Is Combined Ultrasound with Radiography Sufficient for the Diagnosis of Obstructive Ureteric Stone in Patients with Acute Flank Pain?

CONTEXT: Ultrasound (US) is excellent for detection of hydronephrosis but has poor sensitivity for stone detection. In contrast, radiography of the kidney-ureter-bladder has better sensitivity for detection of stone but limited sensitivity for hydronephrosis detection. A combination of these two modalities may improve both sensitivity and specificity for the diagnosis of obstructive ureteric stone. AIMS: This study aims to investigate the diagnostic accuracy of combined US with radiography for the diagnosis of obstructive ureteric stone in adult patients. SETTINGS AND DESIGN: Retrospective study with retrospective data collection performed in a 1500-bed university hospital. MATERIALS AND METHODS: A total of 90 patients were included. The electronic medical record, radiological reports, laboratory results, and patient management were extracted and analyzed. STATISTICAL ANALYSIS USED: The diagnostic performance of US, radiography, and combined US with radiography were calculated and compared. The computed tomography was used as diagnostic reference. RESULTS: US alone had a sensitivity of 73.5%, specificity of 92.7%, and negative predictive value (NPV) of 74.5% for hydronephrosis. When US showed both ureteric stone and hydronephrosis, sensitivity dropped to 14.3% but specificity increased to 100%. Radiography alone had a sensitivity of 34.7%, specificity of 100%, and NPV of 56.2% for the detection of ureteric stone. Combining radiography with US raised the sensitivity for diagnosis of obstructive ureteric stone to 88% with a specificity of 93% and accuracy of 90%. CONCLUSIONS: Combined US with radiography was accurate for the diagnosis of obstructive ureteric stone in patients presenting with acute flank pain.

A randomized controlled trial of sitafloxacin vs. ertapenem as a switch therapy after treatment for acute pyelonephritis caused by extended-spectrum ß-lactamase-producing Escherichia coli: A pilot study.

BACKGROUND: The overuse and misuse of carbapenems have contributed to the antibiotic resistance crisis. The role of oral fluoroquinolones as a switch therapy for the treatment of urinary tract infection from Escherichia coli (ESBL-EC) is limited. OBJECTIVE: To compare the clinical and bacteriological efficacy of sitafloxacin and ertapenem for non-bacteremic acute pyelonephritis caused by ESBL-EC. METHODS: A prospective randomized controlled trial of patients with acute pyelonephritis caused by ESBL-EC was performed as a pilot study. One of the carbapenems was initially given to the patients. After day 3, patients were randomized to receive either sitafloxacin or ertapenem. RESULTS: Thirty-six patients were enrolled: 19 (52.8%) in the sitafloxacin group and 17 (47.2%) in the ertapenem group. There was no statistically significant difference in baseline characteristics between the two groups except a lower proportion of previous urinary catheter insertion in the sitafloxacin group (15.8% vs. 52.9%, p = 0.018). Signs and symptoms at presentation were similar between the two groups except a higher proportion of patients with chills in the sitafloxacin group (68.4% vs. 29.4%, p = 0.019). At day 10, all but one patient in the ertapenem group had clinical cure. Microbiological eradication was comparable between the sitafloxacin and ertapenem groups (84.2% vs. 75%, p = 0.677). There were no significant adverse effects. CONCLUSIONS: Treatment of non-bacteremic acute pyelonephritis caused by ESBL-EC with carbapenem followed by oral sitafloxacin is effective and well-tolerated. Sitafloxacin may be considered as an alternative choice of switch therapy in this clinical setting.

What clinical factors are associated with biphasic anaphylaxis in Thai adult patients?

BACKGROUND: Anaphylaxis is an emergency condition and may be fatal. Approximately 20% of patients with anaphylaxis may develop recurrent episodes of anaphylaxis within 72 hours or biphasic anaphylaxis. The severity of biphasic anaphylaxis can be either more or less severe than the first episode. Knowledge of factors associated with biphasic anaphylaxis in particular in Asian populations is still limited. OBJECTIVES: To study predictors for biphasic anaphylaxis in Thai patients at the Emergency Department (ED). METHODS: All consecutive patients diagnosed as anaphylaxis at the ED, Ramathibodi Hospital, Mahidol University, Bangkok were enrolled. The study was prospectively conducted from January to December 2011. Patients were divided into two groups; uniphasic and biphasic anaphylaxis. Multivariate logistic regression was used to identify factors associated with biphasic anaphylaxis. RESULTS: During the study period, there were 63 patients diagnosed with anaphylaxis at the ED. Of those, 16 patients were excluded due to or treatment of anaphylaxis, concomitant medications or pre hospital treatment. In total, there were 47 patients remaining in the study, including 10 patients with biphasic anaphylaxis (21.28%). The clinical characteristics of the uniphasic and biphasic anaphylaxis groups were comparable. In multivariate logistic regression analyses, only respiratory rate and abdominal pain were significantly associated with biphasic anaphylaxis. The adjusted ORs (95% CI) of both factors were 0.653 (0.457, 0.932) and 15.429 (1.395, 170.690), respectively. CONCLUSION: Reduced respiratory rate and the presence of abdominal pain were two significant factors associated with biphasic anaphylaxis.

