title: STONE PLUS: Evaluation of Emergency Department Patients With Suspected Renal Colic, Using a Clinical Prediction Tool Combined With Point-of-Care Limited Ultrasonography.
abstract: OBJECTIVE
  We determine whether renal point-of-care limited ultrasonography (PLUS) used in conjunction with the Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction score can aid identification of emergency department (ED) patients with uncomplicated ureteral stone or need for urologic intervention.
  
  
  METHODS
  This was a prospective observational study of adult ED patients undergoing computed tomography (CT) scan for suspected ureteral stone. The previously validated STONE score classifies patients into risk categories of low (≈10%), moderate (≈50%), or high (≈90%) for symptomatic stone. Renal PLUS assessed for presence of hydronephrosis before CT scanning. The primary outcomes of symptomatic ureteral stone or acutely important alternative finding were abstracted from CT reports. The secondary outcome, urologic intervention, was assessed by 90-day follow-up interview and record review.
  
  
  RESULTS
  Of 835 enrolled patients, ureteral stone was identified in 53%, whereas 6.5% had an acutely important alternative finding on CT. Renal PLUS modestly increased sensitivity for symptomatic stone among low and moderate STONE score categories. Moderate or greater hydronephrosis improved specificity from 67% (62% to 72%) to 98% (93% to 99%) and 42% (37% to 47%) to 92% (86% to 95%) in low- and moderate-risk patients, with likelihood ratios of 22 (95% CI, 4.2-111) and 4.9 (95% CI, 2.9-8.3), respectively. Test characteristics among high-risk patients were unchanged by renal PLUS. For urologic intervention, any hydronephrosis was 66% sensitive (57% to 74%), whereas moderate or greater hydronephrosis was 86% specific overall (83% to 89%) and 81% (69% to 90%) sensitive and 79% 95% CI, (73-84) specific among patients with the highest likelihood of symptomatic stone.
  
  
  CONCLUSIONS
  Hydronephrosis on renal PLUS modestly improved risk stratification in low- and moderate-risk STONE score patients. The presence or absence of hydronephrosis among high-risk patients did not significantly alter likelihood of symptomatic stone but may aid in identifying patients more likely to require urologic intervention.
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT. Electronic address: brockdaniels@gmail.com.
authors.forename: Brock
authors.initials: B
authors.lastname: Daniels
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
authors.affiliation: Department of Neurosurgery, University of California, San Francisco School of Medicine, San Francisco, CA.
authors.forename: Annette
authors.initials: A
authors.lastname: Molinaro
authors.affiliation: Department of Urology, Yale University School of Medicine, New Haven, CT.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Singh
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Seth
authors.initials: S
authors.lastname: Luty
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Richelle
authors.initials: R
authors.lastname: Jessey
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
mesh_terms: D000328:Adult; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000150:complications / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D056844:Renal Colic / Q000000981:diagnostic imaging* / Q000209:etiology; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography