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Orosco E, Terai H, Lotterman S, Baker R, Friedman C, Watt A, Beaubian D, Grady J, Delgado J, Herbst MK. Point-of-care ultrasound associated with shorter length of stay than computed tomography for renal colic. Am J Emerg Med 2024; 79:167-171. [PMID: 38452429 DOI: 10.1016/j.ajem.2024.02.024] [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: 12/27/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Despite similar diagnostic effectiveness for renal colic, computed tomography (CT) is more resource intensive than point-of-care ultrasound (PoCUS). We sought to compare Emergency Department (ED) length of stay (LOS) among patients with renal colic according to imaging modality utilized. We secondarily compared rates of infection, return ED visits, missed significant pathology, and urologic intervention. METHODS This was a 12-month (1/1/22-12/31/22) multi-site retrospective cohort study of all patients diagnosed with renal colic who presented to the ED on days when at least one patient had a billable renal PoCUS examination performed. Patients with a history of genitourinary malignancy, pregnancy, renal transplant, hemodialysis, single kidney, prior visit for renal colic in the previous 30 days, or an incomplete workup were excluded. Median ED LOS was compared using a Wilcoxon rank sum test, and the 95% confidence limits for the difference between medians was calculated. Secondary outcomes were compared using a Fisher's Exact test. RESULTS Of 415 patients screened, 325 were included for analysis: 150 had CT alone, 80 had PoCUS alone, 54 had PoCUS plus CT, and 41 had neither. Median LOS for PoCUS alone was 75.0 (95% CI 39.3-110.7) minutes shorter than CT alone (231.5 vs. 307.0 min, p < 0.0001). Similar rates of infection, return visits, and missed pathology occurred across all groups (p > 0.10). Urologic interventions were higher in the PoCUS plus CT (25.9%) group compared to CT alone (7.3%), PoCUS alone (2.5%), and neither (7.3%), p < 0.0001. CONCLUSION Among patients with renal colic, PoCUS was associated with shorter ED LOS compared to CT, without differences in infection rates, return visits, or missed pathology. Patients with PoCUS plus CT had a higher rate of urologic interventions, suggesting PoCUS may have a role in identifying patients who would most benefit from CT.
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Affiliation(s)
- Emily Orosco
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Hiromi Terai
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Seth Lotterman
- Hartford Hospital, Department of Emergency Medicine, Hartford, CT, United States of America
| | - Riley Baker
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Cade Friedman
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Aren Watt
- University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Drew Beaubian
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - James Grady
- University of Connecticut School of Medicine, Department of Public Health Sciences, Farmington, CT, United States of America
| | - João Delgado
- Hartford Hospital, Department of Emergency Medicine, Hartford, CT, United States of America
| | - Meghan Kelly Herbst
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America.
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Wang M, Zhang J, Zhang B, Ma Q. Value of detected hydronephrosis and hydroureter on ultrasound for detecting a ureteral stone: a retrospective study. Urolithiasis 2023; 51:67. [PMID: 37029823 DOI: 10.1007/s00240-023-01445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
To investigate the predictive value of hydronephrosis and hydroureter in the detection of ureteral stones using ultrasound, a total of 366 patients suffering from ureteral stones confirmed by ultrasound, computed tomography (CT) and their follow-up treatments were consecutively collected. All the included patients underwent systematic ultrasound scanning of the kidney and ureter. The hydronephrosis and hydroureter in each patient were measured using a digital caliper. Then, receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values for hydronephrosis and hydroureter to predict a ureteral stone's location and size. The hydronephrosis, hydroureter, and stone size measurements showed good interobserver agreement (P < 0.001). Using the lower border of the sacroiliac joint as a demarcation point, we found larger widths of hydronephrosis and hydroureter in the proximal ureteral stone group than in the distal ureteral stone group (P < 0.001). Additionally, 10.9 mm and 5.9 mm were identified as optimal cutoff values for predicting a distal position (P < 0.001), with no significant difference in their predictive value (P > 0.05). Similar comparisons between groups based on size stratification revealed no significant difference in hydronephrosis between the > 5 mm group and the ≤ 5 mm group. However, the hydroureter was larger in the > 5 mm group than in the ≤ 5 mm group after identifying 6 mm as the best cutoff (P =0.004). In summary, the ultrasound measurement of hydronephrosis and hydroureter may predict the position and size of a possible ureteral stone in patients with colic symptoms.
