腎結石症疑いには、エコーかCTか」

1 JHOSPITALIST network ! CT . Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis N Engl J Med 2014;371:1100- 10. PMID: 25229916 2016 6 29 .. 43 18 .. 9/10 . ER (+),HT(+), (+), 5 104/67mmHg HR 86 reg 3+ . CT EBM 5 steps Step1 PICO . Step2 . Step3 . Step4 . Step5 Step1-4 . Step 1 PICO . P: . I: . C: CT. O: . Step 2 . (primary studies)PubMed . "Nephrolithiasis"[Mesh] AND ("ultrasonography"[Subheading] OR "ultrasonography"[All Fields] OR "ultrasonography"[MeSH Terms]) AND Randomized Controlled Trial[ptyp]. 29 1 . The n e w e ng l a n d j o u r na l of m e dic i n e Original Article Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis.

2 P I C C CT O Primary / 30 (Point- of- Care US)(POCUS) .. FAST RUSH Exam(Pump- Tank- Pipes ) Emerg Med J. 2013 Jan;30(1):3- 8. The RUSH Exam 257. N Engl J Med 2011;364:749- 57. Table 1. Rapid Ultrasound in SHock (RUSH) protocol: ultrasonographic findings seen with classic shock states RUSH. Evaluation Hypovolemic Shock Cardiogenic Shock Obstructive Shock Distributive Shock Pump Hypercontractile Hypocontractile Hypercontractile Hypercontractile heart heart heart heart (early sepsis). Small chamber size Dilated heart Pericardial effusion Hypocontractile Cardiac tamponade heart (late sepsis). RV Strain Cardiac thrombus Tank Flat IVC Distended IVC Distended IVC Normal or small IVC.

3 Flat jugular veins Distended jugular Distended jugular (early sepsis). Peritoneal fluid veins veins Peritoneal fluid (fluid loss) Lung rockets Absent lung (peritonitis). Pleural fluid (pulmonary sliding Pleural fluid (fluid loss) edema) (pneumothorax) (empyema). Pleural fluid (effusions). Peritoneal fluid (ascites). Pipes Abdominal aneurysm Normal DVT Normal Aortic dissection Abbreviations: DVT, deep venous thrombosis; IVC, inferior vena cava; RV, right ventricle. Ultrasound Clin 7 (2012) 255 278 CT CT Acad Emerg Med. 2011 July ; 18(7): 699 707 Ultrasound Q. 2012 Sep;28(3):227- 33 . CT . Inclusion criteria 2011 10 2013 2 . 18- 76 .. Exclusion criteria .. ).

4 129kg 113kg .. IntervenVon Point- of- care ultrasound ( ) .. Radiology ultrasound .. Comparison CT local standard . Outcome Primary Endpoints . high- risk diagnoses with complica_ons that could be related to missed or delayed diagnoses .. ( ) . Outcome Secondary Endpoints .. 3,7,30,90 outcome .. IC .. Commibee on Human Research and the ins_tu_onal review board at each par_cipa_ng site approved the study. All par_cipants gave wriben informed consent. Step 3 .. (concealment) . =base line .. ( ) .. Intention to treat .. ultr asonogr aphy vs. ct for suspected nephrolithiasis .. 3638 Patients were assessed for eligibility 229 Were ineligible 309 Declined to participate before eligibility confirmed 324 Were eligible, but declined to participate 2759 1:1.

5 1 2776 Underwent randomization 908, 893, 958 17 Withdrew before any data collected 1 Underwent point-of-care ultrasonography 8 Underwent radiology ultrasonography 8 Underwent computed tomography 2759 Were included in intention-to-treat population 908 Were assigned to point- 893 Were assigned to 958 Were assigned to of-care ultrasonography radiology ultrasonography computed tomography 32 ( ) Were lost 49 ( ) Were lost 32 ( ) Were lost to follow-up to follow-up to follow-up 876 Had at least one 844 Had at least one 926 Had at least one follow-up assessment follow-up assessment follow-up assessment . Ranuni Randomiza_on was performed with the use of the RANUNI func_on in SAS sodware at the study website.

6 The n e w e ng l a n d j o u r na Table 1. Baseline Characteristics of the Study Participants.*. Point-of-Care 2 . Ultrasonography Characteristic (N = 908). Female sex no. (%) 443 ( ). (Table1 no signi cant ) Age Mean yr . Distribution no. (%). 18 30 yr 250 ( ). CVA 31 40 yr 41 50 yr 222 ( ). 223 ( ). 51 64 yr 65 76 yr 197 ( ). 16 ( ). Race or ethnic group no. (%) . Non-Hispanic white 369 ( ). Black 236 ( ). Asian 35 ( ). Native American 12 ( ). Pacific Islander Hispanic 1 ( ). 218 ( ). Mixed or other Data missing 32 ( ). 5 ( ). Self-reported pain score Hospital admission directly from emergency 73 ( ). department no. (%). 40 65 . * Plus minus values are means SD.

7 The data exclude the 17 patient but before any baseline data were collected. There were no significa tic listed here. 2% Race or ethnic group was self-reported. Pain was assessed on an 11-point visual-analogue scale, with highe High-Risk Diagnoses with Complications phy th .. Pa_ents and providers were aware of the imaging method to which the pa_ents had been assigned.. 324 Were eligible, but declined to participate 2776 Underwent randomization . 17 Withdrew before any data collected 1 Underwent point-of-care ultrasonography 8 Underwent radiology ultrasonography 8 Underwent computed tomography Figure1 113 ( lost 2759 Were included in intention-to-treat population 908 Were assigned to point- 893 Were assigned to 958 Were assigned to of-care ultrasonography radiology ultrasonography computed tomography 32 ( ) Were lost 49 ( ) Were lost 32 ( ) Were lost to follow-up to follow-up to follow-up 876 Had at least one 844 Had at least one 926 Had at least one follow-up assessment follow-up assessment follow-up assessment Figure 1.)

8 Screening, Randomization, and Follow-up. inten_on- to- treat principle groups of 5% for events with a prevalence of 10%, rectly to the hospital from the emergency depart- for events with a prevalence of , and ment did not differ significantly among the groups, SD for radiation exposure. Our target sam- suggesting that the severity of illness was simi- ple size was 2500 patients. We used SAS software, lar in the three groups. A total of 113 patients version , for all the analyses. ( ) were lost to follow-up, with no significant .. RRR ARR NNT .. 95%CI .. Primary CT P (908 ) (893 ) (958 ) 6 ( ) 3 ( ) 2 ( ) P 11 OR 8 1 CT P (908 ) (893 ) (958 ) < mSv . ( ).

9 ( ) 50msv .. 1/3000 1/2000. UpToDate Diagnos_c imaging procedures during pregnancy Secondary 12 ER ( ) . ER , , . Outcome . ER CT 5% .. 31- 35 .. CT .. Step4 .. JAMA P79- 83 .. 43 .. ER .. CT 830 . 550 . Step5 1- 4 .. Pubmed .. CT .. US .. NSAIDs .. CT KUB struvite .. UpToDat