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Antoci G, Tunn R, Beilecke K. Urolithiasis diagnosed with endovaginal ultrasound after vaginal prolapse repair surgery using mesh: A case report. Case Rep Womens Health 2024; 42:e00627. [PMID: 38946844 PMCID: PMC11214166 DOI: 10.1016/j.crwh.2024.e00627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 07/02/2024] Open
Abstract
Pain after vaginal prolapse repair surgery with mesh is generally attributed to the mesh fixation, particularly to mesh erosion, dislocation or the development of hematoma. However, once all the causes have been excluded, the urinary system, bladder and ureters should be accurately examined by means of endovaginal ultrasound. This report concerns the case of a 72-year-old woman who had undergone mesh-supported prolapse surgery 3 months prior, with no other relevant diseases, who visited the emergency department complaining of dull, right-sided colic pain. The endovaginal ultrasound examination revealed a prevesical ureteral calculus on the right side with consequent dilatation of the proximal ureter. Computed tomography of the abdomen and pelvis confirmed the calculus in the distal right ureter and revealed a right renal lower pole calculus. The patient underwent treatment via an operative ureterorenoscopy with removal of stones and placement of a double-J-stent. Two months later, a second ureterorenoscopy was performed with double-J-stent removal and concomitant stone extraction. It appears that no similar cases have been reported in the literature. This is why, during the urogynecological postoperative follow-up, it is of paramount importance to examine the entire urogenital system with endovaginal ultrasound. This case report highlights how, through a simple, non-invasive, radiation-free examination, like ultrasound, most of the post-operative complications of vaginal prolapse repair surgery using mesh, including urolithiasis, can be excluded.
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Affiliation(s)
- Graziana Antoci
- Department of Urogynecology, German Pelvic Floor Center, Alexianer St. Hedwig Hospital, 10115 Berlin, Germany
| | - Ralf Tunn
- Department of Urogynecology, German Pelvic Floor Center, Alexianer St. Hedwig Hospital, 10115 Berlin, Germany
| | - Kathrin Beilecke
- Department of Urogynecology, German Pelvic Floor Center, Alexianer St. Hedwig Hospital, 10115 Berlin, Germany
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Whitworth P, Courtney KG, Oto A, Allen BC, Akin O, Barker SJ, Bartel TB, DuBeau C, Gerena M, Kraft KH, Lew SQ, Mankowski Gettle L, Turkbey B, Uyeda JW, Nikolaidis P. ACR Appropriateness Criteria® Hydronephrosis on Prior Imaging-Unknown Cause. J Am Coll Radiol 2024; 21:S144-S167. [PMID: 38823942 DOI: 10.1016/j.jacr.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Initial imaging evaluation of hydronephrosis of unknown etiology is a complex subject and is dependent on clinical context. In asymptomatic patients, it is often best conducted via CT urography (CTU) without and with contrast, MR urography (MRU) without and with contrast, or scintigraphic evaluation with mercaptoacetyltriglycine (MAG3) imaging. For symptomatic patients, CTU without and with contrast, MRU without and with contrast, MAG3 scintigraphy, or ultrasound of the kidneys and bladder with Doppler imaging are all viable initial imaging studies. In asymptomatic pregnant patients, nonionizing imaging with US of the kidneys and bladder with Doppler imaging is preferred. Similarly, in symptomatic pregnant patients, US of the kidneys and bladder with Doppler imaging or MRU without contrast is the imaging study of choice, as both ionizing radiation and gadolinium contrast are avoided in pregnancy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Pat Whitworth
- Thomas F. Frist, Jr. College of Medicine, Belmont University, Nashville, Tennessee.
| | - Kelsey G Courtney
- Research Author, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aytekin Oto
- Panel Chair, University of Chicago, Chicago, Illinois
| | - Brian C Allen
- Panel Vice Chair, Duke University Medical Center, Durham, North Carolina
| | - Oguz Akin
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Twyla B Bartel
- Global Advanced Imaging, PLLC, Little Rock, Arkansas; Commission on Nuclear Medicine and Molecular Imaging
| | - Catherine DuBeau
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; American Geriatrics Society
| | - Marielia Gerena
- Stony Brook University Medical Center, Stony Brook, New York
| | - Kate H Kraft
- University of Michigan, Ann Arbor, Michigan; American Urological Association
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Baris Turkbey
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer W Uyeda
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
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Cheon EJ, Yoon JM. Reliability of renal point-of-care ultrasound (POCUS) performed by pediatric postgraduates to diagnose hydronephrosis in infants. Front Pediatr 2024; 12:1361223. [PMID: 38655276 PMCID: PMC11035807 DOI: 10.3389/fped.2024.1361223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
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.
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Affiliation(s)
- Eun Jung Cheon
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jung Min Yoon
- Department of Pediatrics, Konyang University Hospital, Daejeon, Republic of Korea
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Lee WF, Goh SJ, Lee B, Juan SJ, Asinas-Tan M, Lim BL. Renal point-of-care ultrasound performed by ED staff with limited training and 30-day outcomes in patients with renal colic. CAN J EMERG MED 2024; 26:198-203. [PMID: 38219263 DOI: 10.1007/s43678-023-00645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND AIM Emergency Department (ED) renal point-of-care ultrasound (PoCUS) in renal colic by accredited specialists has good prognostic value. This may not be generalizable to under-resourced EDs. We investigated PoCUS in renal colic in our ED with lesser training. METHODS We performed a single-centre health records review of adult ED patients with renal colic and PoCUS. Patients were managed by a non-ED specialist/resident doctor with no POCUS accreditation in consultation with an attending. These doctors attended a 3.5-h training session conducted by accredited attendings to examine hydronephrosis. They needed to verify their PoCUS findings with an attending during the first two weeks of their six-month posting before performing it independently. The primary outcome was 30-day urological procedures in hydronephrotic vs. non-hydronephrotic groups. Secondary outcomes were the distribution of primary outcome with grades of hydronephrosis, 30-day ED nephrolithiasis-related reattendances in hydronephrotic vs. non-hydronephrotic groups and its distribution with grades of hydronephrosis. We compared outcomes using Fisher's exact test. We also reported crude odds ratio (COR) and 95% CI of primary outcome between hydronephrotic vs. non-hydronephrotic groups. p values ≤ 0.05 were significant. RESULTS We recruited 651 patients; 160 (24.6%) without and 491 (75.4%) with hydronephrosis. Rates of grades of hydronephrosis were: mild (76.6%), moderate (13.8%), severe (1.2%) and undifferentiated (8.4%). There was a difference in 30-day urological procedures (rates [95% CI]) in hydronephrotic vs. non-hydronephrotic groups, 11.2 [8.7-14.0]% vs. 2.5 [1.0-6.3]%; p < 0.001; COR (95% CI) 4.9 (1.8-13.8); p = 0.002. Increasing 30-day urological procedural rates were associated with increasing grade of hydronephrosis [no: 2.5%, mild: 7.7%, moderate: 23.5%, severe: 67.0% and undifferentiated: 14.6%; p < 0.001]. No differences occurred in other secondary outcomes. CONCLUSIONS Renal PoCUS could be performed by non-ED specialist/resident doctors to identify patients without hydronephrosis who rarely required urological intervention. Hydronephrotic patients could benefit from further risk stratification.