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Affiliation(s)
- Meng Wang
- Department of Ultrasound, Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
| | - Jinfang Zhang
- Caixiang First Village Community Healthcare Service Center, Suzhou, 215004, China
| | - Bo Zhang
- Department of Radiology, Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Qi Ma
- Department of Ultrasound, Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
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3
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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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Liu Y, Li M, Qiang L, Sun X, Liu S, Lu TJ. Critical size of kidney stone through ureter: A mechanical analysis. J Mech Behav Biomed Mater 2022; 135:105432. [DOI: 10.1016/j.jmbbm.2022.105432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 08/20/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022]
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Point-of-Care Abdominal Ultrasonography (POCUS) on the Way to the Right and Rapid Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12092052. [PMID: 36140454 PMCID: PMC9497677 DOI: 10.3390/diagnostics12092052] [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: 07/29/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis.
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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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Haimowitz M, Gonzalez L. Renal Vein Thrombosis on Point-of-care Ultrasound in the Emergency Department: A Case Report. Clin Pract Cases Emerg Med 2022; 6:17-20. [PMID: 35226840 PMCID: PMC8885229 DOI: 10.5811/cpcem.2021.9.53714] [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: 06/17/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction This case report of renal vein thrombosis found on emergency bedside
ultrasound illustrates the expanding role of point-of-care ultrasound
(POCUS) in rapidly identifying rare renal pathologies. Case Report A 16-year-old female with a complex medical history presenting with
right-sided abdominal pain and tenderness was found to have significant
renal POCUS findings consistent with renal vein thrombosis. Conclusion In the medically complex patient with nonspecific chief complaints, it can be
challenging to rapidly narrow a broad differential diagnosis. Point-of-care
ultrasound has proven to be an extremely useful tool for this purpose. As
emergency physicians become more proficient in the use of ultrasonography,
it is likely that POCUS will be used with increasing frequency to identify
additional pathology outside its traditional applications.
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Affiliation(s)
- Michelle Haimowitz
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Laura Gonzalez
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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8
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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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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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Value of the color Doppler imaging mode in improving physicians' diagnostic performance in patients with mid-ureteric stones larger than 5 mm: a retrospective study. Urolithiasis 2021; 49:463-469. [PMID: 33576842 DOI: 10.1007/s00240-021-01250-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: 10/22/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
The aim of this study was to retrospectively evaluate the value of the color Doppler flow imaging mode compared to the gray-scale mode for diagnosing mid-ureteric stones larger than 5 mm. We consecutively collected images from 79 patients possibly suffering from mid-ureteric stones under gray-scale and color Doppler flow imaging modes. Using computed tomography as the gold standard, all the included images were reviewed in a blinded manner for the confirmation of ureteral stones by 15 physicians divided into three groups according to their clinical experience level (resident, attending, and senior). During the evaluation process, the evaluation consistency was calculated and compared using Kendall's coefficient of concordance (Kendall's W). Moreover, diagnostic performance considering gray-scale and color imaging modes was compared. Especially for the diagnosis of mid-ureteric stones larger than 5 mm, the Kendall's W for the combined gray-scale and color Doppler flow imaging ultrasound scanning modes was greater than that for the gray-scale mode (P < 0.05). Additionally, significant improvements in the diagnostic sensitivity, negative predictive value, and accuracy were noted with color Doppler imaging (P < 0.05). Under isolated gray-scale mode, the resident group had reduced diagnostic sensitivity and negative predictive value and poorer accuracy compared with the attending and senior groups (P < 0.05). In contrast, no significant differences in the combined gray-scale and color Doppler flow imaging modes were noted among all groups (P > 0.05). In summary, the color Doppler flow imaging mode is useful for the diagnosis of mid-ureteric stones larger than 5 mm, especially in the resident group.
