Introduction In this study, we investigated the correlation of severity of renal colic with clinical parameters like pain characteristics, haematuria and pyuria, laboratory parameters such as inflammatory markers, and radiological parameters including site and size of stone and hydronephrosis. Methods The Visual Analogue Scale (VAS) determined the pain severity. Detailed history and clinicodemographic profiling of the patient was done, laboratory investigations were done, ultrasound and non-contrast computed tomography of kidney-ureter-bladder were done and all the parameters were duly noted and correlated with the pain severity. Result The mean age of the 183 patients was 43.96 ± 15.16 years, and 62.8% were male. The patients’ mean VAS score at presentation was 8.57 ± 1.08. The mean VAS score was found to be statistically higher in patients having a first episode of renal colic, solitary kidney, pyuria, raised creatinine, severe hydronephrosis, and stones located at the renal pelvis. In addition, higher VAS scores led to more surgical interventions. Conclusion The correlation of pain severity of renal colic with various parameters can aid in the development of quick diagnostic and therapeutic protocols for patients presenting to the emergency department with renal stone disease. This study shows that pain scores can correlate with various parameters and predict the outcome and complications in these patients.

https://www.cureus.com/articles/107375-correlation-of-severity-of-renal-colic-with-clinical-laboratory-and-radiological-parameters-an-emergency-department-based-prospective-observational-study.pdf

Correlation of Severity of Renal Colic With Clinical, Laboratory, and Radiological Parameters: An Emergency Department-Based Prospective Observational Study

Predictive factors for stone management timing after emergency percutaneous nephrostomy drainage in patients with infection and hydronephrosis secondary to ureteral calculi

The lifetime risk of nephrolithiasis is 10.6% in men and 7.1% in women in the United States. Patients frequently seek emergency care for the pain associated with nephrolithiasis because it is typically severe and refractory to over-the-counter analgesics. A recent study showed that computed tomography (CT) scanning is the predominant test used and is performed in more than 90% of patients diagnosed with kidney stones. A more recent study has examined the sensitivity and specificity of radiology-performed US for the detection of nephrolithiasis. The focus was on scenarios where either standard or reduced-radiation-dose CT may not be the clear, initial approach, and other approaches could be taken such as point-of-care or radiology-performed US or no imaging. A 2014 study aimed to derive and validate a clinical prediction rule to identify the presence of uncomplicated ureteral stones in emergency department patients who otherwise undergo unenhanced CT. 

Nephrolithiasis

Abstract Background  To develop risk scoring for the use of computed tomography (CT) imaging using the visual analog scale (VAS), physical examination, and laboratory findings of renal colic patients admitted to the emergency department (ED). Materials and Methods  This is prospective observational study. Among the patients who presented to the ED with abdominal or flank pain, patients who were scheduled for CT imaging for urolithiasis were included in the study. The mean VAS pain scores, physical examination findings, laboratory parameters, and macroscopic and microscopic values in urinalysis were compared between the two groups with and without stones on CT. Results  Of the 196 urolithiasis patients included in the study, 165 had ureteral stones, 76 had renal stones, and 45 had renal and ureteral stones. While the difference between the urine erythrocyte averages of the two groups was borderline significant ( p  = 0.04), there was a high difference between the urinary hemoglobin amounts ( p  < 0.001). In patients with urinary system stone disease, hydronephrosis, and ureteral dilatation, hemoglobin ++ and above were more significant ( p  < 0.001). For ureteral stones, pain intensity increased as the size increased ( r  = 0.34 p  < 0.001). White blood cells > 10,000 10 3 /mL, and C-reactive protein (CRP) ≤ 5 mg/L were more significant in patients with acute renal colic. Conclusions  Although we cannot develop a clinical scoring system for renal colic patients, the meaningful results we found for urinary stone disease can be used in a newly developed scoring system. It can be used in new scoring systems in the ED using a high VAS score, presence and amount of urine hemoglobin, CRP) ≤ 5 mg/L, and creatinine value.

Clinical Score Application for Abdominopelvic Computed Tomography Used in the Diagnosis of Renal Colic Patients

The Tree of Life and other tragedies: a brief response L’Arbre de Vie et autres tragédies : une brève réponse Marcel F D’Eon 1Augusta University, Augusta, Georgia, USA Correspondence to: Marcel D’Eon; email: marcel.deon@usask.ca Published: Jun 27, 2023; CMEJ 2023, 14(3). Available at https://doi.org/10.36834/cmej.77688 © 2023 D’Eon; licensee Synergies Partners. This is an Open Journal Systems article distributed under the terms of the Creative Commons Attribution License. (https://creativecommons.org/licenses/by-nc-nd/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is cited. In November 2018, in response to the hateful shooting on October 28 in Pittsburgh at the Tree of Life synagogue, I wrote: “I am going to use the means at my disposal to respond. Each of us can do the same. As a non-Jew, in solidarity with my Jewish friends and acquaintances, with all Jews worldwide, and with people of good will wherever they may be, I want to share three thoughts related to this unfathomable and preventable tragedy.”1 This past week the shooter was found guilty.2 Sentencing may not be concluded by the time this editorial is published. So, here I am again, responding to this tragedy, taking this opportunity at my disposal, to try to make a difference in our shared world.

