Ultrasonography by emergency physicians in patients with suspected ureteral colic

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

Background

Diagnosing a ureteral colic is sometimes difficult; however, clinicians should not fail to detect a surgical emergency. This is why diagnostic strategies depend on the imaging examinations, especially ultrasound. Prior studies have investigated the accuracy of Point of Care Ultrasound (PoCUS), but there are relatively few. This study aimed to evaluate the performance of the PoCUS in the diagnosis of renal colic. The secondary objective was to evaluate the relationship between the imaging results and the treatment performed.

Methods

After the clinical evaluation of patients aged > 18 years with suspected ureteral colic, the Emergency Physician (EP) trained in ultrasound performed PoCUS to conclude whether a diagnosis of “renal colic” should be made. A computed tomography (CT) examination was subsequently performed, to determine whether ureteral or bladder lithiasis was present to diagnose a ureteral colic. The patient’s management was decided according to the to degree of urinary tract dilatation, presence of perinephric fluid, size, and localization of stones.

Results

Of the 12 Eps in our units, seven met the training criteria for the inclusion of patients. A total of 103 patients were analyzed, and the renal colic diagnosis was retained in 85 cases after the CT examination. The accuracy of PoCUS was 91% (86; 95%) for detecting urinary tract dilatation, 83% (76; 90%) for detecting perinephric fluid, and 54% (44; 64%) for detecting lithiasis. Only high urinary tract stones with ≥ 6 mm diameter were surgically managed (p < 0.01). Conversely, distal ureteral stones with a diameter of < 6 mm were managed with medical ambulatory treatment (p < 0.05).

Conclusion

PoCUS is a good diagnostic tool, for renal colic, and could help reduce the requirement for the CT examinations and, hence, reduce induced radiation exposure.

The use of point-of-care ultrasound in a regional emergency department in KwaZulu-Natal, South Africa

Background

Formal ultrasonography has advanced to point-of-care ultrasound (POCUS) in the emergency department (ED) for the purpose of acute critical care. While POCUS application expands, little is known about POCUS utilisation in public hospital EDs. This study aimed to describe the use of POCUS in an ED in KwaZulu-Natal.

Methods

A retrospective chart review study was conducted on all patients who had POCUS exams performed in the ED at the General Justice Gizenga Mpanza Regional Hospital from 01 September 2019 to 31 March 2020. A data collection tool was used to extract the required data from the Mindray M6 ultrasound machine. The data were processed using the Statistical Package for Social Sciences (SPSS version 26) and descriptive statistics were used to summarise the data.

Results

A total of 978 POCUS were performed on 784 patients. Point-of-care ultrasound was utilised more often for focused emergency echocardiography in resuscitation (n = 383) and extended focused assessment with sonography for trauma (n = 319). The findings were normal in 17% of exams, 31% were positive, 9% were unspecified and 43% of POCUS exams were inconclusive. Seven percent of POCUS exams were performed by accredited level 1 emergency POCUS providers and ultrasounds occurred more frequently during day-shift hours than after-hours.

Conclusion

Point-of-care ultrasound core applications were utilised by ED doctors for various emergency care scenarios, mainly for trauma and cardiac assessments.

Minimizing radiation dose in management of stone disease: how to achieve 'ALARA'

PURPOSE OF REVIEW

Exposure to radiation is known to have adverse effects such as secondary malignancies. Patients with nephrolithiasis are exposed to radiation in the workup and treatment of their condition. Furthermore, exposure to radiation is often repeated due to the high recurrence rate of nephrolithiasis.

RECENT FINDINGS

We discuss practices inside and outside of the operating room to strive to keep radiation exposure as low as reasonably achievable (ALARA) for patients being treated for nephrolithiasis. These efforts include reduced dose computed tomography scans, fluoroless surgical techniques and new alternative technologies.

SUMMARY

Maintaining radiation exposure ALARA for our patients is increasingly practical. The urologist must make every effort to adhere to ALARA principles to protect patients from the stochastic effects of radiation.

