作者第一階段利用回溯性收案找出5個因素組成STONE score
Sex: male or female
Timing: > 24h, 6-24h, < 6h
Origin: black or nonblack
Nausea: none, nausea alone, vomiting alone
Erythrocytes: hematuria absent or present
第二階段進行前膽性的收案,將上述對象進行STONE score評分及分類的驗証,

要注意這個臨床計分對亞洲族群而言不適用的一部份是Race: black vs non-block



Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone—the STONE score: retrospective and prospective observational cohort studies

  1. Christopher L Moore, associate professor1,
  2. Scott Bomann, emergency physician1,
  3. Brock Daniels, emergency physician2,
  4. Seth Luty, research assistant3,
  5. Annette Molinaro, associate professor1,
  6. Dinesh Singh, assistant professor4,
  7. Cary P Gross, professor56

BMJ 2014;348:g2191


Objective To derive and validate an objective clinical prediction rule for the presence of uncomplicated ureteral stones in patients eligible for computed tomography (CT). We hypothesized that patients with a high probability of ureteral stones would have a low probability of acutely important alternative findings.

Design Retrospective observational derivation cohort; prospective observational validation cohort.

Setting Urban tertiary care emergency department and suburban freestanding community emergency department.

Participants Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The derivation cohort comprised a random selection of patients undergoing CT between April 2005 and November 2010 (1040 patients); the validation cohort included consecutive prospectively enrolled patients from May 2011 to January 2013 (491 patients).

Main outcome measures In the derivation phase a priori factors potentially related to symptomatic ureteral stone were derived from the medical record blinded to the dictated CT report, which was separately categorized by diagnosis. Multivariate logistic regression was used to determine the top five factors associated with ureteral stone and these were assigned integer points to create a scoring system that was stratified into low, moderate, and high probability of ureteral stone. In the prospective phase this score was observationally derived blinded to CT results and compared with the prevalence of ureteral stone and important alternative causes of symptoms.

Results The derivation sample included 1040 records, with five factors found to be most predictive of ureteral stone: male sex, short duration of pain, non-black race, presence of nausea or vomiting, and microscopic hematuria, yielding a score of 0-13 (the STONE score). Prospective validation was performed on 491 participants. In the derivation and validation cohorts ureteral stone was present in, respectively, 8.3% and 9.2% of the low probability (score 0-5) group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6% and 88.6% of the high probability (score 10-13) group. In the high score group, acutely important alternative findings were present in 0.3% of the derivation cohort and 1.6% of the validation cohort.

Conclusions The STONE score reliably predicts the presence of uncomplicated ureteral stone and lower likelihood of acutely important alternative findings. Incorporation in future investigations may help to limit exposure to radiation and over-utilization of imaging.

作者說給你聽: master.m3u8

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Clinical relevance of seasonal changes in the prevalence of ureterolithiasis in the diagnosis of renal colic

Fukuhara H1, Ichiyanagi O2, Kakizaki H3, Naito S2, Tsuchiya N2.

Ureterolithiasis is one of the most frequently diagnosed urologic diseases worldwide. Its annual incidence in Japan increased three-fold from 1965 to 2005.

Ureterolithiasis incidence is affected by numerous factors, including race, sex, body weight, fluid intake, and climate.

Here, we aimed to address the latter by considering the effect of seasonal variation on stone incidence and incorporating this information into a predictive model for differential diagnosis of ureteral stone from other conditions with similar presentations. We retrospectively identified 491 patients in our emergency department computer database who complained of back, flank, or lower abdominal pain during 2007-2015. Among them, 358 had stones, as confirmed by computerized tomography or plain abdominal X-ray of kidney-ureter-bladder. We also charted the mean ambient temperatures in our city for a year. The cases of ureteral stones paralleled the ambient temperatures, peaking during the hottest weather. Univariate analysis identified 13 factors associated with ureteral stones. Multivariate analysis narrowed the number to eight: age <60 years, male sex, short duration of pain (<6 h), nausea/vomiting, hydronephrosis, hematuria, history of urinary stone(s), and summer (July-September in Japan). Pain appearing during summer was nine times more likely to be due to a ureteral stone than was pain appearing during other seasons. We incorporated the eight variables identified into a predictive logistic regression model, which yielded good prediction of ureteral stones.

Awareness that hot weather is associated with increased incidence of ureterolithiasis could facilitate differential diagnosis, and our prediction model could be useful for screening for ureterolithiasis.

2016 Nov;44(6):529-537. Epub 2016 Jun 17.



如果能夠看到Acoustic shadow,則異物存在的可能性就大增

Role of ultrasound in detection of radiolucent foreign bodies in extremities

Tantray MD1, Rather A2, Manaan Q3, Andleeb I3, Mohammad M3, Gull Y4.

Removal of foreign bodies from soft tissues in emergency is very challenging and becomes more problematic when it is radiolucent. Blind exploration is sometimes hazardous for patients especially when it is in proximity to a vessel or a nerve or an overlying tendon.

The purpose of this study was to determine the accuracy of ultrasonography (USG) in detecting radiolucent soft tissue foreign bodies in the extremities.

From January 2014 to January 2016, 120 patients with either a positive history or clinically suspected soft tissue foreign body and negative radiography were evaluated by USG with a high-frequency (13-6 MHz) linear-array transducer. The sonographic findings were used to guide surgical exploration.

