สำเนา Journal uro new

Ext.
Thanawat Sima
INTRODUCTION
• Pain from nephrolithiasis is a common reason for emergency department visits in the United States.
• Abdominal computedtomography (CT) has become the most common initial imaging test for suspected nephrolithiasis
because of its high sensitivity for the diagnosis of urinary stone disease.
• However, CT entails exposure to ionizing radiation with attendant long term cancer risk, is associated with a high rate of
incidental findings that can lead to inappropriate follow-up referral and treatment, and contributes to growing annual care
costs for acute nephrolithiasis.
• No evidence has shown that increased CT use, despite its higher sensitivity, is associated with improved patient
outcomes.
S T U D Y D E S I G N A N D R A N D O M I Z ATI O N
• Study patients were recruited in 15 geographically diverse academic emergency departments.

• Patients with suspected nephrolithiasis were randomly assigned in a 1:1:1 ratio, to one of three imaging
groups
• ultrasonography performed by an emergency physician (point-of-care ultrasonography)
• ultrasonography performed by a radiologist (radiology ultrasonography)
• abdominal CT
• Patients were randomly assigned only during hours when all three imaging techniques were feasible.
• The patients’ care during the emergency department visit at the time of enrollment was managed at the
discretion of the treating physicians.
STUDY POPULATION
• We enrolled patients from October 2011 through February 2013.
INCLUSION CRITERIA
• Patients 18 to 76 years of age who reported flank or abdominal pain were eligible for entry
into the study if the treating emergency physician decided to order imaging to establish or rule out a primary
diagnosis of kidney stones.
STUDY POPULATION
EXCLUSION CRITERIA
• Patients whom the treating physician considered to be at high risk for serious alternative diagnoses, such as
acute cholecystitis, appendicitis, aortic aneurysm, or bowel disorders, were not eligible, nor were pregnant
women.
• Patients who had a single kidney, who had undergone renal transplantation, or who were undergoing
dialysis were ineligible.
INITIAL IMAGING
• Point-of-care ultrasound examinations were performed by emergency physicians who had had
training as recommended by the American College of Emergency Physicians.
• Radiology ultrasound examinations were performed in radiology departments according to the guidelines
of the Society of Radiologists in Ultrasound or the American Institute of Ultrasound in Medicine.
• CT was performed according to local standards.

PR I M A RY O U T C O M ES
1. High-risk diagnoses with complications that could be related to missed or delayed diagnoses
2. Cumulative radiation exposure from imaging
3. Total costs
1. High-risk diagnoses with complications that could be related to missed or delayed diagnoses
High-risk diagnoses with complications were prespecified and were defined as any of the following
diagnoses within 30 days after the emergency department visit
- abdominal aortic aneurysm with rupture
- pneumonia with sepsis
- appendicitis with rupture
- diverticulitis with abscess or sepsis
- bowel ischemia or perforation
- renal infarction
- renal stone with abscess
- pyelonephritis with urosepsis or bacteremia
- ovarian torsion with necrosis
-aortic dissection with ischemia
II. Cumulative radiation exposure

was defined as the sum of the effective doses from all imaging that was performed within 6 months after
randomization. with the results reported in millisieverts
III. Total costs

Analyses of costs, which are ongoing, are based on national Medicare reimbursements for costs
associated with the emergency department visits.
SECONDARY OUTCOME
• serious adverse events,
• serious adverse events related to participation in the study,
• return emergency department visits and hospitalizations after discharge from the emergency department,
• self-reported pain scores (as assessed on an 11-point visual-analogue scale, with higher scores indicating more severe
pain), and
• diagnostic accuracy for nephrolithiasis (assessed diagnostic accuracy for nephrolithiasis by comparing the baseline
diagnosis at the time of discharge from the emergency department with the reference standard of confirmed stone
diagnosis )
S TAT I S T I C A L A N A LY S I S
• Statistical analyses were performed according to the intention-to-treat principle.

• Baseline characteristics and outcomes were compared across study groups with the use of chi-square tests.
• Fisher’s exact test
• Kruskal–Wallis test
• We used SAS software, version 9.4, for all the analyses.
R E S U LT S
R E S U LT S S T R AT I F I E D A C C O R D I N G T O H I S T O R Y
OF NEPHROLITHIASIS
• There were no significant differences among the groups with respect to high-risk diagnoses with
complications when the results were stratified according to whether patients had a history of
nephrolithiasis
• The mean radiation exposure was significantly lower in the ultrasonography groups than in the CT group
among patients with and those without a history of nephrolithiasis
• Patients in the ultrasonography groups were less likely to undergo additional diagnostic testing
with CT when they reported a history of nephrolithiasis (31% vs. 36%, P<0.001).
DISCUSSION
• In the current study, patients in the ultrasonography groups were exposed to a lower total
amount of radiation than were patients in the CT group
• no significant difference in high-risk diagnoses with complications, total serious adverse events, or related
serious adverse events.
• secondary outcomes of pain scores, hospital admissions, and emergency department readmissions during
follow-up also did not differ significantly among the groups.
DISCUSSION
• Our results do not suggest that patients should undergo only ultrasound imaging
• ultrasonography should be used as the initial diagnostic imaging test, with further imaging studies performed at the
discretion of the physician on the basis of clinical judgment.
• Some patients in each study group — but more in the ultrasonography groups — underwent additional imaging.
• Radiation exposure was slightly higher in the point of-care ultrasonography group because of greater use of
subsequent CT, possibly because emergency room physicians may have less confidence than radiologists in
performing ultrasonography and interpreting the results.
• length of stay in the emergency department was slightly but significantly shorter (0.7 hours) in the point-of care
ultrasonography group.
DISCUSSION
strengths
• Large size
• diverse emergency departments
• randomized design
DISCUSSION
limitation
• could not blind the investigators, patients, or physicians to the study group assignment.
CONCLUSION
• The use of CT for the diagnosis of suspected renal stones has increased by a factor of 10 over
the past 15 years in the United States
• Probably because of its greater sensitivity and because it can be performed at will in most emergency
departments in the United States.
• Ultrasonography as the initial test in patients with suspected nephrolithiasis
• No need for CT in most patients
• lower cumulative radiation exposure
• no significant differences in the risk of subsequent serious adverse events,pain scores, return emergency department
visits, or hospitalizations

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Ext.

• Study patients were recruited in 15 geographically diverse academic emergency departments.

• We enrolled patients from October 2011 through February 2013.

• CT was performed according to local standards.

II. Cumulative radiation exposure

III. Total costs

• serious adverse events,

• serious adverse events related to participation in the study,

• Statistical analyses were performed according to the intention-to-treat principle.

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