Acute Kidney Injury Caused by Obstructive Nephropathy

Acute kidney injury secondary to obstructive nephropathy is a frequent event that accounts for 5 to 10% of all acute kidney injury cases and has a great impact on the morbidity and mortality in those affected. The obstruction in the urinary tract has a profound impact on kidney function due to damage produced by ischemic and inflammatory factors that have been associated with intense fibrosis. This pathology is characterized by its effects on the management of fluids, electrolytes, and the acid-base mechanisms by the renal tubule; consequently, metabolic acidosis, hyperkalemia, uremia, and anuria are seen during acute kidney injury due to obstructive nephropathy, and after drainage, polyuria may occur. Acute urine retention is the typical presentation. The diagnosis consists of a complete medical history and should include changes in urinary voiding and urgency and enuresis, history of urinary tract infections, hematuria, renal lithiasis, prior urinary interventions, and constipation. Imaging studies included tomography or ultrasound in which hydronephrosis can be seen. Management includes, in addition to drainage of the obstructed urinary tract system, providing supportive treatment, correcting all the metabolic abnormalities, and initiating renal replacement therapy when required. Although its recovery is in most cases favorable, it seems to be an undervalued event in nephrology and urology. This is because it is mistakenly believed that the resolution and recovery of kidney function is complete once the urinary tract is unobstructed. It can have serious kidney sequelae. In this review, we report the epidemiology, incidence, pathophysiological mechanisms, diagnosis, and treatment of acute kidney injury due to obstructive nephropathy.

Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study

Background and Objectives: Ultrasonography is useful in evaluating patients with renal colic and it has high sensitivity and specificity for diagnosing ureter stones by revealing hydronephrosis. We evaluated the efficacy of point-of-care ultrasonography protocol in managing patients with acute renal colic who visited the emergency department (ED). Materials and Methods: Between March 2019 and July 2019, patients who visited the ED because of renal colic were randomly assigned by date of visit either to the conventional group (CG), who underwent routine diagnostic work-up without ultrasonography, or to the ultrasonography group (UG), who underwent bedside ultrasonography as an initial diagnostic testing. When hydronephrosis was detected in the UG group, a confirmatory non-contrast abdomen computed tomography scan was promptly performed. The ED length of stay, complications, and missed or delayed high-risk diagnosis were evaluated. Results: In total, 128 of 147 analyzed patients were confirmed to have ureter stones. The ED length of stay was significantly lower in the UG group than in the CG group (mean 172 min; 95% confidence interval (CI): 151–194 min vs. mean 234 min; 95% CI: 216–252 min). The medical cost was also remarkably lower in the UG group than in the CG group (259 USD vs. 319 USD; p < 0.001). The incidence of complications within 30 days after visiting ED and missed or delayed high-risk diagnosis were not significantly different between the two groups. Conclusions: We found that protocolized point-of-care ultrasonography in patients with acute renal colic who visited the ED can more effectively reduce the length of stay and medical cost without 30-day complication than usual clinical practice.

Imaging Modalities in Genitourinary Emergencies

Emergency physicians rely on a multitude of different imaging modalities in the diagnosis of genitourinary emergencies. There are many considerations to be taken into account when deciding which imaging modality should be used first, as oftentimes several diagnostic tools can be used for the same pathologic condition. These factors include radiation exposure, sensitivity, specificity, age of patient, availability of resources, cost, and timeliness of completion. In this review, the strengths and weaknesses of different imaging tools in the evaluation of genitourinary emergencies are discussed.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Emergency Department Diagnosis and Management of Urinary Tract Infection

Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Testing often includes urinalysis and/or urine dipstick, and several pitfalls may occur in interpretation. Urine cultures should be obtained in complicated or upper UTIs but not simple and lower tract UTIs, unless a patient is pregnant. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones

Introduction

Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72–83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number.

Methods

This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results.

Results

125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2–85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82–98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65–86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63–100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria.

Conclusion

In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

My patient has abdominal and flank pain: Identifying renal causes

Acute flank and abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound (PoCUS), emergency physicians have an added tool to help identify renal problems as a cause of a patient's pain. PoCUS for hydronephrosis has a sensitivity of 72-83.3% and a varying specificity, similar to radiology-performed ultrasonography. In addition to assessment for hydronephrosis, PoCUS can help emergency physicians to exclude other serious causes of flank and abdominal pain such as the presence of an abdominal aortic aneurysm, or free fluid in the intraperitoneal space, which could represent hemorrhage. Use of PoCUS for the assessment of flank pain has resulted in more rapid diagnosis, decreased use of computed tomography, and shorter emergency department length of stay.

The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients

Objective:

Computed tomography (CT) is an imaging modality used to detect renal stones. However, there is concern about the lifetime cumulative radiation exposure attributed to CT. Ultrasonography (US) has been used to diagnose urolithiasis, thereby avoiding radiation exposure. The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial emergency department (ED) visit.

Methods:

We completed a retrospective medical record review for all adult patients who underwent ED-ordered renal US for suspected urolithiasis over a 1-year period. Independent, double data extraction was performed for all imaging reports and US results were categorized as “normal,” “suggestive of ureterolithiasis,” “ureteric stone seen” or “disease unrelated to urolithiasis.” Charts were reviewed to determine how many patients underwent subsequent CT and urologic intervention.

Results:

Of the 817 renal US procedures ordered for suspected urolithiasis during the study period, the results of 352 (43.2%) were classified as normal, and only 2 (0.6%) of these patients required urologic intervention. The results of 177 (21.7%) renal US procedures were suggestive of ureterolithiasis. Of these, 12 (6.8%) patients required urologic intervention. Of the 241 (29.5%) patients who had a ureteric stone seen on US, 15 (6.2%) required urologic intervention. The rate of urologic intervention was significantly lower in those with normal results on US (p &lt; 0.001) than in those with abnormal results on US.

Conclusion:

A normal result on renal US predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected urolithiasis.

Clinician-performed abdominal sonography

INTRODUCTION

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

METHODS

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

CONCLUSION

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

Diagnostic point-of-care ultrasound for hospitalists

We review the literature on diagnostic point-of-care ultrasound applications most relevant to hospital medicine and highlight gaps in the evidence base. Diagnostic point-of-care applications most relevant to hospitalists include cardiac ultrasound for left ventricular systolic function, pericardial effusion, and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax, and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm, and hydronephrosis; and venous ultrasound for central venous volume assessment and lower extremity deep venous thrombosis. Hospitalists and other frontline providers, as well as physician trainees at various levels of training, have moderate to excellent diagnostic accuracy after brief training programs for most of these applications. Despite the evidence supporting the diagnostic accuracy of point-of-care ultrasound, experimental evidence supporting its clinical use by hospitalists is limited to cardiac ultrasound.

The comparison of ultrasound and non-contrast helical computerized tomography for children nephrolithiasis detection

AIMS

Nephrolithiasis is less common in children than adults, but its diagnosis and management in children may be more perplexing. In this article, we compare two imaging ultrasound (US) and non-contrast helical computerized tomography (CT) for diagnosis of nephrolithiasis.

SUBJECTS AND METHODS

A total of 20 children who diagnosed as nephrolithiasis by US were imaged simultaneously by non-contrast helical CT. Their history like as family history in first and second degree relatives and urine analysis for hematuria and urine randomly calcium to creatinine ratio was obtained. All data analyzed by χ(2) and Mann-Whitney U-test in SPSS 16 and P < 0.05 was considered to be significant.

RESULTS

Out of 20 cases, only 5 cases diagnosed as nephrlithiasis by US were confirmed by CT method 2 out of 20 cases had another extrarenal origin for their complaint who diagnosed wrongly as nephrolithiasis by US. Stone size based of US that was confirmed by CT method was larger 4.6 ± 1.5 (minimum 3 max 6 mm) than non-confirmed ones 2.3 ± 0.7 mm (P 0.002). Hematuria occurred more in correct diagnosed compared with misdiagnosed (P 0.005). Positive family history and urine calcium ratio was not differed between two groups.

CONCLUSIONS

Non contrast helical CT is essential to confirm of nephrolithiasis and other extrarenal origin of complaints, which diagnosed wrongly as nephrolithiasis in children. Stone size and presence of hematuria are two major factors for right diagnosis of nephrolithiasis as US method but Urine calcium excretion ratio or positive family history cannot be predictive as this study.

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

STUDY OBJECTIVE

Hydronephrosis is readily visible on ultrasonography and is a strong predictor of ureteral stones, but ultrasonography is a user-dependent technology and the test characteristics of clinician-performed ultrasonography for hydronephrosis are incompletely characterized, as is the effect of ultrasound fellowship training on predictive accuracy. We seek to determine the test characteristics of ultrasonography for detecting hydronephrosis when performed by clinicians with a wide range of experience under conditions of direct patient care.

METHODS

This was a prospective study of patients presenting to an academic medical center emergency department with suspected renal colic. Before computed tomography (CT) results, an emergency clinician performed bedside ultrasonography, recording the presence and degree of hydronephrosis. CT data were abstracted from the dictated radiology report by an investigator blinded to the bedside ultrasonographic results. Test characteristics of bedside ultrasonography for hydronephrosis were calculated with the CT scan as the reference standard, with test characteristics compared by clinician experience stratified into 4 levels: attending physicians with emergency ultrasound fellowship training, attending physicians without emergency ultrasound fellowship training, ultrasound experienced non-attending physician clinicians (at least 2 weeks of ultrasound training), and ultrasound inexperienced non-attending physician clinicians (physician assistants, nurse practitioners, off-service rotators, and first-year emergency medicine residents with fewer than 2 weeks of ultrasound training).

