Comparing visual and automated urine dipstick analysis in a general practice population.

INTRODUCTION: Urinary symptoms constitute the primary reason for female patients to consult their general practitioner. The urinary dipstick test serves as a cornerstone for diagnosing urinary tract infections (UTIs), yet traditional visual interpretation may be subject to variability. Automated devices for dipstick urinalysis are routinely used as alternatives, yet the evidence regarding their accuracy remains limited. Therefore we aimed to compare concordance between visual and automated urinary dipstick interpretation and determine their test characteristics for the prediction of bacteriuria. MATERIAL AND METHODS: We conducted a prospective validation study including urine samples originating from adult patients in general practice that were sent to the Maastricht Medical Centre + for urinary culture. Urinary dipstick tests were performed on each sample, which were interpreted visually and automatically. We calculated Cohen's κ and percentage agreement and used 2 × 2 tables to calculate test characteristics. RESULTS: We included 302 urine samples. Visual and automated analysis showed almost perfect agreement (κ = 0.82 and κ = 0.86, respectively) for both nitrite and leukocyte esterase, but moderate agreement for erythrocytes (κ = 0.51). Interpretation of clinically relevant (nitrite and/or leukocyte esterase positive) samples showed almost perfect agreement (κ = 0.88). Urinary dipsticks show similar test characteristics with urinary culture as gold standard, with sensitivities of 0.92 and 0.91 and specificities of 0.37 and 0.41 for visual and automated interpretation respectively. CONCLUSION: Automated and visual dipstick analysis show near perfect agreement and perform similarly in predicting bacteriuria. However, automated analysis requires maintenance and occasionally measurement errors can occur.

The effect of size-scale on the kinematics of elastic energy release.

Elastically-driven motion has been used as a strategy to achieve high speeds in small organisms and engineered micro-robotic devices. We examine the size-scaling relations determining the limit of elastic energy release from elastomer bands that efficiently cycle mechanical energy with minimal loss. The maximum center-of-mass velocity of the elastomer bands was found to be size-scale independent, while smaller bands demonstrated larger accelerations and shorter durations of elastic energy release. Scaling relationships determined from these measurements are consistent with the performance of small organisms and engineered devices which utilize elastic elements to power motion.

Beyond power amplification: latch-mediated spring actuation is an emerging framework for the study of diverse elastic systems.

Rapid biological movements, such as the extraordinary strikes of mantis shrimp and accelerations of jumping insects, have captivated generations of scientists and engineers. These organisms store energy in elastic structures (e.g. springs) and then rapidly release it using latches, such that movement is driven by the rapid conversion of stored elastic to kinetic energy using springs, with the dynamics of this conversion mediated by latches. Initially drawn to these systems by an interest in the muscle power limits of small jumping insects, biologists established the idea of power amplification, which refers both to a measurement technique and to a conceptual framework defined by the mechanical power output of a system exceeding muscle limits. However, the field of fast elastically driven movements has expanded to encompass diverse biological and synthetic systems that do not have muscles - such as the surface tension catapults of fungal spores and launches of plant seeds. Furthermore, while latches have been recognized as an essential part of many elastic systems, their role in mediating the storage and release of elastic energy from the spring is only now being elucidated. Here, we critically examine the metrics and concepts of power amplification and encourage a framework centered on latch-mediated spring actuation (LaMSA). We emphasize approaches and metrics of LaMSA systems that will forge a pathway toward a principled, interdisciplinary field.

The Interaction of Compliance and Activation on the Force-Length Operating Range and Force Generating Capacity of Skeletal Muscle: A Computational Study using a Guinea Fowl Musculoskeletal Model.

A muscle's performance is influenced by where it operates on its force-length (F-L) curve. Here we explore how activation and tendon compliance interact to influence muscle operating lengths and force-generating capacity. To study this, we built a musculoskeletal model of the lower limb of the guinea fowl and simulated the F-L operating range during fixed-end fixed-posture contractions for 39 actuators under thousands of combinations of activation and posture using three different muscle models: Muscles with non-compliant tendons, muscles with compliant tendons but no activation-dependent shift in optimal fiber length (L0), and muscles with both compliant tendons and activation-dependent shifts in L0. We found that activation-dependent effects altered muscle fiber lengths up to 40% and increased or decreased force capacity by up to 50% during fixed-end contractions. Typically, activation-compliance effects reduce muscle force and are dominated by the effects of tendon compliance at high activations. At low activation, however, activation-dependent shifts in L0 are equally important and can result in relative force changes for low compliance muscles of up to 60%. There are regions of the F-L curve in which muscles are most sensitive to compliance and there are troughs of influence where these factors have little effect. These regions are hard to predict, though, because the magnitude and location of these areas of high and low sensitivity shift with compliance level. In this study we provide a map for when these effects will meaningfully influence force capacity and an example of their contributions to force production during a static task, namely standing.