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11
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Acute Kidney Injury Caused by Obstructive Nephropathy. Int J Nephrol 2020; 2020:8846622. [PMID: 33312728 PMCID: PMC7719507 DOI: 10.1155/2020/8846622] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/21/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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12
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Saw JTS, Imeri NN, Aldridge ES, Buntine PG. Predictive values of haematuria and hydronephrosis in suspected renal colic: An emergency department retrospective audit. Emerg Med Australas 2020; 32:573-577. [DOI: 10.1111/1742-6723.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/21/2019] [Accepted: 12/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Paul G Buntine
- Eastern Health Melbourne Victoria Australia
- Monash University Melbourne Victoria Australia
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13
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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: 18] [Impact Index Per Article: 4.5] [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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14
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Kaya C, Kaynak Y, Karabag A, Aykaç A. The Predictive Role of Abdominal Fat Parameters and Stone Density on SWL Outcomes. Curr Med Imaging 2020; 16:80-87. [PMID: 31989897 DOI: 10.2174/1573405614666180927112127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 08/04/2018] [Accepted: 08/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Our aim was to detect the role of radiological abdominal fat parameters by tomography and stone density by plain X-ray on extracorporeal Shock Wave Lithotripsy (SWL) stone-free rate. METHODS The patients who had undergone SWL for a single opaque renal stone < 2 cm in diameter and proximal ureteric stone < 1 cm in diameter were collected retrospectively. The characteristics of patients and stones were recorded. The stone attitude, HU, abdominal fat parameters, paraperirenal fat area, perirenal infiltration and severity of hydronephrosis with pre-treatment Non- Contrast Computed Tomography (NCCT) and stone density with radiography were evaluated by a radiologist. Four weeks after the last SWL; all patients were evaluated by plain X-ray and categorized as Stone Free (SF) and Residual Fragment (RF) group. RESULTS 51 patients with renal stones and 88 patients with proximal ureteral stones were included in the study. 24 (47%) and 63 (71%) patients were classified as SFfor renal and ureteral stones respectively. Only stone size was an independent predictor for stone-free rates after SWL for renal and proximal ureteral stones on multivariate analysis. The Receiver Operating Characteristic (ROC) curves for renal calculi revealed that creatinine level, stone size, stone attitude, Houns-Field Unit (HU) and Skin-to-Stone Distance (SSD) were the predictive factors for the SWL outcome (p< 0.05). The ROC curve for ureteral calculi demonstrated that HU, stone size and attitude were the predictive factors (p< 0.05). CONCLUSION All abdominal fat parameters and the stone density were not related to SWL failure. A large follow-up with more patients is essential to confirm the role of radiological parameters on the outcome of SWL.
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Affiliation(s)
- Coskun Kaya
- Department of Urology, Eskisehir City Hospital, Eskisehir, Turkey
| | - Yurdaer Kaynak
- Department of Urology, Eskisehir Ümit Visnelik Hospital, Eskisehir, Turkey
| | - Aral Karabag
- Department of Radiology, Eskisehir City Hospital, Eskisehir, Turkey
| | - Aykut Aykaç
- Department of Urology, Medical School, Karabuk University, Karabuk, Turkey
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15
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Khan MAB, Abu-Zidan FM. Point-of-care ultrasound for the acute abdomen in the primary health care. Turk J Emerg Med 2020; 20:1-11. [PMID: 32355895 PMCID: PMC7189821 DOI: 10.4103/2452-2473.276384] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/07/2019] [Indexed: 01/07/2023] Open
Abstract
Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.
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Affiliation(s)
- Moien A B Khan
- Department of Family Medicine, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
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16
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Kim SG, Jo IJ, Kim T, Hwang SY, Park JH, Shin TG, Sim MS, Cha WC, Yoon H. Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study. ACTA ACUST UNITED AC 2019; 55:medicina55110717. [PMID: 31661942 PMCID: PMC6915595 DOI: 10.3390/medicina55110717] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/07/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Seok Goo Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Joo Hyun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
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Jakubowski J, Moskovitz J, Leonard NJ. Imaging Modalities in Genitourinary Emergencies. Emerg Med Clin North Am 2019; 37:785-809. [PMID: 31563208 DOI: 10.1016/j.emc.2019.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Julian Jakubowski
- Department of Emergency Medicine, Emergency Medicine Residency Marietta Memorial Hospital, 401 Matthew Street, Marietta, OH 45750, USA; The Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA.
| | - Joshua Moskovitz
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Building 6 Room 1B25, Bronx, NY 10461, USA; Hofstra School of Health and Human Services, Hempstead, NY, USA
| | - Nicole J Leonard
- Department of Emergency Medicine, Jacobi Montefiore Emergency Medicine Residency, 1400 Pelham Parkway South, Building 6, Bronx, NY 10461, USA
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18
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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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Nadav G, Eyal K, Noam T, Yeruham K. Evaluation of the clinical significance of sonographic perinephric fluid in patients with renal colic. Am J Emerg Med 2019; 37:1823-1828. [PMID: 30595428 DOI: 10.1016/j.ajem.2018.12.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To evaluate the significance of sonographic perinephric fluid collection on the emergent management of patients with acute urinary stone obstruction. METHODS We conducted a prospective study with retrospective analysis. Since January 2016 through July 2017, patients admitted to our tertiary hospital's emergency department (ED) with suspected symptomatic urinary stones underwent ultrasound evaluation. Images were prospectively interpreted by experienced radiologist who analyzed each case for the following imaging features: hydronephrosis, perinephric fluid and urethral stone identification. The presence and measurements of perinephric fluid were re-evaluated by second radiologist who was blinded for the first reader's measurements. Retrospective analysis was conducted to evaluate for an association between perinephric fluid collection and the following outcome variables: need for analgesics, the number of doses of analgesics and the amount of morphine (mg) in the ED, elevation of creatinine levels, hospitalization and need for urological interventions. RESULTS The need for analgesics, the number of doses of analgesics and the amount of morphine were significantly associated with the presence of perinephric fluid (p < 0.05). The odds ratio for the need for analgesics was 3.8 in the presence of any perinephric fluid, and 8.9 in the presence of moderate/severe perinephric fluid. No other patient outcome variables were found to be significantly associated with the presence of perinephric fluid (p > 0.05). CONCLUSIONS This study shows a correlation between sonographic evidence of perinephric fluid and more severe pain. Therefore, an emergency physician can consider the evidence of perinephric fluid, in acute urethral stone obstruction, a predictor for more severe pain.