RESULTS

There were 670 interpretable bedside ultrasonographic tests performed by 144 unique clinicians, 80.9% of which were performed by clinicians directly involved in the care of the patient. On CT, 47.5% of all subjects had hydronephrosis and 47.0% had a ureteral stone. Among all clinicians, ultrasonography had a sensitivity of 72.6% (95% confidence interval [CI] 65.4% to 78.9%), specificity of 73.3% (95% CI 66.1% to 79.4%), positive likelihood ratio of 2.72 (95% CI 2.25 to 3.27), and negative likelihood ratio of 0.37 (95% CI 0.31 to 0.44) for hydronephrosis, using hydronephrosis on CT as the criterion standard. Among attending physicians with fellowship training, ultrasonography had sensitivity of 92.7% (95% CI 83.8% to 96.9%), positive likelihood ratio of 4.97 (95% CI 2.90 to 8.51), and negative likelihood ratio of 0.08 (95% CI 0.03 to 0.23).

CONCLUSION

Overall, ultrasonography performed by emergency clinicians was moderately sensitive and specific for detection of hydronephrosis as seen on CT in patients with suspected renal colic. However, presence or absence of hydronephrosis as determined by emergency physicians with fellowship training in ultrasonography yielded more definitive test results. For clinicians without fellowship training, there was no significant difference between groups in the predictive accuracy of the application according to experience level.

Implementation of a successful incentive-based ultrasound credentialing program for emergency physicians

Introducion:

With the rapid expansion of emergency ultrasound, resident education in ultrasound has become more clearly developed and broadly integrated. However, there still exists a lack of guidance in the training of physicians already in practice to become competent in this valuable skill. We sought to employ a step-wise, goal-directed, incentive-based credentialing program to educate emergency physicians in the use of emergency ultrasound. Successful completion of this program was the primary outcome.

Methods:

The goal was for the physicians to gain competency in 8 basic ultrasound examinations types: aorta, focused assessment with sonography in trauma, cardiac, renal, biliary, transabdominal pelvic, transvaginal pelvic, and deep venous thrombosis. We separated the 2.5 year training program into 4 distinct blocks, with each block focusing on 2 of the ultrasound examination types. Each block consisted of didactic and hands-on sessions with the goal of the physician completing 25 technically-adequate studies of each examination type. There was a financial incentive associated with completion of these requirements.

Results:

A total of 31 physicians participated in the training program. Only one physician, who retired prior to the end of the 2.5 year period, did not successfully complete the program. All have applied for and received hospital privileging in emergency ultrasound and incorporated it into their daily practice.

Conclusion:

We found that a step-wise, incentive-based ultrasound training program with a combination of didactics and ample hands-on teaching was successful in the training of physicians already in practice.

Focused renal sonography performed and interpreted by internal medicine residents

OBJECTIVES

Intensivist-performed focused sonography, including renal sonography, is becoming accepted practice. Whether internal medicine residents can be trained to accurately rule out renal obstruction and identify sonographic findings of chronic kidney disease is unknown. The purpose of this study was to test the ability of residents to evaluate for this specific constellation of findings.

METHODS

Internal medicine residents were trained in a 5-hour module on focused renal sonography evaluating renal length, echogenicity, hydronephrosis, and cysts on a convenience sample of medical ward, intermediate care, and medical intensive care unit patients. All patients underwent comprehensive sonography within 24 hours. The primary outcome was represented by the Fleiss κ statistic, which indicated the degree of interobserver agreement between residents and radiologists. Sensitivity, specificity, and positive and negative predictive values were calculated using the comprehensive radiologist-read examination as the reference.

RESULTS

Seventeen internal medicine residents imaged 125 kidneys on 66 patients. The average number of studies performed was 7.3 (SD, 6.6). Residents demonstrated excellent agreement with radiologists for hydronephrosis (κ = 0.73; P < .001; SE, 0.15; sensitivity, 94%; specificity, 93%), moderate agreement for echogenic kidneys (κ = 0.43; P < .001; SE, 0.13; sensitivity, 40%; specificity, 98%), and substantial agreement for renal cysts (κ = 0.61; P < .001; SE, 0.12; sensitivity, 60%; specificity, 96%). Residents showed sensitivity of 100% and specificity of 88% for identification of atrophic kidneys, defined as length less than 8 cm.

