Evaluation of the patients with flank pain in the emergency department by modified STONE score.

BACKGROUND/AIM: Computed tomography (CT) is generally used for ureteral stone diagnosis. Unnecessary imaging use should be reduced to prevent increased radiation exposure and lower costs. For this reason, scoring systems that evaluate the risk of ureteral stones have been developed. In this study, we aimed to investigate the diagnostic accuracy of the modified STONE score (MSS) and its ability to predict ureteral stones. MATERIALS AND METHODS: The research was conducted as a multi-center, prospective and observational study. Patients aged 18 and over who presented to EDs with complaints of flank pain and who received a CT were included. Patients were divided into two groups based on the presence or absence of stones, and the categories of the MSS were determined. The ability of the MSS to predict the ureteral stone and its diagnostic accuracy were calculated. RESULTS: The median age (min/max) of the 367 study patients was 37 (18/91), and 244 (66.5%) were male. A ureteral stone was present in 228 (73.0%) patients. Male gender, previous stone history, duration of pain less than 6 h, presence of hematuria, and CRP value below 0.5 mg/dL were significantly more common in the group with stones. The prevalence of ureter stones in the MSS high-risk group was 96.0%. The area under the receiver operating characteristic curve and sensitivity of the MSS was 0.903 and 0.81, respectively. CONCLUSION: The modified STONE score has high diagnostic performance in suspected urinary stone cases. This scoring system can assist clinicians with radiation reducing decision-making.

The Efficacy of Antimuscarinics Alone or in Combination with Alpha-Blockers for the Treatment of Ureteral Stent-Related Symptoms: A Systematic Review and Meta-Analysis.

INTRODUCTION AND AIM: The purpose of this meta-analysis was to evaluate the efficacy of antimuscarinics alone or in combination with alpha-blockers for the treatment of ureteral stent-related symptoms. METHODS: The databases MEDLINE, EMBASE, PubMed, the Cochrane Controlled Trial Register of Controlled Trials from 2000 to February 2016 were searched to identify randomized controlled trials that referred to the use of a combination of antimuscarinics and alpha-blockers for the treatment of ureteral stent-related symptoms. A systematic review and meta-analysis was conducted. RESULTS: Seven publications involving 710 patients were included in the meta-analysis. In the analysis, we found significantly improved total International Prostate Symptom Score, quality of life, body pain and work performance score of the Ureteral Stent Symptom Questionnaire (USSQ) in the combination group compared with antimuscarinics alone (p = 0.00001, p = 0.00001, p = 0.00001 and p = 0.004, respectively). Antimuscarinics alone versus the control group showed significant improvement in urinary symptom, body pain and general health score of USSQ (p = 0.002, p = 0.00001 and p = 0.003, respectively). CONCLUSIONS: Our meta-analysis shows the beneficial effect of antimuscarinics alone in reducing stent-related symptoms. The combined use of antimuscarinics and alpha-blockers results in additive favorable effects in patients with ureteral stent-related symptoms compared with antimuscarinics monotherapy. The alpha-blockers may enhance the efficacy of the antimuscarinics, which is beneficial for the treatment of ureteral stent-related symptoms.

Predicting ureteral stones in emergency department patients with flank pain: an external validation of the STONE score.

PURPOSE: The ability to objectively predict which emergency department patients are likely to have a ureteral stone may aid in cost-effectiveness and patient-centered diagnostic imaging decisions. We performed an external validation of the STONE score, a clinical prediction rule for the presence of uncomplicated ureteral stones in emergency department patients developed at Yale University School of Medicine. METHODS: Five hundred thirty-six (536) consecutive patients evaluated in an urban tertiary care emergency department for the possible diagnosis of ureteral stone were retrospectively reviewed. The STONE score uses five factors (gender, duration of pain, race, nausea/vomiting, erythrocytes on urine dipstick) to categorize patients into low, medium, and high probability of having a ureteral stone. The total STONE score risk is 0-13 and divided into three groups: low risk = 0-5, moderate risk = 6-9, and high risk = 10-13. RESULTS: Of the 536 patients evaluated for suspected ureteral stone, 257 (47.8 %) had a ureteral stone. Mean patient age was 45.9 years (SD 16.3), and gender distribution was 43.9 % female and 56.1 % male. Distribution of STONE score risk was 24.1 % low, 48.1 % moderate, and 27.7 % high. Diagnosis of ureteral stone by STONE score risk was 14 % for low-risk group, 48.3 % for moderate-risk group, and 75.8 % for high-risk group. This distribution is consistent with internal validation at Yale University School of Medicine, where values were 8.3-9.2 % for low risk, 51.3-51.6 % for moderate risk, and 88.6-89.6 % for high risk. CONCLUSIONS: Our study validates the use of the STONE clinical score to categorize patients as low, moderate, and high risk for ureteral stone. This could help guide development of clinical decision rules for diagnostic studies and imaging in the future.