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Affiliation(s)
- W F Lee
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore.
| | - S J Goh
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - Berlin Lee
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - S J Juan
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - Marxengel Asinas-Tan
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - B L Lim
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
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Barton MF, Brower CH, Barton BL, Duggan NM, Baugh CW, Haleblian GE, Goldsmith AJ. POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation. Am J Emerg Med 2023; 74:41-48. [PMID: 37769445 DOI: 10.1016/j.ajem.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/05/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure. METHODS We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure. RESULTS Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually. CONCLUSION If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.
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Affiliation(s)
- Michael F Barton
- Department of Emergency Medicine, University of Chicago Medicine, Chicago, IL, USA.
| | - Charles H Brower
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA.
| | - Brenna L Barton
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Nicole M Duggan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - George E Haleblian
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Goldsmith
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Beeston D, Dirrig H, Cole L. The utility of clinicopathological findings and point-of-care ultrasound in increasing the index of suspicion of ureteral obstruction in azotaemic cats presenting to the emergency room. J Small Anim Pract 2023; 64:781-787. [PMID: 37565352 DOI: 10.1111/jsap.13661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 03/06/2023] [Accepted: 04/21/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES Ureteral obstruction is a common post-renal cause of azotaemia in cats. The objective of this study was to describe clinicopathological and point-of-care ultrasound findings in azotaemic cats that may increase the index of suspicion of ureteral obstruction. MATERIALS AND METHODS A retrospective case-control study was conducted of azotaemic cats presenting to the emergency room of a referral teaching hospital. Cats were included if they were azotaemic and had point-of-care ultrasound and formal ultrasound performed. Cats were grouped into obstructed and non-obstructed groups based on formal specialist ultrasound and pyelography. Point-of-care ultrasound findings were described, including renal size and symmetry, renal pelvis dilation, perinephric fluid, and visualisation of the proximal ureter or calculi. Univariate analysis was performed to identify historical, biochemical and point-of-care ultrasound findings associated with ureteral obstruction before multivariate analysis. RESULTS One hundred twenty-two azotaemic cats met the inclusion criteria. Seventy-four cats were included in the obstructed azotaemic group and 48 cats in the non-obstructed azotaemic groups. Point-of-care ultrasound abnormalities were detected in 60 of 74 (81.1%) obstructed cats and 18 of 48 (37.5%) non-obstructed cats. Renal pelvis dilation (odds ratio 38.8; 95% confidence interval 2.9 to 515), hyporexia (odds ratio 5.9; 95% confidence interval 1.15 to 30.13), hypercalcaemia (odds ratio 16.6; 95% confidence interval 1.2 to 223.0) and hypokalaemia (odds ratio 21.7; 1.33 to 354.62) were more likely to be associated with ureteral obstruction than non-obstructive disease. CLINICAL SIGNIFICANCE Point-of-care ultrasound abnormalities are documented frequently in azotaemic cats with ureteral obstruction. Cats with renal pelvis dilation were 39 times more likely to have ureteral obstruction than non-obstructive acute kidney injury.
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Affiliation(s)
- D Beeston
- Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, Hertfordshire, AL9 7TA, UK
| | - H Dirrig
- Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, Hertfordshire, AL9 7TA, UK
| | - L Cole
- Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, Hertfordshire, AL9 7TA, UK
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Kim HJ, Oh SH. Comprehensive prediction of urolithiasis based on clinical factors, blood chemistry and urinalysis: UROLITHIASIS score. Sci Rep 2023; 13:14885. [PMID: 37689768 PMCID: PMC10492849 DOI: 10.1038/s41598-023-42208-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/06/2023] [Indexed: 09/11/2023] Open
Abstract
Comprehensive prediction of urolithiasis using available factors obtained in the emergency department may aid in patient-centered diagnostic imaging decisions. This retrospective study analyzed the clinical factors, blood chemistry and urine parameters of patients who underwent nonenhanced urinary computed tomography for suspected urolithiasis. A scoring system was developed from a logistic regression model and was tested using the area under the curve (AUC). The prevalence of urolithiasis and important possible causes in the three risk subgroups were determined. Finally, the scoring model was validated. In the derivation cohort (n = 673), 566 patients were diagnosed with urolithiasis. Age > 35 years, history of urolithiasis, pain duration < 8 h, nausea/vomiting, costovertebral angle tenderness, serum creatinine ≥ 0.92 mg/dL, erythrocytes ≥ 10/high power field, no leukocytes ≤ + , and any crystalluria were retained in the final multivariable model and became part of the score. This scoring model demonstrated good discrimination (AUC 0.808 [95% CI, 0.776-0.837]). In the validation cohort (n = 336), the performance was similar (AUC 0.803 [95% CI, 0.756-0.844]), surpassing that of the STONE score (AUC 0.654 [95% CI, 0.601-0.705], P < 0.001). This scoring model successfully stratified patients according to the probability of urolithiasis. Further validation in various settings is needed.
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Affiliation(s)
- Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06509, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06509, Republic of Korea.
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8
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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Kim DJ, Bell CR, Jelic T, Thavanathan R, Heslop CL, Myslik F, Lewis D, Atkinson P, Chenkin J, Buchanan IM, Olszynski P, Sheppard G, Burwash-Brennan T, Lalande E. Point-of-Care Ultrasound (POCUS) Literature Primer: Key Papers on Renal and Biliary POCUS. Cureus 2023; 15:e37294. [PMID: 37168176 PMCID: PMC10166360 DOI: 10.7759/cureus.37294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Daniel J Kim
- Department of Emergency Medicine, University of British Columbia, Vancouver, CAN
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, CAN
| | - Colin R Bell
- Department of Emergency Medicine, University of Calgary, Calgary, CAN
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | | | - Claire L Heslop
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, CAN
| | - Frank Myslik
- Department of Emergency Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, CAN
| | - David Lewis
- Department of Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
- Department of Emergency Medicine, Dalhousie University New Brunswick, Saint John, CAN
| | - Paul Atkinson
- Department of Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
- Department of Emergency Medicine, Dalhousie University New Brunswick, Saint John, CAN
| | - Jordan Chenkin
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, CAN
| | - Ian M Buchanan
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, CAN
| | - Paul Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, CAN
| | - Gillian Sheppard
- Department of Emergency Medicine, Memorial University of Newfoundland, St. John's, CAN
| | | | - Elizabeth Lalande
- Department of Emergency Medicine, Université Laval, Quebec City, CAN
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10
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CT Use Reduction In Ostensive Ureteral Stone (CURIOUS). Am J Emerg Med 2023; 67:168-175. [PMID: 36898306 DOI: 10.1016/j.ajem.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
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.