CONCLUSIONS

After a 5-hour training course, medical residents accurately identified hydronephrosis and key sonographic findings of chronic kidney disease in a cohort of medical patients. Screening for hydronephrosis and renal atrophy can be performed by medical residents after adequate training.

Purposeful variable selection and stratification to impute missing Focused Assessment with Sonography for Trauma data in trauma research

BACKGROUND

The Focused Assessment with Sonography for Trauma (FAST) examination is an important variable in many retrospective trauma studies. The purpose of this study was to devise an imputation method to overcome missing data for the FAST examination. Owing to variability in patients' injuries and trauma care, these data are unlikely to be missing completely at random, raising concern for validity when analyses exclude patients with missing values.

METHODS

Imputation was conducted under a less restrictive, more plausible missing-at-random assumption. Patients with missing FAST examinations had available data on alternate, clinically relevant elements that were strongly associated with FAST results in complete cases, especially when considered jointly. Subjects with missing data (32.7%) were divided into eight mutually exclusive groups based on selected variables that both described the injury and were associated with missing FAST values. Additional variables were selected within each group to classify missing FAST values as positive or negative, and correct FAST examination classification based on these variables was determined for patients with nonmissing FAST values.

RESULTS

Severe head/neck injury (odds ratio [OR], 2.04), severe extremity injury (OR, 4.03), severe abdominal injury (OR, 1.94), no injury (OR, 1.94), other abdominal injury (OR, 0.47), other head/neck injury (OR, 0.57), and other extremity injury (OR, 0.45) groups had significant ORs for missing data; the other group's OR was not significant (OR, 0.84). All 407 missing FAST values were imputed, with 109 classified as positive. Correct classification of nonmissing FAST results using the alternate variables was 87.2%.

CONCLUSION

Purposeful imputation for missing FAST examinations based on interactions among selected variables assessed by simple stratification may be a useful adjunct to sensitivity analysis in the evaluation of imputation strategies under different missing data mechanisms. This approach has the potential for widespread application in clinical and translational research, and validation is warranted.

Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period

PURPOSES

Emergency physician-performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician-performed ultrasonography for multiple categories of ultrasound use after a short training period.

BASIC PROCEDURES

This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation.

MAIN FINDINGS

A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained.

PRINCIPAL CONCLUSIONS

Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.

Comparison of conventional radiography combined with ultrasonography versus nonenhanced helical computed tomography in evaluation of patients with renal colic

The aim of this study is to determine whether kidneys ureters bladder X-ray (KUB) film combined with ultrasound (US) can be effectively used in evaluation of renal colic and miss stones with clinically significant size identified on nonenhanced computed tomography (NECT) in patients with urolithiasis. This retrospective study evaluated the clinical and radiological records of 300 patients at our institution undergoing KUB and/or US and/or NECT for the evaluation of renal colic from June 2007 to December 2010. Of patients with negative findings on KUB and/or US, 22 had renal stones on NECT (mean size 4.4 mm, range 3-8), 3 had lower ureteral stone (mean size 3.3 mm, range 2-5). In patients with isolated suspicious renal ectasia without stone image, two had renal stone on NECT (mean size 4 mm, range 2-6), 5 had upper ureteral stone (mean size 4.4 mm, range 4-6), 7 had middle ureteral stone (mean size 3.7 mm, range 3-4) and 14 had lower ureteral stone (mean size 4 mm, range 2-6). The cost-effective and almost radiation-free combination of KUB and US should be preferred for diagnosis of urolithiasis, as it detects most of the ureteral and renal calculi which are clinically significant.

The efficacy and value of emergency medicine: a supportive literature review

Study objectives

The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established.

Methods

The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included.

Results

A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles).

Conclusion

There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

Urologist-operated ultrasound and its use in urological outpatient clinics

INTRODUCTION

Ultrasonograghy plays an important role in the evaluation of urinary tract disorders in cases of medical or surgical renal disorders, because of its lower cost, availability, and lack of ionizing radiation and because with it there is no need for contrast material injection or ingestion. It needs no intervention or preparation and specifically can differentiate between the multiple causes of flank pain. Urologist-operated sonography is a quick, cost-effective, and time-saving modality for both the physician and patient for obtaining first or final diagnosis. Based on its results, patients can be selected for appropriate management and further assessment.

