A clinical prediction rule for uncomplicated ureteral stone: The STONE score; a prospective observational validation cohort study

Comprehensive prediction of urolithiasis based on clinical factors, blood chemistry and urinalysis: UROLITHIASIS score

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.

Use of STONE Score to Predict Urolithiasis in an Asian Emergency Department

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.

Intravenous morphine plus ibuprofen or ketorolac versus intravenous morphine alone in reducing renal colic pain intensity in emergency department: A randomized, double-blind clinical trial

OBJECTIVES:

This study aimed to compare the efficacy of intravenous (IV) morphine plus ibuprofen or ketorolac versus IV morphine alone in controlling renal colic pain in the emergency department.

METHODS:

This double-blind, randomized clinical trial was conducted during November 2018 and March 2019 in Iran. Patients aged 18–65 years with acute renal colic and numerical rating scale (NRS) score of higher than 6 of 10 were enrolled to the study. They were randomly assigned to I, K, and control groups receiving 5 mg morphine with 800 mg ibuprofen (n = 65), 5 mg morphine with 30 mg ketorolac (n = 65), or only 5 mg morphine (n = 65) intravenously, respectively. NRS was evaluated 0, 15, 30, 60, and 120 min after injection.

RESULTS:

A total of 195 participants took part in the study. The presence of stone in pelvis area was higher in I group (P = 0.027). The mean rescue analgesic dose was higher in the control group and lower in K group (P = 0.031). From the 15^th min, the NRS reduction in I and K group was higher than the control group (P < 0.001), but the difference between I and K group was not statistically significant in total (P = 1.0) or in the all follow-up time intervals (15^thP = 0.864, 30^thP = 0.493, 60^thP = 0.493, and 120^th min P = 1.0). The largest difference in pain reduction was observed in 120^th min and mean of NRS was 2.9 (95% confidence interval [CI]: 2.6–3.3), 2.9 (95% CI: 2.6–3.3) and 7.0 (95% CI: 6.7–7.4) in I, K and control group, respectively. The adverse effects showed in 18.5%, 20.0%, and 13.8% of I, K, and control group, respectively.

CONCLUSION:

IV ibuprofen plus morphine and IV ketorolac plus morphine had similar effects in reducing renal colic pain but were more effective than IV morphine alone.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

NEW KNOWLEDGE ADDED BY THIS STUDY

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

IMPLICATION FOR CLINICAL PRACTICE OR POLICY

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

External validation of STONE, modified STONE, and CHOKAI scores for the diagnosis of ureteral stones in the Turkish population

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.