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Savin Z, Mintz I, Lifshitz K, Achiam L, Aviram G, Bar-Yosef Y, Yossepowitch O, Sofer M. The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments. Emerg Radiol 2023; 30:167-174. [PMID: 36680669 DOI: 10.1007/s10140-023-02114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Ziv Savin
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel.
| | - Ishai Mintz
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Karin Lifshitz
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Lauren Achiam
- Department of Emergency Medicine, Tel-Aviv Sourasky Medical Center, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Galit Aviram
- Department of Radiology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuval Bar-Yosef
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Ofer Yossepowitch
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Mario Sofer
- Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv, 6423906, Israel.,Department of Endourology Unit, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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12
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Dahm P, Koziarz A, Gerardo CJ, Nishijima DK, Jung JH, Benipal S, Raja AS. A systematic review and meta‐analysis of clinical signs, symptoms, and imaging findings in patients with suspected renal colic. J Am Coll Emerg Physicians Open 2022; 3:e12831. [DOI: 10.1002/emp2.12831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 09/18/2022] [Accepted: 09/22/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Philipp Dahm
- Urology Section Minneapolis VA Medical Center and Department of Urology University of Minnesota Minneapolis Minnesota USA
| | - Alex Koziarz
- Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Charles J. Gerardo
- Department of Emergency Medicine Duke University Medical Center Durham North Carolina USA
| | - Daniel K. Nishijima
- Department of Emergency Medicine Davis School of Medicine University of California Sacramento California USA
| | - Jae Hung Jung
- Department of Urology Yonsei University Wonju College of Medicine Wonju Gangwon‐do South Korea
| | - Simranjeet Benipal
- College of Medicine California Northstate University Elk Grove California USA
| | - Ali S. Raja
- Department of Emergency Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
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13
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Ok F, Durmuş E. External Validation of CHOKAI and STONE Scores for Detecting Ureter Stones in the Eastern Turkish Population. JOURNAL OF UROLOGICAL SURGERY 2022. [DOI: 10.4274/jus.galenos.2022.2022.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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14
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Sasipattarapong P, Omer T, Sajed D, Shin H, Lam CN, Mailhot T. Point‐of‐care renal ultrasound: Are longitudinal views of the kidney alone sufficient to rule out hydronephrosis? J Am Coll Emerg Physicians Open 2022; 3:e12794. [PMID: 35978655 PMCID: PMC9365235 DOI: 10.1002/emp2.12794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 06/27/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Piyachat Sasipattarapong
- Department of Emergency Medicine, Keck School of Medicine University of Southern California Los Angeles California USA
| | - Talib Omer
- Department of Emergency Medicine, Keck School of Medicine University of Southern California Los Angeles California USA
| | - Dana Sajed
- Department of Emergency Medicine, Keck School of Medicine University of Southern California Los Angeles California USA
| | - Heeseop Shin
- Department of Radiology Los Angeles County + University of Southern California Los Angeles California USA
| | - Chun Nok Lam
- Department of Emergency Medicine, Keck School of Medicine University of Southern California Los Angeles California USA
- Department of Preventive Medicine Keck School of Medicine University of Southern California Los Angeles California USA
| | - Thomas Mailhot
- Department of Emergency Medicine, Keck School of Medicine University of Southern California Los Angeles California USA
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15
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Ang JS, Wong SYV, Ooi CK. Use of STONE Score to Predict Urolithiasis in an Asian Emergency Department. J Acute Med 2022; 12:53-59. [PMID: 35860712 PMCID: PMC9283116 DOI: 10.6705/j.jacme.202206_12(2).0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/27/2021] [Accepted: 07/09/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND The STONE score was developed to predict uncomplicated ureteral stones in patients so that they can be managed without imaging. Validation studies had been conducted previously but the results were varied. This study aims to investigate the utility of the STONE score in an emergency department in Singapore. METHODS We retrospectively analyzed the records of adult patients presenting with ureteric colic in the emergency department in 2015. STONE score as well as the proportion of urolithiasis diagnosed on advanced imaging in each STONE score group were calculated. Logistic regression was used to calculate the odds ratios (ORs) for the STONE score components in our study and compared with the ORs obtained in the original study. Measures of diagnostic accuracy for a high STONE score were also calculated. RESULTS 753 cases were included in the final analysis. Among patients with a high STONE score, 66.7% had urolithiasis and 2.6% had significant alternative diagnoses. Compared to original studies, ORs for the STONE score components obtained for our study were different. From our study, the sensitivity of a high STONE score was 47.0%, specificity was 68.7%, positive predictive value was 66.7%, negative predictive value was 49.3%, positive likelihood ratio was 1.50, and negative likelihood ratio was 0.77. CONCLUSION The STONE score is not expected to perform well in Singapore based on our study. It should be used with caution in similar Asian populations.
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Affiliation(s)
| | - Su Yee Vanice Wong
- National University Health System Department of Internal Medicine Singapore
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16
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EMEM MK, HOKENEK NM, KILIÇ M. Investigation of the CHOKAI score used to predict ureteral stones in patients presenting to the emergency department with renal colic. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1100861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Mehmet Kemal EMEM
- Department of Emergency Medicine, Balıklıgöl State Hospital, Şanlıurfa, Turkey
| | - Nihat Mujdat HOKENEK
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Mazlum KILIÇ
- Department of Emergency Medicine, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, İstanbul, Turkey
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17
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Castelletto S, Amore G, Giudice CA, Orso D, Copetti R. A Preliminary Investigation on the “Swinging Kidney”: A Sonographic Sign Useful for Diagnosing Renal Colic. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793211073693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: During acute renal colic due to nephrolithiasis, a new sonographic diagnostic sign was noted, called “a swinging kidney.” This term was given due to a characteristic anteroposterior “rolling” movement of the kidney. A preliminary investigation was conducted to evaluate the correlation between this new diagnostic sign and nephrolithiasis. Materials and Methods: An exploratory observational investigation was conducted on adult patients who accessed an emergency medicine department, with acute renal colic, between June 1, 2019, and October 31, 2019. Results: Thirty-seven patients were enrolled. The “swinging kidney” was present in 26 cases (70%). This sign was correlated with a stone’s diameter of less than 10 mm (χ2: 4.68; P = .031), and with a stone localization in the juxtavesical ureter tract site (χ2: 10.83; P = .029). Spontaneously stone expulsion was correlated with the presence of the “swinging kidney” (χ2: 4.66; P = .031); with the minor degree of hydronephrosis (χ2: 16.82; P = .0008), and with a distal localization of the stone (χ2: 25.11; P = 1:47 × 10−5). Conclusion: The “swinging kidney” may be a promising diagnostic sign that could be useful in diagnosing nephrolithiasis besides the other indirect sonographic signs. This new diagnostic sign could have a prognostic role.
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Affiliation(s)
- Silvia Castelletto
- Department of Emergency Medicine, ASUFC Community Hospital of Latisana, Latisana, Italy
| | - Giulia Amore
- Department of Emergency Medicine, ASUFC Community Hospital of Latisana, Latisana, Italy
| | - Caterina Anna Giudice
- Department of Emergency Medicine, ASUFC Community Hospital of Latisana, Latisana, Italy
| | - Daniele Orso
- Department of Medicine, University of Udine, Udine, Italy
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Roberto Copetti
- Department of Emergency Medicine, ASUFC Community Hospital of Latisana, Latisana, Italy
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18
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Can plain film radiography improve the emergency department detection of clinically important urinary stones? Am J Emerg Med 2021; 50:449-454. [PMID: 34492590 DOI: 10.1016/j.ajem.2021.08.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/25/2021] [Accepted: 08/28/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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19
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Innes GD, Scheuermeyer FX, McRae AD, Teichman JMH, Lane DJ. Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic. CAN J EMERG MED 2021; 23:687-695. [PMID: 34304393 DOI: 10.1007/s43678-021-00168-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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Affiliation(s)
- Grant D Innes
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joel M H Teichman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Daniel J Lane
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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20
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Eraybar S, Yuksel M. The prospective evaluation of the effectiveness of scoring systems in the emergency department in cases with suspected ureteral stones: STONE? CHOKAI? Am J Emerg Med 2021; 49:94-99. [PMID: 34098332 DOI: 10.1016/j.ajem.2021.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Suna Eraybar
- University of Health Sciences Turkey, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Emergency Medicine, Bursa, Turkey.
| | - Melih Yuksel
- University of Health Sciences Turkey, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Emergency Medicine, Bursa, Turkey.