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Affiliation(s)
- Granat Nadav
- Emergency Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
| | - Klang Eyal
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tau Noam
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Kleinbaum Yeruham
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Ahmed F, Askarpour MR, Eslahi A, Nikbakht HA, Jafari SH, Hassanpour A, Makarem A, Salama H, Ayoub A. The role of ultrasonography in detecting urinary tract calculi compared to CT scan. Res Rep Urol 2018; 10:199-203. [PMID: 30510920 PMCID: PMC6248231 DOI: 10.2147/rru.s178902] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the accuracy of ultrasonography (US) in measuring the urinary tract stone using non-contrast computed tomography (NCCT) as the standard reference. Patients and methods A total of 184 patients suspected with urolithiasis who had undergone NCCT and US radiologic investigation from 2015 to 2017 were enrolled in this study. The sensitivity, specificity, and stone size measured in US were validated by NCCT. Data of the stone size in US were classified into four groups (0–3.5, 3.6–5, 5.1–10, >10 mm) and then compared with NCCT data. Results In 184 patients, NCCT detected 276 (97.2%) stones, while US could identify 213 (75.5%) stones. Overall sensitivity and specificity of US were 75.4% and 16.7%, respectively. Detection rate of mid and distal ureteral stone was lower than that at other locations. The detection rate increased with the stone size. About 73% concordance was obtained for the stone size measured by US and NCCT (Pearson’s correlation coefficient was 0.841). Factors such as the stone size, amount of hydronephrosis, and weight affected the detection rate of the urinary tract stone using US (P<0.001, P=0.02, and P=0.01, respectively). Conclusion The stone size obtained by US was almost the same as that detected by NCCT; however, US is a limited imaging modality in detecting urinary tract stone, especially when used by an inexperienced radiologist, and in the case of smaller stone size, increased weight, and low grade of hydronephrosis.
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Affiliation(s)
- Fisal Ahmed
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran,
| | | | - Ali Eslahi
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran,
| | | | - Seyed-Hamed Jafari
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Hassanpour
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Alireza Makarem
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Hussein Salama
- Student Research Committee, Shiraz Medical University, Shiraz, Iran
| | - Abbas Ayoub
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
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21
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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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Alshoabi SA. Association between grades of Hydronephrosis and detection of urinary stones by ultrasound imaging. Pak J Med Sci 2018; 34:955-958. [PMID: 30190760 PMCID: PMC6115544 DOI: 10.12669/pjms.344.14602] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To correlate between hydronephrosis grades and detection of urinary stones by B-mode ultrasound imaging. Methods: This study included 210 ultrasound reports of patients who underwent abdominal ultrasound imaging in the period from 1st January 2016 to 31st October 2017, and diagnosed as hydronephrosis. Data collected from the ultrasound reports. The detection rates of stones using B-mode ultrasound imaging compared in different grades of hydronephrosis. Chi-square test and Odds Ratio (OR) were performed to assess the relationship between variables. Results: Of 210 patients, hydronephrosis was unilateral in 91.8% of patients and bilateral in 8.1%. It was distributed in grade 2, grade 3, grade 1 and grade 4 in 58.57%, 20%, 12.38% and 9.1% of the patients respectively. B-mode ultrasound imaging determined the cause of hydronephrosis in 65.2% of cases. Urinary stones were the cause in 60% of the patients. The detection rate of urinary stones was 50%, 61% and 71.4% for grades 1, 2 and 3 hydronephroses respectively. On simple logistic regression analysis, urinary stones detected in Grade-3 were four times more compared to that in grade 4 (P=0.016) (OR 4.125, 95% CI 1.29-13.136%). Conclusion: Detection of urinary stones as the cause of hydronephrosis increases with increasing the grade of hydronephrosis from Grade-I to Grade-III and decrease in Grade-IV. Urinary stones were the cause of hydronephrosis in 60% of the patients in this study.
