title: Ureteral Stones: Implementation of a Reduced-Dose CT Protocol in Patients in the Emergency Department with Moderate to High Likelihood of Calculi on the Basis of STONE Score.
abstract: Purpose To determine if a reduced-dose computed tomography (CT) protocol could effectively help to identify patients in the emergency department (ED) with moderate to high likelihood of calculi who would require urologic intervention within 90 days. Materials and Methods The study was approved by the institutional review board and written informed consent with HIPAA authorization was obtained. This was a prospective, single-center study of patients in the ED with moderate to high likelihood of ureteral stone undergoing CT imaging. Objective likelihood of ureteral stone was determined by using the previously derived and validated STONE clinical prediction rule, which includes five elements: sex, timing, origin, nausea, and erythrocytes. All patients with high STONE score (STONE score, 10-13) underwent reduced-dose CT, while those with moderate likelihood of ureteral stone (moderate STONE score, 6-9) underwent reduced-dose CT or standard CT based on clinician discretion. Patients were followed to 90 days after initial imaging for clinical course and for the primary outcome of any intervention. Statistics are primarily descriptive and are reported as percentages, sensitivities, and specificities with 95% confidence intervals. Results There were 264 participants enrolled and 165 reduced-dose CTs performed; of these participants, 108 underwent reduced-dose CT alone with complete follow-up. Overall, 46 of 264 (17.4%) of patients underwent urologic intervention, and 25 of 108 (23.1%) patients who underwent reduced-dose CT underwent a urologic intervention; all were correctly diagnosed on the clinical report of the reduced-dose CT (sensitivity, 100%; 95% confidence interval: 86.7%, 100%). The average dose-length product for all standard-dose CTs was 857 mGy · cm ± 395 compared with 101 mGy · cm ± 39 for all reduced-dose CTs (average dose reduction, 88.2%). There were five interventions for nonurologic causes, three of which were urgent and none of which were missed when reduced-dose CT was performed. Conclusion A CT protocol with over 85% dose reduction can be used in patients with moderate to high likelihood of ureteral stone to safely and effectively identify patients in the ED who will require urologic intervention. (©) RSNA, 2016 Online supplemental material is available for this article.
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Brock
authors.initials: B
authors.lastname: Daniels
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Dinesh
authors.initials: D
authors.lastname: Singh
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Seth
authors.initials: S
authors.lastname: Luty
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Gowthaman
authors.initials: G
authors.lastname: Gunabushanam
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Monica
authors.initials: M
authors.lastname: Ghita
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Annette
authors.initials: A
authors.lastname: Molinaro
authors.affiliation: From the Department of Emergency Medicine (C.L.M., B.D.), Department of Urology (D.S.), Yale Center for Clinical Investigation (S.L.), Department of Diagnostic Radiology (G.G.), and Department of Internal Medicine (C.P.G.), Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; Department of Radiology, Virginia Commonwealth University, Richmond, Va (M.G.); and Department of Epidemiology and Biostatistics, University of California, San Francisco Medical Center, San Francisco, Calif (A.M.).
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011829:Radiation Dosage; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014514:Ureteral Calculi / Q000000981:diagnostic imaging*