Validity of STONE scores in younger patients presenting with suspected uncomplicated renal colic.

OBJECTIVES: Recent studies have cast doubt on the routine need for emergent computed tomographic (CT) scan in patients with suspected renal colic. A clinical prediction rule, the STONE score, was recently published with the goal of helping clinicians predict obstructive kidney stones in noninfected flank pain patients before CT scan. We sought to examine the validity of this score in younger, noninfected flank pain patients. METHODS: A secondary analysis of a retrospective cohort study was performed to determine the validity of STONE scores for predicting the outcome of obstructive kidney stone in patients age 18 to 50 years presenting with flank pain suggestive of uncomplicated ureterolithiasis. Validity was measured by calculation of the area under the curve of the receiver operating characteristic curve. Sensitivity, specificity, negative predictive value, positive predictive value, and ±likelihood ratios were calculated for various cutoff values. RESULTS: Of 134 patients who met inclusion criteria, 56.7% were female, average age was 37 years, and 52% had an obstructing kidney stone by CT scan. The receiver operating characteristic curve for the STONE score had an area under the curve of 0.87 (95% confidence interval, 0.80-0.93) and indicated that a cutoff of greater than or equal to 8 would have a sensitivity of 78.6%, specificity of 84.4%, negative predictive value of 78.3%, positive predictive value of 84.6%, and +likelihood ratio of 4.9. CONCLUSIONS: This analysis suggests that the STONE score is valid in younger populations. It can aid in determining pretest probability and help inform conversations about the likelihood of the diagnosis of renal colic before imaging, which may be useful for decision making.

External validation of the STONE score and derivation of the modified STONE score.

OBJECTIVE: The STONE score is a clinical prediction rule for the presence of uncomplicated ureter stones with a low probability of acutely important alternative findings. This study performed an external validation of the STONE score, focusing on the Korean population, and a derivation of the modified STONE score for better specificity and sensitivity. METHODS: We retrospectively reviewed medical records of patients complaining of flank pain at a single emergency department from January 2013 to December 2014. Patients were categorized into 3 groups according to their STONE score. The prevalence of ureter stones and other alternative findings were calculated in each group. We derived a modified STONE score based on a multivariable analysis and performed an interval validation. RESULTS: From the 700 patients included in the analysis, 555 patients (79%) had a ureter stone. The area under the receiver operating characteristic curve of the STONE score was 0.92. The sensitivity of the high stone score was 0.56. In the modified STONE score, nausea, vomiting, and racial predictors were substituted by C-reactive protein and previous stone history. The area under the receiver operating characteristic curve and sensitivity of the modified STONE score in the internal validation group significantly increased to 0.94 and 0.80, respectively. CONCLUSION: The STONE score can be used to predict a ureter stone with a low probability of other alternative findings. The modified STONE score might increase the diagnostic performance in suspicious urinary stone cases. KEY POINTS: We performed external validation of the STONE score and derivation of the modified STONE score. This scoring system could help the clinicians with radiation reducing decision making.

Clinical variables and stone detection in patients with flank pain.

INTRODUCTION: Non-contrast CT (NCT) is commonly used to evaluate flank pain (FP). We sought to evaluate incidence of ureteral calculi on NCT in patients with FP, and to determine if clinical variables are associated with higher detection rates. MATERIALS AND METHODS: Retrospective review identified 613 patients undergoing NCT for FP. Patient clinical data, NCT findings, and intervention were analyzed. Focus was placed on variables commonly associated with urolithiasis (Vstone), comprising hematuria, nausea/vomiting, and prior stone history. Statistical analysis was performed to identify risk of ureteral stones based on number and type of Vstone. RESULTS: No stone disease was identified on NCT in 175 patients (28.5%). NCT demonstrated 214 (35%), 72 (12%), and 152 (25%) patients with stones located in the kidney, ureter, or both, respectively. Only 33 (5%) patients had FP as their sole Vstone, with ureteral calculi identified in 6% of this cohort. The rate of ureteral calculi increased with more Vstone. Patients having all four Vstone were found to have the highest rate of ureteral stones (59%). Statistical analysis demonstrated a statistically significantly increased relative risk of stone formation given three or four Vstone when compared with FP alone. CONCLUSIONS: Whereas isolated FP is associated with a lower rate of ureteral calculus detection, a significant increased relative risk of ureteral calculus is seen in patients with additional clinical variables associated with stone disease. Accordingly, it may be possible to improve detection rates of ureteral stones through the use of additional clinical variables to guide NCT selection.