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Affiliation(s)
- Sultan Abdulwadoud Alshoabi
- Dr. Sultan Abdulwadoud Alshoabi, MBBS, MD. Arab board and Jordanian Board of Radiology, Assistant Professor of Radiology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Saudi Arabia
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23
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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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Kameda T, Uebayashi K, Wagai K, Kawai F, Taniguchi N. Assessment of the renal collecting system using a pocket-sized ultrasound device. J Med Ultrason (2001) 2018; 45:577-581. [PMID: 29721640 DOI: 10.1007/s10396-018-0881-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the performance of a pocket-sized ultrasound device (PUD) for evaluating dilatation of the renal collecting system with high-end ultrasound devices (HUDs) as a reference standard. METHODS One sonographer examined both kidneys using a PUD to evaluate dilatation of the collecting system. The grading of the dilatation ranged from 0 to 4. Immediately after the examination, another sonographer blinded to the previous results performed a formal examination with a HUD. RESULTS Two hundred kidneys in 100 patients were included in the analysis. The agreement of grades between the PUD and HUDs was excellent (weighted kappa = 0.83; P < 0.001). When hydronephrosis was defined as grade 1 or higher, the test characteristics of the PUD were as follows: sensitivity 91% (95% confidence interval (CI) 79-97%), positive predictive value 73% (95% CI 60-83%), and negative predictive value 96% (95% CI 92-99%). When hydronephrosis was defined as grade 2 or higher, the test characteristics were as follows: sensitivity 88% (95% CI 73-97%), positive predictive value 75% (95% CI 59-87%), and negative predictive value 98% (95% CI 94-99%). CONCLUSION Ultrasound using a PUD is useful for evaluating dilatation of the collecting system, especially for ruling out its presence.
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Affiliation(s)
- Toru Kameda
- Department of Clinical Laboratory Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974, Japan.
| | - Kumiko Uebayashi
- Department of Clinical Laboratory Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974, Japan
| | - Kazuko Wagai
- Department of Clinical Laboratory, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Fukiko Kawai
- Department of Clinical Laboratory Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974, Japan
| | - Nobuyuki Taniguchi
- Department of Clinical Laboratory Medicine, Jichi Medical University, Shimotsuke, Japan
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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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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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Leo MM, Langlois BK, Pare JR, Mitchell P, Linden J, Nelson KP, Amanti C, Carmody KA. Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic. West J Emerg Med 2017; 18:559-568. [PMID: 28611874 PMCID: PMC5468059 DOI: 10.5811/westjem.2017.04.33119] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/04/2017] [Accepted: 04/25/2017] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Megan M Leo
- Boston University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.,Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Breanne K Langlois
- Tufts University, Friedman School of Nutrition Science and Policy, Boston, Massachusetts
| | - Joseph R Pare
- Boston University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.,Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Patricia Mitchell
- Boston University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.,Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Judith Linden
- Boston University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.,Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Kerrie P Nelson
- Boston University, School of Public Health, Boston, Massachusetts
| | - Cristopher Amanti
- Boston University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.,Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Kristin A Carmody
- New York University School of Medicine, Department of Emergency Medicine, New York, New York
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Wang RC, Fahimi J. In reply:. Ann Emerg Med 2017; 69:524-525. [DOI: 10.1016/j.annemergmed.2016.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 10/19/2022]
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Hall MK, Sorenson M, Harper J. Should Kidney Stone Patients With Diagnosis by Ultrasonography Be Prescribed Tamsulosin? Ann Emerg Med 2017; 69:523-524. [DOI: 10.1016/j.annemergmed.2016.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Indexed: 11/17/2022]
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Abstract
Urolithiasis in children is an underrecognized cause of pediatric abdominal pain. Our case describes a child who presented to the emergency department with right lower quadrant pain, in whom a point-of-care ultrasound detected an ureterovesicular stone, which obviated the need for any further radiographic studies. We review the current literature on pediatric urolithiasis with a focus on sonographic diagnosis.