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Doty E, DiGiacomo S, Gunn B, Westafer L, Schoenfeld E. What are the clinical effects of the different emergency department imaging options for suspected renal colic? A scoping review. J Am Coll Emerg Physicians Open 2021; 2:e12446. [PMID: 34179874 PMCID: PMC8208654 DOI: 10.1002/emp2.12446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Erik Doty
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Stephen DiGiacomo
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Bridget Gunn
- Information and Knowledge Services, Health Sciences Library, Baystate Medical CenterSpringfieldMAUSA
| | - Lauren Westafer
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
- Institute for Healthcare Delivery and Population ScienceUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Elizabeth Schoenfeld
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
- Institute for Healthcare Delivery and Population ScienceUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
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22
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Jones P, Pietropaolo A, Chew BH, Somani BK. Atlas of scoring systems, grading tools and nomograms in Endourology: A comprehensive overview from The TOWER Endourological Society research group. J Endourol 2021; 35:1863-1882. [PMID: 33878937 DOI: 10.1089/end.2021.0124] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION With an increase in the prevalence of kidney stone disease (KSD), there has been a universal drive to develop reliable and user-friendly tools such as grading systems and predictive nomograms. An atlas of scoring systems, grading tools and nomograms in Endourology is provided in this paper. METHODS A comprehensive search of world literature was performed to identify nomograms, grading systems and classification tools in endourology related to KSD. Each of these were reviewed by the authors and have been evaluated in a narrative format with details on those which are externally validated and their respective citation count on google scholar. RESULTS A total of 54 endourological tools have been described in our atlas of endourological scoring systems, grading tools and nomograms. Of the tools, 23 (43%) are published in the last 3 years showing an increasing interest in this area. This includes 5 for percutaneous nephrolithotomy (PCNL), 6 for flexible ureteroscopy (fURS), 3 for semi-rigid URS (sURS), 9 for shockwave lithotripsy (SWL), 2 for stent encrustations, 3 for intra-operative appearance at the time of URS and 3 to classify intra-operative ureteric injury. There were 3 tools for renal colic assessment, one each for prediction of future stone event, stone classification and stone impaction and 2 for need of emergency intervention in ureteric stone. While 2 tools are related to stone recurrence, 6 are related to post-procedural complications. There are now 2 tools for simulation in endourology and 5 for patient reported outcome measures (PROMS). CONCLUSIONS A number of reliable and established tools exist currently in endourology. Each of these offers their own respective advantages and disadvantages. While nomograms and scoring systems can help in the decision making, these must be tailored to individual patients based on their specific clinical scenarios, expectations and informed consent.
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Affiliation(s)
- Patrick Jones
- Haukeland University Hospital, 60498, Urology, Bergen, Norway;
| | - Amelia Pietropaolo
- University Hospital Southampton NHS Foundation Trust, 7425, Urology, Southampton, Southampton , United Kingdom of Great Britain and Northern Ireland;
| | - Ben H Chew
- University of British Columbia, Urologic Sciences, Vancouver, British Columbia, Canada;
| | - Bhaskar K Somani
- University Hospital Southampton NHS Foundation Trust, 7425, Urology, Southampton, Southampton , United Kingdom of Great Britain and Northern Ireland.,University of Southampton, 7423, Southampton, Hampshire, United Kingdom of Great Britain and Northern Ireland;
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Application of decision rules on diagnosis and prognosis of renal colic: a systematic review and meta-analysis. Eur J Emerg Med 2020; 27:87-93. [PMID: 31356369 DOI: 10.1097/mej.0000000000000610] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Renal colic is a prevalent emergency department presentation resulting from urolithiasis. Clinical decision rules for the diagnosis of urolithiasis were developed to help clinicians with better judgment. In this systematic review, we assessed the performance of prediction rules on urolithiasis diagnosis and prognosis. MEDLINE, Embase, Web of Science, and Scopus were searched for studies on the performance of a clinical decision tool for diagnosis or prognosis of urolithiasis. Performance and accuracy of the rules were the key outcomes of interest. Databases were searched from inception to March 2019. Of the 4980 articles reviewed, 28 studies were included in the present analysis. Twenty-one studies were on urolithiasis diagnosis (including eight studies on STONE rule), and 10 studies reported urolithiasis outcomes. Studies were at low to moderate risk of bias. The pooling of data on STONE showed that the prevalence of urolithiasis in low, moderate, and high risk groups were: 12% (95% confidence interval 9%-15%), 53% (95% confidence interval 43%-62%), and 83% (95% confidence interval 75%-91%), respectively. In the high risk score group, prevalence of clinically important alternative diagnosis was 1% (95% confidence interval 0%-2%) and 11% (95% confidence interval 8%-13%) of patients needed intervention. STONE scoring system is useful in estimating the prevalence of urolithiasis but high heterogeneity among the studies makes it unsuitable for application. Other decision tools were poorly studied and cannot be recommended for clinical use.
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Faget C, Millet I, Sebbane M, Thuret R, Verheyden C, Curros-Doyon F, Molinari N, Taourel P. Imaging strategies for patients with suspicion of uncomplicated colic pain: diagnostic accuracy and management assessment. Eur Radiol 2020; 31:2983-2993. [PMID: 33051735 DOI: 10.1007/s00330-020-07264-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/15/2020] [Accepted: 09/04/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Compare different imaging scenarios in the diagnosis of uncomplicated renal colic due to urolithiasis (URCU). MATERIALS AND METHODS A total of 206 prospectively included patients had been admitted with suspected URCU and had undergone abdominal plain film (APF), US and unenhanced CT after clinical STONE score evaluation. CT was the reference standard. We assessed sensitivity (Se), specificity (Spe) and Youden index for colic pain diagnosis, percentage of patients managed by urologic treatment with stone identified, percentage of alternative diagnoses (AD) and exposure to radiation, according to single imaging approaches, strategies driven by patient characteristics and conditional imaging strategies after APF and US. RESULTS One hundred (48.5%) patients had a final diagnosis of URCU and 19 underwent urologic treatment. The conditional strategy, i.e. CT in patients who had no stone identified at US, had a perfect sensitivity and specificity. This enabled diagnosis of all stones requiring urology management while decreasing the number of CT exams by 22%. The strategy whereby CT was used when there was neither direct or indirect APF + US finding of colic pain nor alternative diagnoses in patients with a STONE score ≥ 10 had a sensitivity of 0.95 and a specificity of 0.99, identified 84% of stones managed by urologic treatment and decreased the number of CT examinations by 76%. CONCLUSION In patients with clinical findings consistent with URCU, the use of ultrasound as first-line imaging modality, with CT restricted to patients with negative US and a STONE score ≥ 10, led to a sensitivity and specificity of above 95%, identified 84% of stones requiring urological management and reduced the number of CT scans needed by fourfold. KEY POINTS • For diagnosis, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, provides both a sensitivity and specificity superior or equal to 95% and reduces the number of CT scans necessary by fourfold. • For management, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, maintains a 84% stone identification rate in urology-treated patients.