The Tree of Life and other tragedies: a brief response

Objectives After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes. Methods We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8–10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention. Results We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days. Conclusions Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic

Objective Physicians frequently use ultrasound to assess hydronephrosis in patients with suspected renal colic, but ultrasound has limited diagnostic sensitivity and rarely clarifies stone size or location. Consequently, up to 80% of emergency department (ED) renal colic patients undergo confirmatory CT imaging. Our goal was to estimate x-ray sensitivity for urinary stones and determine whether x-ray substantially improves stone detection (sensitivity) compared to hydronephrosis assessment alone. Methods We reviewed imaging reports from all renal colic patients who underwent x-ray and CT at four EDs. For each patient, we documented stone size, location and hydronephrosis severity on CT and whether stones were identified on x-ray. We considered moderate and severe hydronephrosis (MS-Hydro) as significant positive findings, then calculated the sensitivity (detection rate) of MS-Hydro and x-ray for large stones ≥5 mm and for stones likely to require intervention (all ureteral stones >7 mm and proximal or middle stones >5 mm). We then tested a diagnostic algorithm adding x-ray to hydronephrosis assessment. Results Among 1026 patients with 1527 stones, MS-Hydro sensitivity was 39% for large stones and 60% for interventional stones. X-ray sensitivity was 46% for large stones and 52% for interventional stones. Adding x-ray to hydronephrosis assessment increased sensitivity in all stone categories, specifically from 39% to 68% for large stones (gain = 29%; 95%CI, 23% to 35%) and from 60% to 82% for interventional stones (gain = 22%; 95%CI, 13% to 30%). Because CT and ultrasound show strong agreement for MS-Hydro identification, physicians who depend on ultrasound-based hydronephrosis assessment could achieve similar gains by adding x-ray. Conclusions Adding x-ray to hydronephrosis assessment substantially improves diagnostic sensitivity, enabling the detection of nearly 70% of large stones and over 80% of interventional stones. This level of sensitivity may be sufficient to reassure physicians about a renal colic diagnosis without CT imaging for many patients.

Can plain film radiography improve the emergency department detection of clinically important urinary stones

Implication Statement Wilderness medicine education is interesting to medical students, yet not widely implemented in Canadian medical curricula. We describe a curriculum for a pre-clerkship wilderness medicine elective at a Canadian medical school. Our study reports increased student awareness of career opportunities in wilderness medicine after elective completion, and interest in hands-on learning for wilderness medicine topics. Medical schools may benefit from incorporating feedback from our elective towards a successful wilderness medicine curriculum in their own programs.

/pdf/call-of-the-wild-creating-a-formal-wilderness-medicine-382q2sf1.pdf

Call of the wild: creating a formal wilderness medicine elective for Canadian pre-clerkship medical students