Out of 120 patients who underwent surgical exploration, USG was positive in 114 cases, and foreign body was retrieved in 108 cases, and among the six cases where USG was negative, foreign body was retrieved from one case. In one case with strong clinical suspicion of foreign body USG was falsely negative. Majority of foreign bodies were removed from foot (69 cases) and hands (26 cases), and rest of foreign bodies were removed from ankle (4 cases), wrist (3 cases), thigh (2 cases), leg (1 case), knee (2 cases), forearm (2 cases).

Accuracy, sensitivity, and positive predictive value were determined as 94.16, 99.08, and 94.13%, respectively.

The real-time high-frequency USG is a highly sensitive and accurate tool for detecting and removing radiolucent foreign bodies which cannot be visualized by routine radiography.

2018 Feb 9. doi: 10.1007/s11751-018-0308-z.
[Epub ahead of print]

【Full article PDF


Critical Care Ultrasounds – Theory and practice (Agenda)

WFPICCS 2018 Pre-Congress Workshops
9th Congress of the World Federation of Pediatric Intensive & Critical Care Societies (WFPICCS 2018) to be held in Singapore on June 9-13, 2018.

​Max Participants: 50
Time: ​08:30- 17:00
Place: KK Women and Children’s Hospital

$850 for non-congress participant,
$650 for physicians and
$350 for Trainees, Nurses and AHP

Objectives: The workshop will be a mixture of didactic sessions and hands-on experiences. All of the relevant ultrasound modalities will be taught including cardiac ultrasound, thoracic, abdominal, vascular and procedural ultrasound.

POCUS for APE management

Device: Hand-Held Ultrasound: GE Vscan with dual transducers
治療前 & 治療後的比較,


74M complained of dyspnea and unable to talk.
PE: cold sweating with bilateral rales and fine wheezing
Echo: Bilateral and diffuse lung rockets , c/w acute lung edema

CXR: cardiomegaly & acute lung edema

Treated as acute pulmonary edema for 14 hours
Echo: less lung rockets compared to initial findings
==> wet lung to dry lung

f/u CXR 14 hours later

【Take Home Message】
BLUE protocol
SEARCH protocol
再來可以看血管(IVC & Deep veins),

2015 Jun;147(6):1659-1670. doi: 10.1378/chest.14-1313.

BLUEprotocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.


This review article describes two protocols adapted from lung ultrasound: the bedside lung ultrasound in emergency (BLUE)-protocol for the immediate diagnosis of acute respiratory failure and the fluid administration limited by lung sonography (FALLS)-protocol for the management of acute circulatory failure. These applications require the mastery of 10 signs indicating normal lung surface (bat sign, lung sliding, A-lines), pleural effusions (quad and sinusoid sign), lung consolidations (fractal and tissue-like sign), interstitial syndrome (lung rockets), and pneumothorax (stratosphere sign and the lung point). These signs have been assessed in adults, with diagnostic accuracies ranging from 90% to 100%, allowing consideration of ultrasound as a reasonable bedside gold standard. In the BLUEprotocol, profiles have been designed for the main diseases (pneumonia, congestive heart failure, COPD, asthma, pulmonary embolism, pneumothorax), with an accuracy &gt; 90%. In the FALLS-protocol, the change from A-lines to lung rockets appears at a threshold of 18 mm Hg of pulmonary artery occlusion pressure, providing a direct biomarker of clinical volemia. The FALLS-protocol sequentially rules out obstructive, then cardiogenic, then hypovolemic shock for expediting the diagnosis of distributive (usually septic) shock. These applications can be done using simple grayscale machines and one microconvex probe suitable for the whole body. Lung ultrasound is a multifaceted tool also useful for decreasing radiation doses (of interest in neonates where the lung signatures are similar to those in adults), from ARDS to trauma management, and from ICUs to points of care. If done in suitable centers, training is the least of the limitations for making use of this kind of visual medicine.

2017 Mar 29;12(3):e0174581. doi: 10.1371/journal.pone.0174581. eCollection 2017.

SEARCH 8Es: A novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department.



This study was conducted to evaluate a problem-oriented focused torso bedside ultrasound protocol termed “Sonographic Evaluation of Aetiology for Respiratory difficulty, Chest pain, and/or Hypotension” (SEARCH 8Es) for its ability to narrow differential diagnoses and increase physicians’ diagnostic confidence, and its diagnostic accuracy, for patients presenting with dyspnea, chest pain, or symptomatic hypotension.


This single-center prospective observational study was conducted over 12 months in an emergency department and included 308 patients (184 men and 124 women; mean age, 67.7 ± 19.1 years) with emergent cardiopulmonary symptoms. The paired t-test was used to compare the number of differential diagnoses and physician’s level of confidence before and after SEARCH 8Es. The overall accuracy of the SEARCH 8Es protocol in differentiating 13 diagnostic entities was evaluated based on concordance (kappa coefficient) with the diagnosis made by the inpatient specialists. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.


SEARCH 8Es narrows the number of differential diagnoses (2.5 ± 1.5 vs. 1.4 ± 0.7; p < 0.001) and improves physicians’ diagnostic confidence (2.8 ± 0.8 vs. 4.3 ± 0.9; p < 0.001) significantly. The overall kappa coefficient value was 0.870 (p < 0.001), with the overall sensitivity, specificity, positive predictive value, and negative predictive value at 90.9%, 99.0%, 89.7%, and 99.0%, respectively.


The SEARCH 8Es protocol helps emergency physicians to narrow the differential diagnoses, increase diagnosticconfidence and provide accurate assessment of patients with dyspnea, chest pain, or symptomatic hypotension.


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