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Affiliation(s)
- Claire Faget
- Department of Medical Imaging, Montpellier University Hospital, Lapeyronie Hospital, 191, Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Ingrid Millet
- Department of Medical Imaging, Montpellier University Hospital, Lapeyronie Hospital, 191, Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Mustapha Sebbane
- Department of Emergency, Montpellier University Hospital, Lapeyronie Hospital, Montpellier, France
| | - Rodolphe Thuret
- Department of Urology and Renal Transplantation, Montpellier University Hospital, Lapeyronie Hospital, Montpellier, France
| | - Cécile Verheyden
- Department of Medical Imaging, Montpellier University Hospital, Lapeyronie Hospital, 191, Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Fernanda Curros-Doyon
- Department of Medical Imaging, Montpellier University Hospital, Lapeyronie Hospital, 191, Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Nicolas Molinari
- Department of Biostatistics and Medical Information, Montpellier University Hospital, Lapeyronie Hospital, Montpellier, France
| | - Patrice Taourel
- Department of Medical Imaging, Montpellier University Hospital, Lapeyronie Hospital, 191, Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
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The comparison of two prediction models for ureteral stones: CHOKAI and STONE scores. Am J Emerg Med 2020; 44:187-191. [PMID: 33041128 DOI: 10.1016/j.ajem.2020.08.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 11/21/2022] Open
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Minotti B, Treglia G, Pascale M, Ceruti S, Cantini L, Anselmi L, Saporito A. Prevalence of microhematuria in renal colic and urolithiasis: a systematic review and meta-analysis. BMC Urol 2020; 20:119. [PMID: 32770985 PMCID: PMC7414650 DOI: 10.1186/s12894-020-00690-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/29/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This systematic review and meta-analysis aims to investigate the prevalence of microhematuria in patients presenting with suspected acute renal colic and/or confirmed urolithiasis at the emergency department. METHODS A comprehensive literature search was conducted to find relevant data on prevalence of microhematuria in patients with suspected acute renal colic and/or confirmed urolithiasis. Data from each study regarding study design, patient characteristics and prevalence of microhematuria were retrieved. A random effect-model was used for the pooled analyses. RESULTS Forty-nine articles including 15'860 patients were selected through the literature search. The pooled microhematuria prevalence was 77% (95%CI: 73-80%) and 84% (95%CI: 80-87%) for suspected acute renal colic and confirmed urolithiasis, respectively. This proportion was much higher when the dipstick was used as diagnostic test (80 and 90% for acute renal colic and urolithiasis, respectively) compared to the microscopic urinalysis (74 and 78% for acute renal colic and urolithiasis, respectively). CONCLUSIONS This meta-analysis revealed a high prevalence of microhematuria in patients with acute renal colic (77%), including those with confirmed urolithiasis (84%). Intending this prevalence as sensitivity, we reached moderate values, which make microhematuria alone a poor diagnostic test for acute renal colic or urolithiasis. Microhematuria could possibly still important to assess the risk in patients with renal colic.
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Affiliation(s)
- Bruno Minotti
- Emergency Department, Cantonal Hospital of St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
| | - Giorgio Treglia
- Heath Technology Assessment Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Mariarosa Pascale
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Samuele Ceruti
- Department of Intensive Care Medicine, Clinica Luganese, Lugano, Switzerland
| | - Laura Cantini
- Department of Anesthesia, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Luciano Anselmi
- Department of Anesthesia, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Andrea Saporito
- Department of Anesthesia, Ospedale San Giovanni, Bellinzona, Switzerland
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Acar YA, Uysal E. External validation of STONE, modified STONE, and CHOKAI scores for the diagnosis of ureteral stones in the Turkish population. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920945476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Scoring systems seem to be effective in the management of patients with uncomplicated ureteral stones. However, their efficiency may differ by population. Objectives: We aimed to validate STONE, modified STONE, and CHOKAI scores for the diagnosis of ureteral stones in the Turkish population. Methods: We conducted a retrospective chart review between 01 February 2018 and 30 November 2018, in an academic emergency department. Demographics, laboratory findings, and radiologic tests of patients with flank pain were obtained. Computed tomography was used as the gold standard for the diagnosis of ureteral stones. STONE, modified STONE, and CHOKAI scores were calculated for each patient. The performance of the scoring systems was compared in terms of their specificity, sensitivity, positive likelihood ratio, negative likelihood ratio, negative predictive value, and positive predictive value. Results: A total of 157 patients were included in the study. The mean age was 38.47 ± 14.87 years, and 103 (65.6%) of the patients were males. The prevalence of ureteral stones was 84.0%, 88.9%, and 85.0% in the high-risk patients and 12%, 9.4%, and 22.7% in the low-risk patients for the STONE, modified STONE, and CHOKAI scores, respectively. Area under the curve values for the STONE, modified STONE, and CHOKAI scores were 0.776 (p = 0.001; 0.692–0.860 95% confidence interval), 0.825 (p < 0.001; 0.749–0.901 95% confidence interval), and 0.869 (p < 0.001; 0.806–0.932 95% confidence interval), respectively. The specificity and sensitivity values of STONE, modified STONE, and CHOKAI scores for the diagnosis of ureteral stones were 64.71, 71.70; 70.59, 87.74; and 66.67, 90.57, respectively. Conclusion: The CHOKAI score displayed the best performance compared to STONE and modified STONE in diagnosing ureteral stones in the Turkish population.
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Affiliation(s)
- Yahya Ayhan Acar
- Department of Emergency Medicine, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Emin Uysal
- Department of Emergency Medicine, Bagcilar Training and Research Hospital, Istanbul, Turkey
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Schoenfeld EM, Houghton C, Patel PM, Merwin LW, Poronsky KP, Caroll AL, Sánchez Santana C, Breslin M, Scales CD, Lindenauer PK, Mazor KM, Hess EP. Shared Decision Making in Patients With Suspected Uncomplicated Ureterolithiasis: A Decision Aid Development Study. Acad Emerg Med 2020; 27:554-565. [PMID: 32064724 DOI: 10.1111/acem.13917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis. METHODS We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time. RESULTS From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested. CONCLUSIONS Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
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Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Connor Houghton
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Pooja M. Patel
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Leanora W. Merwin
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Kye P. Poronsky
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | | | | | - Maggie Breslin
- Design for Social Innovation Program School of Visual Arts (SVA) New York NY
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery Duke University School of Medicine Durham NC
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical Schooland the Meyers Primary Care Institute Worcester MA
| | - Erik P. Hess
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham AL
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Sibley S, Roth N, Scott C, Rang L, White H, Sivilotti MLA, Bruder E. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J 2020; 12:31. [PMID: 32507905 PMCID: PMC7276462 DOI: 10.1186/s13089-020-00178-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
Abstract
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
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Affiliation(s)
- Stephanie Sibley
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
| | - Nathan Roth
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Charles Scott
- Department of Radiology, Queen's University, Kingston, ON, Canada
| | - Louise Rang
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Heather White
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | | | - Eric Bruder
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
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Derivation of a clinical predicting rule for obstructive urolithiasis and alternative diagnosis requiring urgent intervention: the CLAD score. Urolithiasis 2020; 49:145-152. [PMID: 32436003 DOI: 10.1007/s00240-020-01191-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
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.