Prehospital time of suspected stroke patients treated by emergency medical service: a nationwide study in Thailand.

BACKGROUND: This work was to study the prehospital time among suspected stroke patients who were transported by an emergency medical service (EMS) system using a national database. METHODS: National EMS database of suspected stroke patients who were treated by EMS system across 77 provinces of Thailand between January 1, 2015, and December 31, 2018, was retrospectively analyzed. Demographic data (i.e., regions, shifts, levels of ambulance, and distance to the scene) and prehospital time (i.e., dispatch, activation, response, scene, and transportation time) were extracted. Time parameters were also categorized according to the guidelines. RESULTS: Total 53,536 subjects were included in the analysis. Most of the subjects were transported during 06.00-18.00 (77.5%) and were 10 km from the ambulance parking (80.2%). Half of the subjects (50.1%) were served by advanced life support (ALS) ambulance. Median total time was 29 min (IQR 21, 39). There was a significant difference of median total time among ALS (30 min), basic (27 min), and first responder (28 min) ambulances, Holm P = 0.009. Although 91.7% and 88.3% of the subjects had dispatch time ≤ 1 min and activation time ≤ 2 min, only 48.3% had RT ≤ 8 min. However, 95% of the services were at the scene ≤ 15 min. CONCLUSION: Prehospital time from EMS call to hospital was approximately 30 min which was mainly utilized for traveling from the ambulance parking to the scene and transporting patients from the scene to hospitals. Even though only 48% of the services had RT ≤ 8 min, 95% of them had the scene time ≤ 15 min.

Satisfaction of imaging report rendered in emergency setting: a survey of radiology and referring physicians.

RATIONALE AND OBJECTIVES: To determine physicians' preference toward three types of structured imaging reports (basic structured report [BSR], itemized report [IR], and point-and-click report [PCR]) used in emergency radiology. MATERIALS AND METHODS: Survey questions were created and considered valid and reliable based on index of item objective congruence from three specialists (>0.75) and a pilot of 25 subjects (Cronbach alpha, 0.83-1.00). Respondents included trainees and attendings in radiology and referring physicians working in the academic emergency department at the time of survey rollout. They were provided report examples of each type and asked to complete a questionnaire consisting of the following five parts: demographics, necessity of imaging report, report quality (content, format and organization, and language), process of reporting, and components of imaging report. For rating scores, the higher value means the higher preference and agreement. RESULTS: The survey received 79.5% response rate. Respondents included 101 physicians (mean age, 29.4 years; 61 radiology physicians and 40 referring physicians; 81 trainees and 20 attending). Overall, IR was preferred over PCR and BSR by all physicians with scores (out of 10) as follows: IR, 7.62-8.83; PCR, 6.62-8.55; BSR, 5.23-6.65; P < .001. IR received scores (out of 5) of 4.03-4.37, PCR 3.32-4.52, and BSR 2.59-3.86 for report quality. For process of reporting, IR had scores (out of 5) of 3.80-4.56, PCR 2.79-4.09, and BSR 2.32-3.56. CONCLUSIONS: In emergency setting, physicians preferred IR over PCR and BSR. IR and PCR were equal in report quality metrics, but IR was most preferred in the process of reporting. BSR ranked last in both quality and process.

Factors associated with overcrowded emergency rooms in Thailand: a medical school setting.

Background. Overcrowding in the emergency department (ED) is a significant public health problem in the US, Europe, and Asia. Factors associated with prolonged length of stay in Thailand are still limited. Methods. This study was conducted at the ED, Ramathibodi Hospital, Mahidol University, Thailand, during July 2011. We selected 300 patients (5.77%) from a total of 5,202 who visited the ED during the study period by simple random sampling. Charts were retrospectively reviewed baseline characteristics, clinical factors, and duration of ED stay. Multivariate logistic regression analyses were performed to identify independent factors for an ED stay more than or equal to 8 hours. Results. We excluded 33 patients (11%) due to incomplete data or stroke fast track enrollment. In total, 267 patients were in the analysis and 53 patients (19.85%) had an ED visit time more than or equal to 8 hours. The number of rounds of blood testing and the type of insurance were associated with prolonged ED stay of more than or equal to 8 hours. Conclusion. ED physicians may need to consider appropriate investigations to shorten the length of stay in the ED.