Loin pain hematuria syndrome.

Loin pain hematuria syndrome is a rare disease with a prevalence of ∼0.012%. The most prominent clinical features include periods of severe intermittent or persistent unilateral or bilateral loin pain accompanied by either microscopic or gross hematuria. Patients with loin pain hematuria syndrome initially present with hematuria, flank pain, or most often both hematuria and flank pain. Kidney biopsies from patients with loin pain hematuria typically reveal only minor pathologic abnormalities. Further, loin pain hematuria syndrome is not associated with loss of kidney function or urinary tract infections. Loin pain hematuria syndrome-associated hematuria and pain are postulated to be linked to vascular disease of the kidney, coagulopathy, renal vasospasm with microinfarction, hypersensitivity, complement activation on arterioles, venocalyceal fistula, abnormal ureteral peristalsis, and intratubular deposition of calcium or uric acid microcrystals. Many patients with loin pain hematuria syndrome also meet criteria for a somatoform disorder, and analgesic medications, including narcotics, commonly are used to treat loin pain hematuria syndrome-associated pain. Interventional treatments include renal denervation, kidney autotransplantation, and nephrectomy; however, these methods should be used only as a last resort when less invasive measures have been tried unsuccessfully. In this review article, we discuss and critique current clinical practices related to loin pain hematuria syndrome pathophysiology, diagnosis, treatment, and prognosis.

Renal infarction versus pyelonephritis in a woman presenting with fever and flank pain.

Patients with fever, flank pain, and dysuria frequently are encountered in the emergency department. Acute pyelonephritis is the most likely diagnosis; however, its clinical and radiologic presentation consistently overlap with that of acute renal infarction. Ultrasound is unable to distinguish early infarction from nonabscessed acute pyelonephritis. Hence, computed tomography or magnetic resonance imaging are needed. We report the case of a 68-year-old woman who presented with fever, flank pain, and dysuria, along with respiratory distress and tachycardia. Elevated values for inflammatory indexes suggested a diagnosis of acute pyelonephritis, and subsequent contrast-enhanced computed tomography showed hypodense wedge-shaped areas in both kidneys. However, the presence of a thin rim of capsular enhancement (cortical rim sign), the absence of perirenal inflammatory changes, and the location of the lesions apart from defined calyces suggested the alternative diagnosis of renal infarction. The underlying cause was not identified until an episode of acute dyspnea revealed paroxysmal arrhythmia. Our case demonstrates that a thorough knowledge of the imaging findings of renal infarction and acute pyelonephritis is essential to correctly making the diagnosis.

[Imaging modalities and therapy options in patients with acute flank pain]. / Bildgebungsmodalitäten und Therapieoptionen bei Patienten mit akutem Flankenschmerz.

The objective of this article is the description of imaging techniques for the evaluation of patients with acute flank pain and suspicion of urolithiasis and the impact of these techniques in the therapy management of patients with calculi.

Renal cyst infection caused by Brucella abortus.

A 49-year-old man with a medical history of polycystic kidney disease was presented to the emergency department with fever and left flank pain. Abdominal examination revealed an enlarged and painful left kidney. The C-reactive protein level was significantly high and the magnetic resonance imaging revealed areas of abnormal intensity and fluid-fluid levels in renal cysts. Brucella abortus was yielded from both blood and cyst fluid culture. Standard therapy (rifampicin plus doxycycline) of brucellosis was started, but the clinical and laboratory signs subsided after the addition of ciprofloxacin. There was no need for aspiration of infected cyst fluid. Hereby, according to the medical database search, we report that the first renal cyst infection caused by B. abortus was successfully treated with triple antibiotic therapy.