MATERIALS AND METHODS

The efficacy of ultrasound examination by a trained urologist in the differentiation of urological emergencies admitted in a district private clinic was studied. Between April 2008 and April 2010, a total of 724 patients (1448 renal units) had renal ultrasound performed by a trained urologist on acute admission. The sonographic findings were compared with subsequent definitive radiological investigations performed as needed, such as KUB (kidney, ureter, bladder) or IVP (intravenous pyelogram). Patient satisfaction and permission for ultrasonography were evaluated by oral consent. Loin pain was the presenting symptom in 45% of the patients (n = 326 cases).

RESULTS

Diagnosis was achieved in 96% of patients. Further evaluations were requested as needed in suspicious cases. If any hydronephrosis was detected and patients' history and/or complaints were suggestive of renal or ureteral stones, an outpatient KUB was requested. For more complex situations, IVP was the next option. Abnormal findings were recorded in 184 cases (25.5%). Mild to moderate unilateral hydronephrosis with or without hydronephrosis was the most common finding observed sonographically. The sensitivity of our ultrasonography evaluation was 99.7%.

CONCLUSION

Office urologist-operated sonograghy may supplement the information available through routine history, physical examination, and laboratory studies. Our study shows that urological trainees can use ultrasound with high levels of accuracy, thereby improving patient management with a high level of patient satisfaction.

The learning curve of resident physicians using emergency ultrasonography for obstructive uropathy

BACKGROUND

Given the time, expense, and radiation exposure associated with computed tomography (CT), ultrasonography (US) is considered an alternative imaging study that could expedite patient care in patients with suspected obstructive uropathy. However, there is a paucity of literature regarding bedside US for obstructive uropathy in the emergency department (ED), and it is unknown how much experience is required for competency in such exams.

OBJECTIVES

The objective was to assess the learning curve for the detection of obstructive uropathy of resident physicians training in ED bedside US (EUS) during a dedicated EUS elective.

METHODS

This was a prospective cohort study of residents participating in an EUS elective. Patients presenting with acute abdominal or flank pain suggestive of an obstructive uropathy were enrolled and underwent EUS prior to noncontrast CT. Physicians who had previously performed at least 10 EUS exams for obstructive uropathy recorded results on a standardized data sheet, which was subsequently compared to the results of noncontrast CT read by board-certified radiologists blinded to the results of the EUS. In addition to an unadjusted chi-square test for trend, a multivariable logistic regression analysis, adjusting for stone size and operator, was performed. Finally, generalized estimating equations were used to describe test characteristics while accounting for potential clustering between exams by operator.

RESULTS

Twenty-three resident physicians participated and enrolled a convenience sample of 393 patients. A total of 157 patients (40%) were diagnosed with an obstructing ureterolith, and three (1%) were diagnosed with nonobstructing ureterolithiasis. An unadjusted chi-square test for trend demonstrated a statistically significant increase in both sensitivity (χ(2) = 11.4, p = 0.02) and specificity (χ(2) = 6.4, p = 0.04) for each level of increase in number of exams. On multivariable regression analysis, when adjusting for size of stone and operator, for every five additional exams after the first 10 EUS exams, the odds ratio for a true positive for obstruction increased by 1.7 (95% confidence interval [CI] = 1.2 to 2.5, p = 0.003). After accounting for clustering of exams by operator, overall EUS sensitivity and specificity for obstructive uropathy were 82% (95% CI = 77% to 87%) and 88% (95% CI = 85% to 92%). Stratifying by number of exams, the sensitivity was 72% (95% CI = 62% to 80%) for the 11th through 20th exams, 90% (95% CI = 83% to 96%) for the 21st through 30th exams, and 95% (95% CI = 91% to 99%) for the 31st through 43rd exams. Likewise, specificity was 82% (95% CI = 75% to 89%) for the 11th through 20th exams, 90% (95% CI = 85% to 95%) for the 21st through 30th exams, and 92% (95% CI = 86% to 98%) for the 31st through 50th exams.

CONCLUSIONS

Physicians training in EUS may be able to accurately assess for obstructive uropathy after 30 exams.

Can bedside ultrasound assist in determining whether serum creatinine is elevated in cases of acute urinary retention?

BACKGROUND

There are no guidelines to determine which patients with acute urinary retention (AUR) require blood testing (i.e., serum creatinine) to assess for renal failure.

OBJECTIVE

To determine if hydronephrosis on bedside ultrasound correlates with an abnormal serum creatinine (Cr) level in cases of AUR.