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31
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Schoenfeld EM, Shieh MS, Pekow PS, Scales CD, Munger JM, Lindenauer PK. Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic. JAMA Netw Open 2019; 2:e1916454. [PMID: 31790565 PMCID: PMC6902745 DOI: 10.1001/jamanetworkopen.2019.16454] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients' likelihood of a subsequent urologic intervention could inform decision-making in this population. OBJECTIVES To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. MAIN OUTCOMES AND MEASURES The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. RESULTS A total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P < .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P < .001) compared with patients with all other insurance types. CONCLUSIONS AND RELEVANCE In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients.
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Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School–Baystate, Springfield
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
| | - Meng-Shiou Shieh
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
| | - Penelope S. Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
- School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Charles D. Scales
- Duke Clinical Research Institute, Division of Urologic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - James M. Munger
- Department of Emergency Medicine, University of Massachusetts Medical School–Baystate, Springfield
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield
- Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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Moore CL, Carpenter CR, Heilbrun ME, Klauer K, Krambeck AC, Moreno C, Remer EM, Scales C, Shaw MM, Sternberg KM. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. J Am Coll Radiol 2019; 16:1132-1143. [PMID: 31402228 DOI: 10.1016/j.jacr.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Christopher L Moore
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in Saint Louis, Saint Louis, Missouri
| | - Marta E Heilbrun
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin Klauer
- Emergency Medicine, University of Tennessee, Chattanooga, Tennessee; Department of Family Medicine, University of Tennessee, Knoxville, Tennessee; Department of Osteopathic Specialties, Michigan State University, East Lansing, Michigan
| | - Amy C Krambeck
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Courtney Moreno
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Erick M Remer
- Imaging Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles Scales
- Duke Clinical Research Institute and Department of Surgery (Urology), Duke University School of Medicine, Durham, North Carolina
| | - Melissa M Shaw
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kevan M Sternberg
- Department of Urology, University of Vermont Medical Center, Burlington, Vermont
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Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Ann Emerg Med 2019; 74:391-399. [PMID: 31402153 DOI: 10.1016/j.annemergmed.2019.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 12/14/2022]
Abstract
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.
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Fukuhara H, Kobayashi T, Takai S, Tawara T, Kikuta M, Sugiura A, Yamagishi A, Toyohara T, Nakane M, Tsuchiya N. External validation of the CHOKAI score for the prediction of ureteral stones: A multicenter prospective observational study. Am J Emerg Med 2019; 38:920-924. [PMID: 31337599 DOI: 10.1016/j.ajem.2019.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/27/2019] [Accepted: 07/14/2019] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Hiroki Fukuhara
- Department of Urology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata City, Yamagata Prefecture 990-9585, Japan.
| | - Tadahiro Kobayashi
- Department of Emergency and Critical Care Medicine, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata City, Yamagata Prefecture 998-9585, Japan
| | - Satoshi Takai
- Department of Urology, Nihonkai General Hospital, 30 Akiho-cho, Sakata City, Yamagata Prefecture 998-8501, Japan
| | - Toshihiro Tawara
- Department of Emergency, Hakodate Municipal Hospital, 1-10-1, Minatomachi, Hakodate City, Hokkaido 041-8680, Japan
| | - Masato Kikuta
- Department of Urology, Okitama General Hospital, 2000 Nishi-otsuka, Kawanishi Town, Yamagata Prefecture 992-0601, Japan
| | - Asumi Sugiura
- Department of Emergency, Yamagata Prefectural Central Hospital, 1800 Aoyagi, Yamagata City, Yamagata Prefecture 990-2292, Japan.
| | - Atsushi Yamagishi
- Department of Urology, Yamagata City Hospital Saiseikan, 1-3-26 Nanokamachi, Yagmagata City, Yamagata Prefecture 990-8533, Japan
| | - Tsubasa Toyohara
- Department of Emergency, Kushiro City General Hospital, 1-12 Shunkodai, Kushiro City, Hokkaido 085-0822, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata City, Yamagata Prefecture 998-9585, Japan.
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata City, Yamagata Prefecture 990-9585, Japan
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Is Point-of-Care Ultrasonography Effective for the Diagnosis of Urolithiasis? Ann Emerg Med 2019; 73:517-519. [DOI: 10.1016/j.annemergmed.2018.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 12/23/2022]
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Safaie A, Mirzadeh M, Aliniagerdroudbari E, Babaniamansour S, Baratloo A. A clinical prediction rule for uncomplicated ureteral stone: The STONE score; a prospective observational validation cohort study. Turk J Emerg Med 2019; 19:91-95. [PMID: 31321340 PMCID: PMC6612622 DOI: 10.1016/j.tjem.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/18/2019] [Accepted: 04/10/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Renal colic is one of the most common complaints in patients admitted to Emergency Department (ED). Computed Tomography (CT) is the reference standard for the diagnosis of any stones in the kidneys or ureters. However, CT has classical disadvantages, such as radiation exposure, cost and availability. Recently, STONE clinical prediction criteria were suggested to identify uncomplicated ureteral stone cases among patiens admitted to the ED with abdominal pain. Primary objective of this study was the external validation of the STONE criteria. Methods This was a diagnostic accuracy study conducted on a prospective, observational cohort. All consecutive patients who underwent a non-enhanced abdominopelvic CT scan in the ED with an initial diagnosis of ureteral stone disease were enrolled. Using a pre-prepared checklist, all data and the final diagnosis according to the CT scan were recorded. STONE score was calculated for all patients. The area under the curve (AUC) of the STONE Score and the CT, the reference standard, were compared using the ROC curve analysis. Results Totally, 237 patients (59.9% male) with an average age of 41.54 years (SD: 13.37) were evaluated, and 156 cases (65.8%) were proved to have renal stone. The mean (SD) STONE scores in the groups of patients with renal stone and in the group of patients without renal stone group were 9.1 (2.6) and 6.0 ( 2.8), respectively (p < 0.001). The area under the curve (AUC) for the STONE score was 0.789 (95% confidence interval (CI) 0.725 to 0.852). The optimum threshold value of the STONE score for the diagnosis of a renal stone was 8 or more, which had a sensitivity of 75.0% and a specificity of 70.4%. Conclusion Despite the acceptable diagnostic accuracy, further modifications and enhancements of the STONE score are needed to differentiate patients with low risk prior to imaging.
