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      Sensitivity of Emergency Bedside Ultrasound to Detect Hydronephrosis in Patients with Computed Tomography-proven Stones

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          Abstract

          Introduction

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

          Methods

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

          Results

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

          Conclusion

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

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          Most cited references13

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          Chart reviews in emergency medicine research: Where are the methods?

          Medical chart reviews are often used in emergency medicine research. However, the reliability of data abstracted by chart reviews is seldom examined critically. The objective of this investigation was to determine the proportion of emergency medicine research articles that use data from chart reviews and the proportions that report methods of case selection, abstractor training, monitoring and blinding, and interrater agreement. Research articles published in three emergency medicine journals from January 1989 through December 1993 were identified. The articles that used chart reviews were analyzed. Of 986 original research articles that were identified, 244 (25%; 95% confidence interval [CI], 22% to 28%) relied on chart reviews. Inclusion criteria were described in 98% (95% CI, 96% to 99%), and 73% (95% CI, 67% to 79%) defined the variables being analyzed. Other methods were seldom mentioned: abstractor training, 18% (95% CI, 13% to 23%); standardized abstraction forms, 11% (95% CI, 7% to 15%); periodic abstractor monitoring, 4% (95% CI, 2% to 7%); and abstractor blinding to study hypotheses, 3% (95% CI, 1% to 6%). Interrater reliability was mentioned in 5% (95% CI, 3% to 9%) and tested statistically in .4% (95% CI, 0% to 2%). A 15% random sample of articles was reassessed by a second investigator; interrater agreement was high for all eight criteria. Chart review is a common method of data collection in emergency medicine research. Yet, information about the quality of the data is usually lacking. Chart reviews should be held to higher methodologic standards, or the conclusions of these studies may be in error.
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            Reassessing the methods of medical record review studies in emergency medicine research.

            An assessment of the methods of medical record review studies published in emergency medicine journals during a 5-year period ending in 1993 provided strategies for improvements. We assess and quantify the current methodologic quality of medical record review studies in emergency medicine journals using published guidelines and compare these results among journals and with those of 10 years previously. Independent, systematic searches of emergency medicine journals identified all medical record review studies published in 2003. Methodology assessments of each selected study were conducted independently by 2 other researchers, and disagreements were resolved by arbitration. We identified 79 (14%) medical record review studies in 563 original research articles in 6 emergency medicine journals. The highest adherence to methodologic standards was found for sampling method (99%; 95% confidence interval [CI] 93% to 100%), and the lowest was for abstractor blinding to hypothesis (4%; 95% CI 1% to 11%). Interobserver agreement for the 12 criteria ranged from 57% to 95%. A comparison of these results with those of 10 years ago revealed significant improvements in 3 of the 8 original criteria assessed: data abstraction forms, mentioning interobserver performance, and testing interobserver performance. Medical record review studies continue to comprise a substantial proportion of original research in the emergency medicine literature. Important improvements are noted in some criteria, but adherence remains below 50% for 7 of the 12 criteria assessed.
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              Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT.

              Prior studies using radiography have examined the relationship of ureteral stone size and location to the probability of spontaneous passage. Given the improved accuracy and new role of unenhanced CT in the diagnosis of acute ureterolithiasis, we studied the relationship of stone size and location as determined by unenhanced CT to the rate of spontaneous passage. Over a 29-month period, 850 patients with acute flank pain were evaluated with unenhanced CT. Confirmation of the CT diagnosis was obtained retrospectively for 172 patients with ureteral stones: 115 stones passed spontaneously and 57 required intervention. Stone size was defined as the maximum diameter within the plane of the axial CT section. Stone location was classified as proximal ureter (above the sacroiliac joints), mid ureter (overlying the sacroiliac joints), distal ureter (below the sacroiliac joints), and ureterovesical junction. The spontaneous passage rate for stones 1 mm in diameter was 87%; for stones 2-4 mm, 76%; for stones 5-7 mm, 60%; for stones 7-9 mm, 48%; and for stones larger than 9 mm, 25%. Spontaneous passage rate as a function of stone location was 48% for stones in the proximal ureter, 60% for mid ureteral stones, 75% for distal stones, and 79% for ureterovesical junction stones. The rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. These rates are similar to those previously published based on radiography.
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                Author and article information

                Journal
                West J Emerg Med
                West J Emerg Med
                WestJEM
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine School of Medicine
                1936-900X
                1936-9018
                February 2014
                : 15
                : 1
                : 96-100
                Affiliations
                [* ]Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, California
                []Department of Emergency Medicine, Oregon Health Sciences University, Portland, Oregon
                []Department of Surgery, Oregon Health Sciences University, Portland, Oregon
                [§ ]Keck School of Medicine, University of Southern California, Los Angeles, California
                [|| ]Department of Emergency Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
                Author notes
                Address for Correspondence: Jeff Riddell, MD. University of California San Francisco-Fresno, 155 N Fresno St., Fresno CA, 93701. Email: jriddell@ 123456fresno.ucsf.edu .

                Supervising Section Editor: Seric Cusick, MD

                Full text available through open access at http://escholarship.org/uc/uciem_westjem

                Article
                wjem-15-96
                10.5811/westjem.2013.9.15874
                3935794
                24578772
                5b4b64ad-c1cb-4832-9e0b-59f76e9cba03
                Copyright © 2014 the authors.

                This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.

                History
                : 14 January 2013
                : 23 June 2013
                : 11 September 2013
                Categories
                Technology in Emergency Care
                Original Research

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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