METHODS

This was a prospective, observational study of subjects clinically diagnosed with AUR at two associated urban academic centers from October 2004 through August 2006. Emergency physicians completed a data form and performed a bedside ultrasound to determine the presence or absence of hydronephrosis. The data collected included suspected cause of AUR, amount of urinary output after Foley insertion, and blood test results. Follow-up was obtained by telephone and electronic medical record for 1 month. Standard statistics were employed.

RESULTS

Among 96 enrolled subjects with AUR, 43 had a serum Cr level obtained on the initial visit, and 10 (23%; 95% confidence interval [CI] 11-36) of these had an elevated Cr (10% [95% CI 4-16] of the study cohort). The test characteristics of hydronephrosis on bedside ultrasound to detect elevation in Cr were a sensitivity, specificity, positive predictive value, and negative predictive value of 70%, 67%, 39%, and 88%, respectively.

CONCLUSION

In cases of AUR, the prevalence of elevated creatinine is high, and hydronephrosis based on bedside ultrasonography does not correlate with elevation in creatinine.

Can the degree of hydronephrosis on ultrasound predict kidney stone size?

OBJECTIVE

The aim of the study was to determine if the degree of hydronephrosis on focused emergency renal ultrasound correlates with kidney stone size on computed tomography.

METHODS

A retrospective study was performed on all adult patients in the emergency department who had a focused emergency renal ultrasound and ureterolithiasis on noncontrast computed tomography. Severity of hydronephrosis was determined by the performing physician. Ureteral stone size was grouped into 5 mm or less and larger than 5 mm based on likelihood of spontaneous passage.

RESULTS

One hundred seventy-seven ultrasound scans were performed on patients with ureteral calculi. When dichotomized using test characteristic analysis, patients with none or mild hydronephrosis (72.9%) were less likely to have ureteral calculi larger than 5 mm than those with moderate or severe hydronephrosis (12.4% vs 35.4%; P < .001) with a negative predictive value of 0.876 (95% confidence interval, 0.803-0.925).

CONCLUSION

Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.

Ultrasonography for ureteral stone detection in patients with or without caliceal dilatation

PURPOSE

To evaluate the relationship between the degree of hydronephrosis and the detection rates of ureteral stones with ultrasonography (US).

METHODS

Of 250 consecutive patients with suspected ureterolithiasis, 214 who were diagnosed with ureterolithiasis were enrolled in this study. First, both kidneys were observed by US to evaluate the intrarenal collecting systems. Thereafter, the possible course of the ureters and the bladder were searched to find any stones.

RESULTS

Stones were clearly observed in 80 (73%) of 109 patients with caliceal dilatation, whereas stones were clearly observed in 46 (44%) of 105 patients without dilatation (P < 0.05). Of the former 80 patients, 31 (39%) had stones in the ureterovesical junction (UVJ), whereas 51 (64%) had stones in the more proximal ureter. Of the latter 46 patients, 37 (80%) had stones in the UVJ or the bladder, whereas 9 (20%) had stones in the more proximal ureter.

CONCLUSION

The US detection rate of ureteral stones was high in patients with caliceal dilatation. The whole ureter should be scanned in patients with caliceal dilatation for detection of ureteral stones. Even when patients have no caliceal dilatation, it is still considered to be useful to scan the UVJ and the bladder.

Emergency ultrasound usage among recent emergency medicine residency graduates of a convenience sample of 14 residencies

BACKGROUND

Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown.

OBJECTIVES

We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings.

METHODS

Graduates from 14 EM residency programs in 2003-2005 were surveyed on their current practice setting and use of EMBU.

RESULTS

There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported "high use" of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was "not enough time" (61%).

CONCLUSIONS

Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common.

Phase inversion harmonic imaging improves assessment of renal calculi: a comparison with fundamental gray-scale sonography

PURPOSE

To compare phase inversion harmonic imaging (PIHI) with fundamental imaging (FI) in the evaluation of renal calculi.

METHODS

Thirty adult patients with renal calculi (17 men, 13 women; mean age 44 years [range, 25-71]) underwent transabdominal sonographic examination of the urinary system. Both kidneys and renal calculi were examined with PIHI and FI. Overall renal conspicuity, calculus visibility, and clarity of posterior shadowing were assessed subjectively using a 4-point scale (0 being the worst, 3 being the best). The maximum diameter of the calculi was measured using both techniques. The effect of body mass index on qualitative scoring and quantitative measurements was evaluated.

