between the two sites, further prospective study is needed to ensure other patient-centred outcomes do not differ.

Internal validation of a scoring system to evaluate the probability of ureteral stones: The CHOKAI score

OBJECTIVE

The CHOKAI and STONE scores are prediction models for ureteral stones. The aims of the present study were to evaluate the diagnostic performance, to examine the optimal cut-off value, and to compare the diagnostic performance of each model.

METHODS

Patients who presented to our emergency department with renal colic were considered for this prospective study. We analyzed the predictive performance of both STONE and CHOKAI scores at their optimal cut-off values, using receiver operating characteristic (ROC) curve and area under the curve (AUC), as well as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) at the optimal cut-off value.

RESULTS

Of the 96 patients who met the inclusion criteria, 79 were definitively diagnosed with ureteral stones. All patients were of Japanese descent. The AUC of the CHOKAI score was 0.971 at an optimal cut-off value of 6, showing a sensitivity of 0.911, specificity of 0.941, LR+ of 15.49, and LR- of 0.094. The AUC of the STONE score was 0.873 at an optimal cut-off value of 8, showing a sensitivity of 0.823, specificity of 0.824, LR+ of 4.662, and LR- of 0.215. The AUC of the CHOKAI score was significantly higher than that of the STONE score (p=0.010). Of the 73 patients with a CHOKAI score of ≥6, 98.6% had ureteral stones, and of the 68 patients with a STONE score of ≥8, 95.6% had ureteral stones.

CONCLUSIONS

The simplified CHOKAI score is a useful tool to screen for ureteral stones in patients with renal colic.

Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic

Introduction

Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events.

Methods

This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed.

Results

We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x²=51.7, p<0.001). Hydronephrosis on EP-performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size >5mm less likely (NPV 89%; LR− 0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03).

Conclusion

Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.

Derivation of decision rules to predict clinically important outcomes in acute flank pain patients

OBJECTIVE

Routine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules.

METHODS

We analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes.

RESULTS

Of 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin <13.2g/dl), WBC count >11000/μl, age>42years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8-99.2%) and specificity of 18.7% (95% 17.2-20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count <8300/μl had a sensitivity of 98.6% (95% CI 94.5-99.7%) and specificity of 26.0% (95% 24.2-27.7%) for clinically important stone.

CONCLUSIONS

We determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients.

Revolution or Evolution? A Proposal for the Integration of Point-of-Care Ultrasound Into Physician Assistant Clinical Practice

Advances in technology and increased affordability of machines have allowed ultrasound to become ubiquitous across the spectrum of medical care. Increasing portability has brought ultrasound to the point of care in multiple medical specialties. Formal ultrasound training is rapidly being incorporated into multispecialty residency programs and undergraduate medical education curricula, yet little formal training exists for physician assistants (PAs) on this emerging clinical adjunct. This article outlines recommendations for and barriers to the incorporation of bedside ultrasound into PA clinical practice.

Overview of point-of-care abdominal ultrasound in emergency and critical care

Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.

Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology

PURPOSE

To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity.

METHODS

A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard.

RESULTS

One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics.

CONCLUSIONS

Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.

Crossed Fused Renal Ectopia Diagnosed After Discovering an Absent Left Kidney by Point-of-Care Ultrasound

We report an incidental diagnosis of crossed fused renal ectopia diagnosed in a patient initially evaluated with an educational point-of-care ultrasound (US). We review the US technique, sonographic findings, and the relevant literature regarding renal US.

STONE PLUS: Evaluation of Emergency Department Patients With Suspected Renal Colic, Using a Clinical Prediction Tool Combined With Point-of-Care Limited Ultrasonography

STUDY OBJECTIVE

We determine whether renal point-of-care limited ultrasonography (PLUS) used in conjunction with the Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction score can aid identification of emergency department (ED) patients with uncomplicated ureteral stone or need for urologic intervention.

METHODS

This was a prospective observational study of adult ED patients undergoing computed tomography (CT) scan for suspected ureteral stone. The previously validated STONE score classifies patients into risk categories of low (≈10%), moderate (≈50%), or high (≈90%) for symptomatic stone. Renal PLUS assessed for presence of hydronephrosis before CT scanning. The primary outcomes of symptomatic ureteral stone or acutely important alternative finding were abstracted from CT reports. The secondary outcome, urologic intervention, was assessed by 90-day follow-up interview and record review.

RESULTS

Of 835 enrolled patients, ureteral stone was identified in 53%, whereas 6.5% had an acutely important alternative finding on CT. Renal PLUS modestly increased sensitivity for symptomatic stone among low and moderate STONE score categories. Moderate or greater hydronephrosis improved specificity from 67% (62% to 72%) to 98% (93% to 99%) and 42% (37% to 47%) to 92% (86% to 95%) in low- and moderate-risk patients, with likelihood ratios of 22 (95% CI, 4.2-111) and 4.9 (95% CI, 2.9-8.3), respectively. Test characteristics among high-risk patients were unchanged by renal PLUS. For urologic intervention, any hydronephrosis was 66% sensitive (57% to 74%), whereas moderate or greater hydronephrosis was 86% specific overall (83% to 89%) and 81% (69% to 90%) sensitive and 79% 95% CI, (73-84) specific among patients with the highest likelihood of symptomatic stone.

CONCLUSION

Hydronephrosis on renal PLUS modestly improved risk stratification in low- and moderate-risk STONE score patients. The presence or absence of hydronephrosis among high-risk patients did not significantly alter likelihood of symptomatic stone but may aid in identifying patients more likely to require urologic intervention.

[Ultrasound of the urinary system]

Ultrasound techniques are able to provide a fairly complete examination of the urinary system, achieving a high sensitivity in relevant-pathology detection, especially in the kidney, bladder and prostate. Early detection of pathologies such as tumors or urinary tract obstructions, sometimes even before their clinical manifestation, has improved their management and prognosis in many cases. This, added to its low cost and harmlessness, makes ultrasound ideal for early approaches and follow-up of a wide number of urinary system pathologies. In this article, the ultrasound characteristics of the main urinary system pathologies that can be diagnosed by this technique, are reviewed.

Clinician-performed abdominal sonography

INTRODUCTION

Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.

METHODS

A literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.

CONCLUSION

Clinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.