A Interação de Conformidade e Ativação na Faixa de Operação Força-Comprimento e Capacidade de Geração de Força do Músculo Esquelético: Um Estudo Computacional Usando um Modelo Musculoesquelético de Galinhas-D'angola O desempenho muscular é influenciado por onde ele opera na sua curva de força-comprimento. Aqui, exploramos como a ativação e a conformidade do tendão interagem para influenciar os comprimentos musculares e a capacidade de geração de força. Para estudar isso, construímos um modelo musculoesquelético do membro inferior da galinha-d'angola e simulamos a faixa de operação força-comprimento durante contrações fixas de postura e extremidade para 39 atuadores sob milhares de combinações de ativação e postura usando três modelos musculares diferentes: músculos com tendões não-complacentes, músculos com tendões complacentes, mas sem desvio dependente de ativação no comprimento ideal de fibra (L0), e músculos com tendões complacentes e desvios dependentes de ativação em L0. Descobrimos que os efeitos dependentes da ativação alteraram os comprimentos da fibra muscular em até 40% e aumentaram ou diminuíram a capacidade de força em até 50% durante as contrações de extremidade fixas. Normalmente, os efeitos de ativação e conformidade reduzem a força muscular e são dominados pelos efeitos de complacência do tendão em altas ativações. Em baixa ativação, no entanto, desvios dependentes de ativação em L0 são igualmente importantes e podem resultar em mudanças de força relativas de até 60% para músculos de baixa complacência. Existem regiões da curva de força-comprimento em que os músculos são mais sensíveis à complacência e há baixas de influência onde esses fatores têm pouco efeito. Essas regiões são difíceis de prever porque a magnitude e a localização dessas áreas de alta e baixa sensibilidade mudam com o nível de conformidade. Neste estudo, fornecemos um mapa para quando esses efeitos influenciarão significativamente a capacidade de força e um exemplo de suas contribuições para a produção de forças durante uma tarefa estática, ou seja, em pé. Translated to Portuguese by G. Sobral (gabisobral@gmail.com).

American Society of Biomechanics Journal of Biomechanics Award 2017: High-acceleration training during growth increases optimal muscle fascicle lengths in an avian bipedal model.

Sprinters have been found to possess longer muscle fascicles than non-sprinters, which is thought to be beneficial for high-acceleration movements based on muscle force-length-velocity properties. However, it is unknown if their morphology is a result of genetics or training during growth. To explore the influence of training during growth, thirty guinea fowl (Numida meleagris) were split into exercise and sedentary groups. Exercise birds were housed in a large pen and underwent high-acceleration training during their growth period (age 4-14 weeks), while sedentary birds were housed in small pens to restrict movement. Morphological analyses (muscle mass, PCSA, optimal fascicle length, pennation angle) of a hip extensor muscle (ILPO) and plantarflexor muscle (LG), which differ in architecture and function during running, were performed post-mortem. Muscle mass for both ILPO and LG was not different between the two groups. Exercise birds were found to have ∼12% and ∼14% longer optimal fascicle lengths in ILPO and LG, respectively, than the sedentary group despite having ∼3% shorter limbs. From this study we can conclude that optimal fascicle lengths can increase as a result of high-acceleration training during growth. This increase in optimal fascicle length appears to occur irrespective of muscle architecture and in the absence of a change in muscle mass. Our findings suggest high-acceleration training during growth results in muscles that prioritize adaptations for lower strain and shortening velocity over isometric strength. Thus, the adaptations observed suggest these muscles produce higher force during dynamic contractions, which is beneficial for movements requiring large power outputs.

The Influence of Visual, Vestibular, and Hindlimb Proprioceptive Ablations on Landing Preparation in Cane Toads.