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Affiliation(s)
- Arash Safaie
- Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojdeh Mirzadeh
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Alireza Baratloo
- Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Affiliation(s)
- Jorge Elias
- Associate Professor in the Division of Imaging Sciences and Medical Physics, Head of the Department of Internal Medicine, Ribeirao Preto Medical School of University of Sao Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil. E-mail: .. https://orcid.org/0000-0002-1158-1045
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Pathan SA, Mitra B, Mirza S, Momin U, Ahmed Z, Andraous LG, Shukla D, Shariff MY, Makki MM, George TT, Khan SS, Thomas SH, Cameron PA. Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists. Acad Emerg Med 2018; 25:1129-1137. [PMID: 29663580 DOI: 10.1111/acem.13432] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/06/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Sameer A. Pathan
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
- Department of Epidemiology & Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Australia
- National Trauma Research Institute The Alfred Hospital MelbourneAustralia
| | - Biswadev Mitra
- Department of Epidemiology & Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Australia
- National Trauma Research Institute The Alfred Hospital MelbourneAustralia
- Emergency & Trauma Centre The Alfred Hospital Melbourne Australia
| | - Salman Mirza
- Emergency Radiology Section Radiology Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Umais Momin
- Emergency Radiology Section Radiology Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Zahoor Ahmed
- Emergency Radiology Section Radiology Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Lubna G. Andraous
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Dharmesh Shukla
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Mohammed Y. Shariff
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Magid M. Makki
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Tinsy T. George
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Saad S. Khan
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
| | - Stephen H. Thomas
- Emergency Department Hamad General Hospital Hamad Medical Corporation DohaQatar
- Weill Cornell Medical College in Qatar Education City Doha Qatar
| | - Peter A. Cameron
- Department of Epidemiology & Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Australia
- National Trauma Research Institute The Alfred Hospital MelbourneAustralia
- Emergency & Trauma Centre The Alfred Hospital Melbourne Australia
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Olszynski P, Anderson J, Trinder K, Domes T. Point-of-Care Ultrasound in Undergraduate Urology Education: A Prospective Control-Intervention Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2209-2213. [PMID: 29476563 DOI: 10.1002/jum.14571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/27/2017] [Accepted: 12/02/2017] [Indexed: 05/18/2023]
Abstract
OBJECTIVES The effect of point-of-care ultrasound (US) training on clinical reasoning in undergraduate medical education remains largely unknown, with concerns arising about possible confusion among learners when such clinical tools are introduced too early. We studied the effect of a urology point-of-care US module on the performance of questions designed to assess clinical reasoning in urinary tract obstruction and voiding dysfunction. METHODS All second-year medical students at the University of Saskatchewan (Regina [n = 36] and Saskatoon [n = 61]) were enrolled in the study. Each cohort participated in the urology point-of-care US module concurrently with its Foundations in the Kidney and Urinary Tract course. The Regina cohort completed the point-of-care US module 1 week before the Saskatoon cohort, thus allowing for a control-intervention comparison of script concordance question scores to evaluate the effect that the urology point-of-care US module had on clinical reasoning skills. Secondary outcomes included program evaluation metrics, such as overall course performance, urology point-of-care US objective structured clinical examination performance, and student course evaluation data. RESULTS The introduction of the urology point-of-care US module was not associated with a deterioration in scores on script concordance questions. There were no statistically significant differences between the Regina and Saskatoon students in their responses to the script concordance questions. There were statistically significant increases in student self-reported achievement of learning objectives, with the effect size being medium to large (Cohen d, 0.5-0.8). CONCLUSIONS Point-of-care US training complements standard undergraduate classroom teaching of urology. Students effectively learned the skills to apply point-of-care US in their assessment of patients, and this process did not interfere with achieving the course objectives.
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Affiliation(s)
- Paul Olszynski
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Krista Trinder
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Trustin Domes
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Chen Z, Bird VY, Ruchi R, Segal MS, Bian J, Khan SR, Elie MC, Prosperi M. Development of a personalized diagnostic model for kidney stone disease tailored to acute care by integrating large clinical, demographics and laboratory data: the diagnostic acute care algorithm - kidney stones (DACA-KS). BMC Med Inform Decis Mak 2018; 18:72. [PMID: 30119627 PMCID: PMC6098647 DOI: 10.1186/s12911-018-0652-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 08/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background Kidney stone (KS) disease has high, increasing prevalence in the United States and poses a massive economic burden. Diagnostics algorithms of KS only use a few variables with a limited sensitivity and specificity. In this study, we tested a big data approach to infer and validate a ‘multi-domain’ personalized diagnostic acute care algorithm for KS (DACA-KS), merging demographic, vital signs, clinical, and laboratory information. Methods We utilized a large, single-center database of patients admitted to acute care units in a large tertiary care hospital. Patients diagnosed with KS were compared to groups of patients with acute abdominal/flank/groin pain, genitourinary diseases, and other conditions. We analyzed multiple information domains (several thousands of variables) using a collection of statistical and machine learning models with feature selectors. We compared sensitivity, specificity and area under the receiver operating characteristic (AUROC) of our approach with the STONE score, using cross-validation. Results Thirty eight thousand five hundred and ninety-seven distinct adult patients were admitted to critical care between 2001 and 2012, of which 217 were diagnosed with KS, and 7446 with acute pain (non-KS). The multi-domain approach using logistic regression yielded an AUROC of 0.86 and a sensitivity/specificity of 0.81/0.82 in cross-validation. Increase in performance was obtained by fitting a super-learner, at the price of lower interpretability. We discussed in detail comorbidity and lab marker variables independently associated with KS (e.g. blood chloride, candidiasis, sleep disorders). Conclusions Although external validation is warranted, DACA-KS could be integrated into electronic health systems; the algorithm has the potential used as an effective tool to help nurses and healthcare personnel during triage or clinicians making a diagnosis, streamlining patients’ management in acute care.
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Affiliation(s)
- Zhaoyi Chen
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, Gainesville, Florida, 32610-0231, USA.
| | - Victoria Y Bird
- Department of Urology, University of Florida, Gainesville, Florida, USA
| | - Rupam Ruchi
- Division of Nephrology, Hypertension, & Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Mark S Segal
- Division of Nephrology, Hypertension, & Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Saeed R Khan
- Department of Pathology, Immunology, and Laboratory Medicine, Gainesville, Florida, USA
| | - Marie-Carmelle Elie
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, Gainesville, Florida, 32610-0231, USA
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Thom C, Eisenstat M, Moak J. Point-of-Care Ultrasound Identifies Urinoma Complicating Simple Renal Colic: A Case Series and Literature Review. J Emerg Med 2018; 55:96-100. [DOI: 10.1016/j.jemermed.2018.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/15/2018] [Accepted: 02/22/2018] [Indexed: 10/14/2022]
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Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2018; 25:684-698. [PMID: 29427476 DOI: 10.1111/acem.13388] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/09/2017] [Accepted: 11/14/2017] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Charles Wong
- Department of Emergency MedicineUniversity of Calgary Calgary AB Canada
- Cumming School of Medicine University of Calgary Calgary AB Canada
| | - Braden Teitge
- Department of Emergency MedicineUniversity of Calgary Calgary AB Canada
| | - Marshall Ross
- Department of Emergency MedicineUniversity of Calgary Calgary AB Canada
| | - Paul Young
- Department of Family MedicineUniversity of Calgary Calgary AB Canada
| | | | - Eddy Lang
- Department of Emergency MedicineUniversity of Calgary Calgary AB Canada
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Venkatesh AK, Scales CD, Heilbrun ME. From Ruling Out to Ruling In: Putting POCUS in Focus. Acad Emerg Med 2018; 25:699-701. [PMID: 29427478 DOI: 10.1111/acem.13389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Arjun K. Venkatesh
- Department of Emergency Medicine and Center for Outcomes Research and Evaluation Yale University School of Medicine New Haven CT
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery Duke University School of Medicine Durham NC
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Baseskioglu B, Ozakin E, Dolgun H, Arslan E, Acar N, Bilgin M, Colak E. Osmangazi University score to reduce ionizing radiation in renal colic patients in emergency department. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918765230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Computerized tomography remains the gold standard imaging in renal colic patients. In this study, we develop a scoring system to select patients in emergency department for unnecessary computerized tomography imaging in order to decrease radiation exposure. Methods: Computerized tomography imaging of patients with renal colic in emergency department were retrospectively reviewed. Symptoms, laboratory results were recorded. Significant parameters were determined by univariate and multivariate analysis. Coefficients were found to obtain score points and receiver operating curve was used to find a cut-off value. Results: A total of 123 patients with a mean age of 42 years (18–75 years) were enrolled in the study. About, 20.3% of patients were stone-free in computerized tomography. Mean stone size was 6.1 ± 1.89 mm. According to analysis, four parameters were significant; nausea, stone history, creatinine, and hematuria with a total score 9 called as Osmangazi University STONE score. Cut-off value was found as >3, which computerized tomography imaging is recommended. Conclusion: Osmangazi University STONE score is useful and simple tool in emergency department to reduce unnecessary computerized tomography imaging in renal colic patients and also lowers cost and ionizing radiation exposure.