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Affiliation(s)
- Antonio Riera
- From the Departments of *Pediatric Emergency Medicine and †Diagnostic Radiology, Yale University School of Medicine, New Haven, CT
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Alevizopoulos A, Zosimas D, Piha L, Hanna M, Charitopoulos K. Managing Small Ureteral Stones: A Retrospective Study on Follow-Up, Clinical Outcomes and Cost-Effectiveness of Conservative Management vs. Early Surgery. Curr Urol 2016; 9:36-43. [PMID: 26989370 DOI: 10.1159/000442849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/20/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The management of ureteral calculi has evolved over the past decades with the advent of new surgical and medical treatments. The current guidelines support conservative management as a possible approach for ureteral stones sized = 10 mm. OBJECTIVES We purport to follow the natural history of ureteral stones managed conservatively in this retrospective study, and attempt to ascribe an estimated health-care and cost-effectiveness, from presentation to time of being stone-free. MATERIALS AND METHODS 192 male and female patients with a single ureteral stone sized = 10 mm were included in this study. The clinical and cost-related outcome was analyzed for different stone sizes (0-4, 4-6 and 6-10 mm). The effectiveness of selected follow-up (FU) scans was also analyzed. RESULTS Stone size was found to be related to the degree of hydronephrosis and to the likelihood of need for a surgical management. Conservative management was found to be clinically effective, as 88% of the patients did not require surgery for their stone. 96.1% of the patients with a stone 0-4mm managed to expel their ureteral stone. Bigger ureteral stones were found to be more costly. The cost-effectiveness of the single FU scans was found to be related to their efficiency, while the global cost-effectiveness of conservative management vs. early surgery was higher for smaller stones (26.8 vs. 17.32% for stones 0-4 vs. 6-10 mm). CONCLUSION Conservative management is clinically effective with a significant cost-benefit, particularly for the subgroup of stones sized 0-4 mm, where a need for FU scans is in dispute.
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Affiliation(s)
| | - Dimitrios Zosimas
- Department of General Surgery, West Midlesex University Hospital of London, London, UK
| | - Lamprini Piha
- Athens University of Economics and Business, Athens, Greece
| | - Milad Hanna
- Department of Urology, West Midlesex University Hospital of London, London, UK
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Daniels B, Gross CP, Molinaro A, Singh D, Luty S, Jessey R, Moore CL. STONE PLUS: Evaluation of Emergency Department Patients With Suspected Renal Colic, Using a Clinical Prediction Tool Combined With Point-of-Care Limited Ultrasonography. Ann Emerg Med 2015; 67:439-48. [PMID: 26747219 DOI: 10.1016/j.annemergmed.2015.10.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 10/07/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE We determine whether renal point-of-care limited ultrasonography (PLUS) used in conjunction with the Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction score can aid identification of emergency department (ED) patients with uncomplicated ureteral stone or need for urologic intervention. METHODS This was a prospective observational study of adult ED patients undergoing computed tomography (CT) scan for suspected ureteral stone. The previously validated STONE score classifies patients into risk categories of low (≈10%), moderate (≈50%), or high (≈90%) for symptomatic stone. Renal PLUS assessed for presence of hydronephrosis before CT scanning. The primary outcomes of symptomatic ureteral stone or acutely important alternative finding were abstracted from CT reports. The secondary outcome, urologic intervention, was assessed by 90-day follow-up interview and record review. RESULTS Of 835 enrolled patients, ureteral stone was identified in 53%, whereas 6.5% had an acutely important alternative finding on CT. Renal PLUS modestly increased sensitivity for symptomatic stone among low and moderate STONE score categories. Moderate or greater hydronephrosis improved specificity from 67% (62% to 72%) to 98% (93% to 99%) and 42% (37% to 47%) to 92% (86% to 95%) in low- and moderate-risk patients, with likelihood ratios of 22 (95% CI, 4.2-111) and 4.9 (95% CI, 2.9-8.3), respectively. Test characteristics among high-risk patients were unchanged by renal PLUS. For urologic intervention, any hydronephrosis was 66% sensitive (57% to 74%), whereas moderate or greater hydronephrosis was 86% specific overall (83% to 89%) and 81% (69% to 90%) sensitive and 79% 95% CI, (73-84) specific among patients with the highest likelihood of symptomatic stone. CONCLUSION Hydronephrosis on renal PLUS modestly improved risk stratification in low- and moderate-risk STONE score patients. The presence or absence of hydronephrosis among high-risk patients did not significantly alter likelihood of symptomatic stone but may aid in identifying patients more likely to require urologic intervention.