Coordinated landing from a jump requires preparation, which must include appropriate positioning and configuration of the landing limbs and body to be successful. While well studied in mammals, our lab has been using the cane toad (Rhinella marinus) as a model for understanding the biomechanics of controlled landing in anurans, animals that use jumping or bounding as their dominant mode of locomotion. In this article, we report new results from experiments designed to explore how different modes of sensory feedback contribute to previously identified features of coordinated landing in toads. More specifically, animals in which vision, hindlimb proprioception, or vestibular feedback were removed, underwent a series of hopping trials while high-speed video was used to record and characterize limb movements and electromyographic (EMG) activity was recorded from a major elbow extensor (anconeus). Results demonstrate that altering any sensory system impacts landing behavior, though loss of vision had the least effect. Blind animals showed significant differences in anconeus EMG timing relative to controls, but forelimb and hindlimb movements as well as the ability to successfully decelerate the body using the forelimbs were not affected. Compromising hindlimb proprioception led to distinctly different forelimb kinematics. Though EMG patterns were disrupted, animals in this condition were also able to decelerate after impact, though with less control, regularly allowing their trunks to make ground contact during landing. Animals with compromised vestibular systems showed the greatest deficits, both in takeoff and landing behavior, which were highly variable and rarely coordinated. Nevertheless, animals in this condition demonstrated EMG patterns and forelimb kinematics similar to those in control animals. The fact that no ablation entirely eliminates all aspects of landing preparation suggests that its underpinnings are complex and that there is no single sensory trigger for its initiation.

Smashing mantis shrimp strategically impact shells.

Many predators fracture strong mollusk shells, requiring specialized weaponry and behaviors. The current shell fracture paradigm is based on jaw- and claw-based predators that slowly apply forces (high impulse, low peak force). However, predators also strike shells with transient intense impacts (low impulse, high peak force). Toward the goal of incorporating impact fracture strategies into the prevailing paradigm, we measured how mantis shrimp (Neogonodactylus bredini) impact snail shells, tested whether they strike shells in different locations depending on prey shape (Nerita spp., Cenchritis muricatus, Cerithium spp.) and deployed a physical model (Ninjabot) to test the effectiveness of strike locations. We found that, contrary to their formidable reputation, mantis shrimp struck shells tens to hundreds of times while targeting distinct shell locations. They consistently struck the aperture of globular shells and changed from the aperture to the apex of high-spired shells. Ninjabot tests revealed that mantis shrimp avoid strike locations that cause little damage and that reaching the threshold for eating soft tissue is increasingly difficult as fracture progresses. Their ballistic strategy requires feed-forward control, relying on extensive pre-strike set-up, unlike jaw- and claw-based strategies that can use real-time neural feedback when crushing. However, alongside this pre-processing cost to impact fracture comes the ability to circumvent gape limits and thus process larger prey. In sum, mantis shrimp target specific shell regions, alter their strategy depending on shell shape, and present a model system for studying the physics and materials of impact fracture in the context of the rich evolutionary history of predator-prey interactions.

Evidence toads may modulate landing preparation without predicting impact time.

Within anurans (frogs and toads), cane toads (Bufo marinus) perform particularly controlled landings in which the forelimbs are exclusively used to decelerate and stabilize the body after impact. Here we explore how toads achieve dynamic stability across a wide range of landing conditions. Specifically, we suggest that torques during landing could be reduced by aligning forelimbs with the body's instantaneous velocity vector at impact (impact angle). To test whether toad forelimb orientation varies with landing conditions, we used high-speed video to collect forelimb and body kinematic data from six animals hopping off platforms of different heights (0, 5 and 9 cm). We found that toads do align forelimbs with the impact angle. Further, toads align forelimbs with the instantaneous velocity vector well before landing and then track its changes until touchdown. This suggests that toads may be prepared to land well before they hit the ground rather than preparing for impact at a specific moment, and that they may use a motor control strategy that allows them to perform controlled landings without the need to predict impact time.

Sensory feedback and coordinating asymmetrical landing in toads.