RESULTS

PIHI improved overall renal conspicuity compared with FI (p < 0.001). The visibility of the calculi and clarity of posterior shadowing were significantly better with PIHI than with FI (p < 0.001 for both parameters). The maximum diameter of calculi was larger with PIHI than with FI (p < 0.001). The superiority of PIHI over FI regarding overall conspicuity of the kidney, visibility of the calculus, and clarity of posterior shadowing scores increased in the obese group (p < 0.001 for all 3 parameters). The mean calculus diameter difference between the 2 techniques was significantly higher in the obese group.

CONCLUSION

The routine use of PIHI is recommended in the evaluation of renal calculi.

Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic

OBJECTIVE

Patients presenting to the ED with obstructive nephropathies benefit from early detection of hydronephrosis. Out of hours radiological imaging is expensive and disruptive to arrange. Emergency physician ultrasound (EPU) could allow rapid diagnosis and disposition. If accurate it might avert the need for formal radiological imaging, exclude an obstruction and improve patient flow through the ED.

METHODS

This was a prospective study of a convenience sample of all adult non-pregnant patients with presumed ureteric colic attending the ED with prior ethics committee approval. An emergency physician or registrar performed a focused ultrasound scan and were blinded to the patient's other management. A computerized tomography scan was also performed for all patients while in the ED or within 24 h of the EPU. The accuracy of EPU detection of hydronephrosis was determined; using computerized tomography scans reported by a senior radiologist as the 'gold-standard'.

RESULTS

Sixty-three patients with suspected ureteric colic were enrolled of whom 57 completed both EPU and computerized tomography imaging. Forty-nine had confirmed nephrolithiasis by computerized tomography with 39 having evidence of hydronephrosis. Overall prevalence of hydronephrosis was 68% (95% confidence interval [CI] 56-79%); compared with computerized tomography, EPU had a sensitivity of 80% (95% CI 65-89%); specificity of 83% (95% CI 61-94%); positive predictive value of 91% (95% CI 75-98%) and negative predictive value of 65% (95% CI 43-83%). The overall accuracy was 81% (95% CI 69-89%).

CONCLUSION

Although the accuracy of detection of hydronephrosis after focused training in EPU is encouraging, further experience and training might improve the accuracy of EPU and allow its use as a screening tool.

History of emergency and critical care ultrasound: The evolution of a new imaging paradigm

The tradition of clinical ultrasound in the hands of physicians who provide critical care to the most acutely ill patients stretches back into the 1980s and is rich with experiences from surgical, emergency medicine, and other practices. Now, as critical care ultrasound explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field. The development and battles for the right to use ultrasound at the patient's bedside for >20 yrs is described in relation to its emergency medicine and surgical origins. Approaches to education, scanning, documentation, and organization at the national and regional levels are described.

Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic

OBJECTIVE

The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) performed by emergency physicians (EP) as a part of this algorithm.

MATERIALS AND METHODS

This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55,000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The chi2 test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression.

RESULTS

Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%.

CONCLUSION

Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.

Is fluid ingestion really necessary during ultrasonography for detecting ureteral stones? A prospective randomized study

OBJECTIVE

Ultrasonographic evaluation of ureteral stones is usually performed after fluid ingestion for filling the bladder to visualize the ureterovesical junction better. We hypothesized that water ingestion may decrease the imaging quality of ultrasonography for detecting ureter stones. In our prospective randomized study, the accuracy of ultrasonography for detecting ureteral stones performed with or without fluid intake were evaluated.

METHODS

The study population comprised 150 consecutive patients thought to have ureteral stones who underwent ultrasonography. Patients were divided into 2 groups. Group A patients ingested 500 mL of water to distend the bladder before ultrasonographic examination. Group B patients were restricted from drinking any water at least 4 hours before the procedure.

RESULTS

Ultrasonography showed 35 (67.30%) of 52 stones in group A and 68 (93.15%) of 73 stones in group B. The difference of detection rates between the 2 groups was statistically significant (P < .001). The greatest improvement in detection rates was noted in the middle ureter stones. The evaluated sensitivity and specificity rates for group A were 67% and 82%, respectively, and those for group B were 93% and 94%. When the 2 methods were compared, total accuracy of ultrasonography increased from 71% in group A to 93% in group B.

CONCLUSIONS

This prospective randomized study showed that the diagnostic accuracy of ultrasonography for detection of middle ureteral stones increased significantly when performed without any water ingestion before the procedure. We recommend that patients thought to have ureteral stones should be first examined without any fluid ingestion.