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Affiliation(s)
- Brock Daniels
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
| | - Cary P Gross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Annette Molinaro
- Department of Neurosurgery, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Dinesh Singh
- Department of Urology, Yale University School of Medicine, New Haven, CT
| | - Seth Luty
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Richelle Jessey
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Christopher L Moore
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
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Parks RM, Behrbalk E, Mosharraf S, Müller RM, Boszczyk BM. Is Hydronephrosis a Complication after Anterior Lumbar Surgery? Global Spine J 2015; 5:466-70. [PMID: 26682096 PMCID: PMC4671910 DOI: 10.1055/s-0035-1566227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Study Design Prospective follow-up design. Objective Ureteral injury is a recognized complication following gynecologic surgery and can result in hydronephrosis. Anterior lumbar surgery includes procedures like anterior lumbar interbody fusion (ALIF) and total disk replacement (TDR). Anterior approaches to the spine require mobilization of the great vessels and visceral organs. The vascular supply to the ureter arising from the iliac arteries may be compromised during midline retraction of the ureter, which could theoretically lead to ureter ischemia and stricture with subsequent hydronephrosis formation. Methods Potential candidates with previous ALIF or TDR via anterior retroperitoneal access between January 2008 and March 2012 were chosen from those operated on by a single surgeon in a university hospital setting (n = 85). Renal ultrasound evaluation of hydronephrosis was performed on all participants. Simple descriptive and inferential statistics were used to generate results. Results A total of 37 voluntary participants were recruited (23 male, 14 female subjects; average age 51.8 years). The prevalence of hydronephrosis in our population was 0.0% (95% confidence interval 0 to 8.1%). Conclusions Retraction of the ureter across the midline in ALIF and TDR does not result in an increase in hydronephrosis and appears to be a safe surgical technique.
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Affiliation(s)
- Ruth M. Parks
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, United Kingdom,Address for correspondence Ruth M. Parks, BMedSci, BMBS The Centre for Spinal Studies and Surgery, Queen's Medical CentreDerby Road, Nottingham NG7 2UHUnited Kingdom
| | - Eyal Behrbalk
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, United Kingdom
| | - Syed Mosharraf
- Radiology Department, Queen's Medical Centre, Nottingham, United Kingdom
| | - Roger M. Müller
- Department of Urology, Hôpital du Valais, Sierre, Switzerland
| | - Bronek M. Boszczyk
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, United Kingdom
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The ability of renal ultrasound and ureteral jet evaluation to predict 30-day outcomes in patients with suspected nephrolithiasis. Am J Emerg Med 2015; 33:1402-6. [DOI: 10.1016/j.ajem.2015.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/10/2015] [Accepted: 07/10/2015] [Indexed: 12/21/2022] Open
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Cox C, MacDonald S, Henneberry R, Atkinson PR. My patient has abdominal and flank pain: Identifying renal causes. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2015; 23:242-50. [PMID: 27433264 DOI: 10.1177/1742271x15601617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/14/2015] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Christopher Cox
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Scott MacDonald
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Ryan Henneberry
- Dalhousie University-Emergency Medicine, Halifax, Nova Scotia, Canada
| | - Paul R Atkinson
- Dalhousie University-Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
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Radecki RP, Spiegel R. Laboring Under the Stone. Ann Emerg Med 2015; 65:706-13. [DOI: 10.1016/j.annemergmed.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Noncontrast computed tomography factors that predict the renal stone outcome after shock wave lithotripsy. Clin Imaging 2015; 39:845-50. [PMID: 25975631 DOI: 10.1016/j.clinimag.2015.04.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/26/2015] [Accepted: 04/17/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Extracorporeal shock wave lithotripsy (ESWL) is a popular treatment for nephrolithiasis. We took advantage of noncontrast abdominal computed tomography (NCCT) to search the possible prognostic factors including abdominal fat distribution influencing stone-free rate. METHODS From August 2008 to August 2010, 145 patients who had renal calculus and had undergone ESWL were retrospectively reviewed. All of them received NCCT assessment before ESWL and were followed up after 1 month for stone clearance. These patients were divided into two groups: one was the stone-free group and the other was the residual-stone group. Affecting parameters included stone size, location, stone surface area, Hounsfield unit density (HU density), skin-to-stone distance (SSD), and abdominal fat area as analyzed between these two groups. RESULTS Of 145 patients, 70 were stone-free and 75 had residual stone after ESWL treatment and 1-month follow-up. From univariate analysis, stone size, HU density, SSD, and stone surface area were significant predicting factors for ESWL success. On multivariate analysis, the important factors influencing ESWL outcomes were HU density and stone surface area (odds ratio 1.002 vs. 77.18, respectively; P<.05). Abdominal fat accumulation and distribution had no significant difference between these two groups. CONCLUSION This study revealed that stone size, HU density, SSD, and stone surface area were associated with stone-free rate after ESWL treatment. Therefore, these factors could be used to assess the feasibility of ESWL before deciding the treatment strategy. Abdominal fat distribution had no significant impact on ESWL outcome for renal stones.