Coordinated landing requires anticipating the timing and magnitude of impact, which in turn requires sensory input. To better understand how cane toads, well known for coordinated landing, prioritize visual versus vestibular feedback during hopping, we recorded forelimb joint angle patterns and electromyographic data from five animals hopping under two conditions that were designed to force animals to land with one forelimb well before the other. In one condition, landing asymmetry was due to mid-air rolling, created by an unstable takeoff surface. In this condition, visual, vestibular and proprioceptive information could be used to predict asymmetric landing. In the other, animals took off normally, but landed asymmetrically because of a sloped landing surface. In this condition, sensory feedback provided conflicting information, and only visual feedback could appropriately predict the asymmetrical landing. During the roll treatment, when all sensory feedback could be used to predict an asymmetrical landing, pre-landing forelimb muscle activity and movement began earlier in the limb that landed first. However, no such asymmetries in forelimb preparation were apparent during hops onto sloped landings when only visual information could be used to predict landing asymmetry. These data suggest that toads prioritize vestibular or proprioceptive information over visual feedback to coordinate landing.

Forelimb kinematics during hopping and landing in toads.

Coordinated landing in a variety of animals involves the re-positioning of limbs prior to impact to safely decelerate the body. However, limb kinematics strategies for landing vary considerably among species. For example, human legs are increasingly flexed before impact as drop height increases, while turkeys increasingly extend their legs before impact with increasing drop height. In anurans, landing typically involves the use of the forelimbs to decelerate the body after impact. Few detailed, quantitative descriptions of anuran forelimb kinematics during jumping exist and it is not known whether they prepare for larger landing forces by changing forelimb kinematics. In this study, we used high-speed video of 51 hops from five cane toads (Bufo marinus) to test the hypothesis that forelimb kinematics change predictably with distance. We measured excursions of the elbow (flexion/extension) and humerus (protraction/retraction and elevation/depression) throughout every hop. The results indicate that elbow and humeral excursions leading up to impact increase significantly with hop length, but do so without any change in the rate of movement. Instead, because the animal is in the air longer during longer hops, near-constant velocity movements lead to the larger excursions. These larger excursions in elbow extension result in animals hitting the ground with more extended forelimbs in longer hops, which in turn allows animals to decelerate over a greater distance.

A physical model of the extreme mantis shrimp strike: kinematics and cavitation of Ninjabot.

To study the mechanical principles and fluid dynamics of ultrafast power-amplified systems, we built Ninjabot, a physical model of the extremely fast mantis shrimp (Stomatopoda). Ninjabot rotates a to-scale appendage within the environmental conditions and close to the kinematic range of mantis shrimp's rotating strike. Ninjabot is an adjustable mechanism that can repeatedly vary independent properties relevant to fast aquatic motions to help isolate their individual effects. Despite exceeding the kinematics of previously published biomimetic jumpers and reaching speeds in excess of 25 m s(-1) at accelerations of 3.2 × 10(4) m s(-2), Ninjabot can still be outstripped by the fastest mantis shrimp, Gonodactylus smithii, measured for the first time in this study. G. smithii reached 30 m s(-1) at accelerations of 1.5 × 10(5) m s(-2). While mantis shrimp produce cavitation upon impact with their prey, they do not cavitate during the forward portion of their strike despite their extreme speeds. In order to determine how closely to match Ninjabot and mantis shrimp kinematics to capture this cavitation behavior, we used Ninjabot to produce strikes of varying kinematics and to measure cavitation presence or absence. Using Akaike Information Criterion to compare statistical models that correlated cavitation with a variety of kinematic properties, we found that in rotating and accelerating biological conditions, cavitation inception is best explained only by maximum linear velocity.

Everyday ethics and help-seeking in early rheumatoid arthritis.

BACKGROUND: Sociological understandings of chronic illness have revealed tensions and complexities around help-seeking. Although ethics underpins healthcare, its application in the area of chronic illness is limited. Here we apply an ethical framework to interview accounts and identify ethical challenges in the early rheumatoid arthritis (RA) experience. METHODS: In-depth interviews were conducted with eight participants who had been diagnosed with RA in the 12 months prior to recruitment. Applying the concepts of autonomous decision-making and procedural justice highlighted ethical concerns which arose throughout the help-seeking process. Analysis was based on the constant-comparison approach. RESULTS: Individuals described decision-making, illness actions and the medical encounter. The process was complicated by inadequate knowledge about symptoms, common-sense understandings about the GP appointment, difficulties concerning access to specialists, and patient-practitioner interactions. Autonomous decision-making and procedural justice were compromised. The accounts revealed contradictions between the policy ideals of active self-management, patient-centred care and shared decision-making, and the everyday experiences of individuals. CONCLUSIONS: For ethical healthcare there is a need for: public knowledge about early RA symptoms; more effective patient-practitioner communication; and increased support during the wait between primary and secondary care. Healthcare facilities and the government may consider different models to deliver services to people requiring rheumatology consults.