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Affiliation(s)
- Barbaros Baseskioglu
- Department of Urology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Engin Ozakin
- Department of Emergency, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Hakan Dolgun
- Department of Emergency, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ebubekir Arslan
- Department of Emergency, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nurdan Acar
- Department of Emergency, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Muzaffer Bilgin
- Department of Statistics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ertugrul Colak
- Department of Statistics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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The evaluation and management of urolithiasis in the ED: A review of the literature. Am J Emerg Med 2018; 36:699-706. [DOI: 10.1016/j.ajem.2018.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/30/2017] [Accepted: 01/03/2018] [Indexed: 12/23/2022] Open
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Pathan SA, Mitra B, Bhutta ZA, Qureshi I, Spencer E, Hameed AA, Nadeem S, Tahir R, Anjum S, Cameron PA. A comparative, epidemiological study of acute renal colic presentations to emergency departments in Doha, Qatar, and Melbourne, Australia. Int J Emerg Med 2018; 11:1. [PMID: 29299773 PMCID: PMC5752646 DOI: 10.1186/s12245-017-0160-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 12/26/2017] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to compare the epidemiology, clinical presentations, management, and outcomes of renal colic presentations in two major academic centers from geographically diverse populations: Qatar (a country in the Afro-Asian stone belt) and South-Eastern Australia (not within a stone belt). Methods We undertook a retrospective cohort study of patients with renal colic who presented to the Hamad General Hospital Emergency Department (HGH-ED), Qatar, and The Alfred ED, Melbourne, Australia, during a period of 1 year from August 1, 2012, to July 31, 2013. Cases were identified using ICD-9-CM codes, and an electronic template was used to record the data on predefined clinical variables. Results A total of 12,223 from the HGH-ED and 384 from The Alfred ED were identified as renal colic presentations during the study period. The rate of renal colic presentations at the HGH-ED was 27.9 per 1000 ED visits compared to 6.7 per 1000 ED visits at The Alfred ED. Patients presenting to the HGH-ED were significantly younger [34.9 years (29.0–43.4) than The Alfred ED [48 years (37–60); P < 0.001]. The median stone size was larger in the HGH-ED group [6 (4–8) mm] versus The Alfred ED group [4 (3–6) mm, P < 0.001]. The intervention rate in the stone-positive population was significantly higher in the HGH-ED group as opposed to The Alfred ED group (38.7 versus 11.9%, P < 0.001). At the time of discharge, The Alfred ED group received fewer analgesic prescriptions (55.8 versus 83.5%, P < 0.001) and more tamsulosin prescriptions (25.3 versus 11.7%, P < 0.001). Conclusions Renal colic presentations to the HGH-ED, Qatar, were younger, with larger stone size mostly located in the lower ureter, compared to The Alfred ED, Melbourne, Australia. The findings suggest that the benefits of treatment including medical expulsion therapy will vary between the two populations. Differences in epidemiology and patient mix should be considered while tailoring strategies for effective management of patients with renal colic in a given setting.
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Affiliation(s)
- Sameer A Pathan
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. .,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.
| | - Biswadev Mitra
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.,Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Zain A Bhutta
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Isma Qureshi
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Elle Spencer
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Asmaa A Hameed
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Sana Nadeem
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Ramsha Tahir
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Shahzad Anjum
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, P.O.BOX 3050, Doha, Qatar
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.,Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
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Mills L, Morley EJ, Soucy Z, Vilke GM, Lam SHF. Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department. J Emerg Med 2017; 54:215-220. [PMID: 29089155 DOI: 10.1016/j.jemermed.2017.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND This review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis. METHODS A PubMed literature search was conducted for articles published between January 1, 1996 and May 31, 2017 and limited to human clinical trials written in English with relevant keywords. High-quality studies identified then underwent a structured review. Recommendations herein are made based on the literature review. RESULTS Two hundred seventy-two abstracts fulfilling the search criteria were screened and 10 appropriate articles were rigorously reviewed in detail. There were 8 prospective studies and 2 retrospective studies. Only 1 of them was a multi-institutional randomized trial. POCUS performed in the emergency department (ED) is moderately sensitive and specific in making the diagnosis of urolithiasis in symptomatic patients. Suspected urolithiasis patients evaluated initially with ED POCUS have complication rates compatible with those evaluated initially with computed tomography. CONCLUSIONS POCUS has moderate accuracy in making the diagnosis of urolithiasis. Nevertheless, it may be safely used as a first line of imaging in ED patients with suspected symptomatic urolithiaisis.
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Affiliation(s)
- Lisa Mills
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Eric J Morley
- Department of Emergency Medicine, Stony Brook University, Stony Brook, New York
| | - Zachary Soucy
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Samuel H F Lam
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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Blecher G, Meek R, Egerton-Warburton D, McCahy P. Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation. Emerg Med J 2017; 34:749-754. [PMID: 28720719 DOI: 10.1136/emermed-2016-206572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Gabriel Blecher
- Emergency Program, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.,Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Rob Meek
- Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Emergency Program, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
| | - Diana Egerton-Warburton
- Emergency Program, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.,Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Philip McCahy
- Urology, Monash Health, Clayton, Victoria, Australia
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Fukuhara H, Ichiyanagi O, Midorikawa S, Kakizaki H, Kaneko H, Tsuchiya N. Internal validation of a scoring system to evaluate the probability of ureteral stones: The CHOKAI score. Am J Emerg Med 2017. [PMID: 28633903 DOI: 10.1016/j.ajem.2017.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Hiroki Fukuhara
- Department of Urology, Nihonkai General Hospital, 30 Akiho, Sakata, Yamagata 998-8501, Japan.
| | - Osamu Ichiyanagi
- Department of Urology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata, Yamagata 990-9585, Japan.
| | - Shinichi Midorikawa
- Department of Emergency, Nihonkai General Hospital, 30 Akiho, Sakata, Yamagata 998-8501, Japan.
| | - Hiroshi Kakizaki
- Department of Urology, Nihonkai General Hospital, 30 Akiho, Sakata, Yamagata 998-8501, Japan.
| | - Hisashi Kaneko
- Department of Urology, Nihonkai General Hospital, 30 Akiho, Sakata, Yamagata 998-8501, Japan.
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata, Yamagata 990-9585, Japan
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Lange RT, Lippa SM. Sensitivity and specificity should never be interpreted in isolation without consideration of other clinical utility metrics. Clin Neuropsychol 2017; 31:1015-1028. [DOI: 10.1080/13854046.2017.1335438] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Rael T. Lange
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Bethesda, MD, USA
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Sara M. Lippa
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Bethesda, MD, USA
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