of the studyThis is the latest iteration of a living systematic review, published Sept 23rd, 2021, meaning that updates are integrated with each iteration of literature searches. Daily searches are made by the WHO, including over 25 “bibliographic and grey literature sources” found in the US Center for Disease Control and Prevention (CDC) COVID-19 Research Articles Downloadable Database. Study selection included preprints—primary research articles that have been released to the public before peer review. Preprints were tracked until publication, and changes were made to the guidelines if discrepancies existed between the preprint and peer-reviewed versions.Trial characteristics, patient demographics, donor characteristics and clinically important outcomes were recorded for each selected article. Outcomes for patients with severe and non-severe disease were studied separately. This severity was determined by the WHO severity scale: non-severe disease mandated that patients have O2 sats > 90% on room air, no signs of pneumonia, and no other clinical signs or symptoms of respiratory distress.Outcomes of interest were decided upon by a team of clinical experts, and included: mortality, mechanical ventilation, adverse events leading to discontinuation within 28 days, viral clearance, TRALI, TACO, infusion reactions, admission to hospital, hospital stay time, ICU length of stay, time to symptom resolution, time to viral clearance. Importantly, side effects of mABs not addressed in these outcomes may include anaphylaxis and sequelae of allergic reactions. mAB infusion may also induce bleeding, soreness, or infection at the site of administration.Fourteen different antibody or cellular treatments were evaluated for the treatment of COVID-19. This review focuses only on the evaluation of 12 studies of 5 monoclonal antibody therapies: bamlanivimab (LY-CoV555; 4 trials), casirivimab-imdevimab (REGEN-COV; 4 trials), bamlanivimab-etesevimab (2 trials), sotrovimab (1 trial), and CT-P59 monoclonal antibody (1 trial). 54.5% of these were preprints. Once preprints were published, there were no statistically significant differences in either outcomes or patient characteristics when comparing the preprint and peer-reviewed publication.There was a lower risk of hospital admission in patients with non-severe COVID-19 when treated with mAB therapy compared to standard care alone: casirivimab-imdevimab odds ratio (OR) 0.29 (95% CI 0.17–0.47); bamlanivimab OR 0.24 (95% CI 0.06–0.86), bamlanivimab-etesevimab OR 0.31 (95% CI 0.11–0.81), sotrovimab OR 0.17 (95% CI 0.04–0.57) and CT-P59 OR 0.48 (95% CI 0.14–1.60). Only casirivimab-imdevimab was shown to have moderate certainty evidence for this outcome; others were rated lower due to small numbers of events. With an assumed hospitalization rate for COVID-19 of 2.1% [2], the number needed to treat (NNT) for casirivimab-imdevimab to reduce the risk of hospital admission was 67 (Calculated separate from publication; OR = 0.29, PEER = 0.021).Only casirivimab-imdevimab (ratio of means 0.72; 95% CI 0.58–0.92, moderate certainty) was shown to reduce duration of symptoms of non-severe COVID-19. Bamlanivimab (ratio of means 0.92; 95% CI 0.64–1.32, low certainty), bamlanivimab-etesevimab (ratio of means 0.89; 95% CI 0.68–1.16, moderate certainty), and CT-P59 (ratio of means 0.66; 95% CI 0.42–1.05, moderate certainty) did not reduce symptom duration.None of the mABs studied showed a difference in mortality for non-severe COVID-19: casirivimab-imdevimab OR 0.58 (95% CI 0.26–1.22), bamlanivimab OR 0.46 (95% CI 0.01–27.79), bamlanivimab-etesevimab OR 0.05 (95% CI 0.00–1.01), sotrovimab OR 0.33 (95% CI 0.01–10.16), CT-P59 OR 0.51 (95% CI 0.01–30.40). Non-severe disease has an inherently low risk of mortality, which may have impacted these outcomes. 

https://link.springer.com/content/pdf/10.1007/s11739-022-02959-1.pdf

Antibody therapies for treatment of non-severe COVID-19

Objective To quantify the frequency and intensity of adverse events (AEs), commonly known as side effects, experienced by children receiving either ibuprofen or oxycodone for pain management following an acute fracture. Secondary objectives were to quantify functional outcome impairment and describe demographic and clinical characteristics associated with AEs. Design Observational cohort study. Setting Paediatric emergency department. Patients Patients (n=240) aged 4–16 years diagnosed with an acute fracture. Intervention Prescribed either ibuprofen (n=179) or oxycodone (n=61) for pain. Main outcome measures Families were called for the first 3 days after discharge to report the presence and intensity of AEs and their child’s functional outcomes (ability to eat, sleep, play or attend school). Results On day 1, children using oxycodone were more likely to report any AE (χ21=13.5, p<0.001), nausea (χ21=17.0, p<0.001), vomiting (χ21=11.2, p<0.001), drowsiness (χ21=13.7,p<0.001), constipation (χ21=8.9, p=0.003) and dizziness (χ21=19.1, p<0.001), compared with those using ibuprofen. Children receiving oxycodone reported greater severity of abdominal pain (oxycodone: mean 5.4 SD 3.1; ibuprofen mean 2.5 SD 1.4, F113=6.5, p=0.02) on day 1 and worse intensity of constipation (oxycodone: mean 4.9 SD 2.1; ibuprofen mean 3.2 SD 2.2, F133=4.5, p=0.04) over all 3 days. Use of oxycodone was associated with an increased odds of experiencing an AE on day 1 (OR=1.31 (95% CI 1.13 to 1.52)). Higher pain scores (OR=1.50 (95% CI 1.12 to 2.01)), lower extremity fracture (OR=1.25 (95% CI 1.07 to 1.47)) and undergoing ED sedation (OR=1.16 (95% CI 1.01 to 1.34)) were associated with missing school. Higher pain scores (OR=1.50 (95% CI 1.14 to 1.97)) and lower extremity fractures (OR=1.23 (95% CI 1.07 to 1.43)) were also associated with less play. Conclusions Oxycodone is associated with more frequent AEs overall, higher intensity gastrointestinal AEs and greater functional limitations compared with ibuprofen. Lower extremity fractures cause more functional limitations than upper extremity fractures. Clinicians should consider these differences when providing fracture pain care for children.

/pdf/quantifying-the-intensity-of-adverse-events-with-ibuprofen-1ha5l44y.pdf

Katie Gourlay

Papers

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic

Can plain film radiography improve the emergency department detection of clinically important urinary stones

Call of the wild: creating a formal wilderness medicine elective for Canadian pre-clerkship medical students

Antibody therapies for treatment of non-severe COVID-19

Quantifying the intensity of adverse events with ibuprofen and oxycodone: an observational cohort study