Discrete solitons in electromechanical resonators.

We consider a particular type of parametrically driven discrete Klein-Gordon system describing microdevices and nanodevices, with integrated electrical and mechanical functionality. Using a multiscale expansion method we reduce the system to a discrete nonlinear Schrödinger equation. Analytical and numerical calculations are performed to determine the existence and stability of fundamental bright and dark discrete solitons admitted by the Klein-Gordon system through the discrete Schrödinger equation. We show that a parametric driving can not only destabilize onsite bright solitons, but also stabilize intersite bright discrete solitons and onsite and intersite dark solitons. Most importantly, we show that there is a range of values of the driving coefficient for which dark solitons are stable, for any value of the coupling constant, i.e., oscillatory instabilities are totally suppressed. Stability windows of all the fundamental solitons are presented and approximations to the onset of instability are derived using perturbation theory, with accompanying numerical results. Numerical integrations of the Klein-Gordon equation are performed, confirming the relevance of our analysis.

Pattern formation in the damped Nikolaevskiy equation.

The Nikolaevskiy equation has been proposed as a model for seismic waves, electroconvection, and weak turbulence; we show that it can also be used to model transverse instabilities of fronts. This equation possesses a large-scale "Goldstone" mode that significantly influences the stability of spatially periodic steady solutions; indeed, all such solutions are unstable at onset, and the equation exhibits spatiotemporal chaos. In many applications, a weak damping of this neutral mode will be present, and we study the influence of this damping on solutions to the Nikolaevskiy equation. We examine the transition to the usual Eckhaus instability as the damping of the large-scale mode is increased, through numerical calculation and weakly nonlinear analysis. The latter is accomplished using asymptotically consistent systems of coupled amplitude equations. We find that there is a critical value of the damping below which (for a given value of the supercriticality parameter) all periodic steady states are unstable. The last solutions to lose stability lie in a cusp close to the left-hand side of the marginal stability curve.

Assessing risk assessment: genetic testing and screening for complex disease.

This paper reports on the presentations from the second session of a 2-day workshop on genetic diversity and science communication, organized by the Institute of Genetics. The four talks in this session (by Sarah Cunningham-Burley, Gail Geller, Michael Hayden, and Theresa Marteau) focused on the topic of risk assessment in the context of genetic testing, screening and preventive medicine for complex disease. Each talk underscored the urgency and importance of evaluating when and for whom risk assessment may be useful. A recurrent theme was the need to attend closely to the diverse ways that risk is constructed, perceived and communicated in a variety of contexts and the significant implications of this for laypersons as well as experts. Although there was no consensus on when genetic risk assessment ceases (or might begin) to be useful, ensuing dialogue between presenters and participants reflected what is perhaps a new and critical engagement with how risk assessment itself is assessed. In response to this impetus, I use the word RISK as a heuristic to identify, extract and amplify four tendencies that appear to advance understandings of risk assessment towards a more explicitly reflexive, interpretive, and situated form of knowing.

A descriptive model of preventability in maternal morbidity and mortality.

OBJECTIVE: To develop a descriptive model of preventability for maternal morbidity and mortality that can be used in quality assurance and morbidity and mortality review processes. STUDY DESIGN: This descriptive study was part of a larger case-control study conducted at the University of Illinois at Chicago in which maternal deaths were cases and women with severe maternal morbidity served as controls. Morbidities and mortalities were classified by a team of clinicians as preventable or not preventable. Qualitative analysis of data was conducted to identify and categorize different types of preventable events. RESULTS: Of 237 women, there were 79 women with preventable events attributable to provider or system factors. The most common types of preventable events were inadequate diagnosis/recognition of high-risk (54.4%), treatment (38.0%), and documentation (30.7%). CONCLUSIONS: A descriptive model was illustrated that can be used to categorize preventable events in maternal morbidity and mortality and can be incorporated into quality assurance and clinical case review to enhance the monitoring of hospital-based obstetric care and to decrease medical error.

Swift-Hohenberg model for magnetoconvection.