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Dickman E, Tessaro MO, Arroyo AC, Haines LE, Marshall JP. Clinician-performed abdominal sonography. Eur J Trauma Emerg Surg 2015; 41:481-92. [PMID: 26038027 DOI: 10.1007/s00068-015-0508-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 03/02/2015] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- E Dickman
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA.
| | - M O Tessaro
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, M5G1X8, Canada
| | - A C Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - L E Haines
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - J P Marshall
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, 11219, USA
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Huang HS, Chu CL, Tsai CT, Wu CK, Lai LP, Yeh HM. Perfusion index derived from a pulse oximeter can detect changes in peripheral microcirculation during uretero-renal-scopy stone manipulation (URS-SM). PLoS One 2014; 9:e115743. [PMID: 25542000 PMCID: PMC4277408 DOI: 10.1371/journal.pone.0115743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 12/01/2014] [Indexed: 11/19/2022] Open
Abstract
Background The objective of this study was to test the effect of removal of a ureteral obstruction (renal calculus) from anesthetized patients on the perfusion index (PI), as measured by a pulse oximeter, and on the estimated glomerular filtration rate (eGFR). Patients and Methods This prospective study enrolled 113 patients with unilateral ureteral obstructions (kidney stones) who were scheduled for ureteroscopy (URS) laser lithotripsy. One urologist graded patient hydronephrosis before surgery. A pulse oximeter was affixed to each patient's index finger ipsilateral to the intravenous catheter, and a non-invasive blood pressure cuff was placed on the contralateral side. Ipsilateral double J stents and Foley catheters were inserted and left indwelling for 24 h. PI and mean arterial pressure (MAP) were determined at baseline, 5 min after anesthesia, and 10 min after surgery; eGFR was determined at admission, 1 day after surgery, and 14 days after surgery. Results Patients with different grades of hydronephrosis had similar age, eGFR, PI, mean arterial pressure (MAP), and heart rate (HR). PI increased significantly in each hydronephrosis group after ureteral stone disintegration. None of the groups had significant post-URS changes in eGFR, although eGFR increased in the grade I hydronephrosis group after 14 days. The percent change of PI correlates significantly with the percent change of MAP, but not with that of eGFR. Conclusion Our results demonstrate that release of a ureteral obstruction leads to a concurrent increase of PI during anesthesia. Measurement of PI may be a valuable tool to monitor the successful release of ureteral obstructions and changes of microcirculation during surgery. There were also increases in eGFR after 14 days, but not immediately after surgery.
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Affiliation(s)
- Ho-Shiang Huang
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Lin Chu
- Institute of Biomedical Engineering National Taiwan University, Taipei, Taiwan
- Department of Anesthesiology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Cardiology, National Taiwan University Hospital, Taipei and Yun-Lin, Taiwan
- * E-mail: (HMY); (CTT)
| | - Cho-Kai Wu
- Division of Cardiology, Department of Cardiology, National Taiwan University Hospital, Taipei and Yun-Lin, Taiwan
| | - Ling-Ping Lai
- Division of Cardiology, Department of Cardiology, National Taiwan University Hospital, Taipei and Yun-Lin, Taiwan
| | - Huei-Ming Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail: (HMY); (CTT)
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Riddell J, Swadron S. In reply. West J Emerg Med 2014; 15:945-6. [PMID: 25493159 PMCID: PMC4251260 DOI: 10.5811/westjem.2014.10.23864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jeff Riddell
- University of California, San Francisco-Fresno, Department of Emergency Mediicne, Fresno, California
| | - Stuart Swadron
- University of Southern California, Keck School of Medicine, Los Angeles, California
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Moore CL, Scoutt L. Sonography first for acute flank pain? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1703-1711. [PMID: 23091240 DOI: 10.7863/jum.2012.31.11.1703] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Christopher L Moore
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, USA.
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The Utilization of Ultrasound in the Diagnosis of Urolithiasis. Urolithiasis 2012. [DOI: 10.1007/978-1-4471-4387-1_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bedside renal ultrasound in the evaluation of suspected ureterolithiasis. Am J Emerg Med 2012; 30:218-21. [DOI: 10.1016/j.ajem.2010.11.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 11/10/2010] [Accepted: 11/14/2010] [Indexed: 11/21/2022] Open
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Abstract
Urolithiasis commonly presents to the emergency department with acute, severe, unilateral flank pain. Patients with a suspected first-time stone or atypical presentation should be evaluated with a noncontrast computed tomography scan to confirm the diagnosis and rule out alternative diagnoses. Narcotics remain the mainstay of pain management but in select patients, nonsteroidal anti-inflammatories alone or in combination with narcotics provide safe and effective analgesia in the emergency department. Whereas most kidney stones can be managed with pain control and expectant management, obstructing kidney stones with a suspected proximal urinary tract infection are urological emergencies requiring emergent decompression, antibiotics, and resuscitation.
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Affiliation(s)
- Autumn Graham
- Department of Emergency Medicine, Washington Hospital Center, Georgetown University, Washington, DC 20007, USA.
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