A model system of partial differential equations in two dimensions is derived from the three-dimensional equations for thermal convection in a horizontal fluid layer in a vertical magnetic field. The model consists of an equation of Swift-Hohenberg type for the amplitude of convection, coupled to an equation for a large-scale mode representing the local strength of the magnetic field. The model facilitates both analytical and numerical studies of magnetoconvection in large domains. In particular, we investigate the phenomenon of flux separation, where the domain divides into regions of strong convection with a weak magnetic field and regions of weak convection with a strong field. Analytical predictions of flux separation based on weakly nonlinear analysis are extended into the fully nonlinear regime through numerical simulations. The results of the model are compared with simulations of the full three-dimensional magnetoconvection problem.

Instability of convection in a fluid layer rotating about an oblique axis.

We analyze thermal convection in a fluid layer confined between isothermal horizontal boundaries at which the tangential component of the fluid stress vanishes. The layer rotates about an oblique, nearly vertical axis. Using a model set of equations for w, the horizontal planform of the vertical velocity component, and psi, a stream function related to a large-scale vertical vorticity field, we describe the instabilities of convection rolls. We show how the usual Küppers-Lortz instability, which leads to a continual precession of the roll pattern, can be suppressed by the oblique rotation vector. Of particular interest is the small-angle instability of rolls, to perturbations in the form of rolls that are almost aligned with the primary rolls; at finite Prandtl number, this instability is not prevented by the horizontal component of the rotation vector, unless this component is sufficiently strong, in which case stability is confined to small-amplitude rolls near the marginal stability boundary. A one-dimensional instability leading to amplitude-modulated rolls is unaffected by the oblique rotation. Numerical simulations of the model equations are presented, which illustrate the instabilities analyzed.

Behavior of the reaction front between initially segregated species in a two-stage reaction.

The large-time asymptotic behavior of a two-stage reaction (A+B-->R, B+R-->S) with initially segregated reactants is described. The concentration of the reactants is found to be significantly less than the initial concentrations in a depletion zone of width proportional to t(1/2), where t is time; the reaction takes place in a thinner zone of width proportional to t(1/6). Similarity solutions for the chemical concentration profiles in the reaction zone are calculated, and are compared with numerical simulations of the full partial differential reaction-diffusion equations. The large-time asymptotic scalings reported here are the same as in the absence of the secondary reaction, but we find that the location of the reaction zone is significantly shifted due to the secondary reaction. The reaction zone may behave in an exotic fashion at large time, moving first one way, then reversing its direction.

Symptomatic nephrolithiasis complicating pregnancy.

OBJECTIVE: To review our experiences with diagnosis and management of symptomatic nephrolithiasis complicating pregnancy and to ascertain the efficacy of renal sonography for initial diagnosis compared with plain x-rays or single-shot intravenous pyelography. METHODS: Perinatal outcomes were evaluated for all pregnant women admitted to Parkland Hospital for nephrolithiasis from 1986 to 1999. Diagnostic studies and management of nephrolithiasis were also evaluated. RESULTS: During the 13-year study period, 57 pregnant women had 73 admissions for symptomatic nephrolithiasis. Symptomatic nephrolithiasis complicated 1 in 3300 (0.03%) deliveries at our institution. Only 12 women (20%) had a history of renal calculi. Mean gestational age at diagnosis was 23 weeks. Imaging techniques included renal ultrasonography, plain abdominal x-ray, and single-shot intravenous pyelography. Calculi were visualized in 21 of 35 (60%) renal ultrasonographic examinations and 4 of 7 (57%) abdominal x-ray studies when these were performed as the initial test. In contrast, urolithiasis was discovered in 13 of 14 (93%) instances in which intravenous pyelography was performed as the initial diagnostic test. When sonography was negative (n = 14), renal calculi were confirmed by single-shot intravenous pyelography (n = 8). Although 43 of 57 (75%) of symptomatic episodes responded to conservative management, 10 women required ureteral stents, 3 needed percutaneous nephrostomy tubes, and 2 underwent ureteral laser lithotripsy for resolution. CONCLUSION: Although the convenience and safety of ultrasonography to initially diagnose nephrolithiasis are indisputable, 40% of calculi were missed when this method alone was used. Thus, if nephrolithiasis is still suspected clinically despite ultrasonographic findings, single-shot pyelography is recommended.