Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.
BMJ. 2014 Mar 26;348:g2191. doi: 10.1136/bmj.g2191.
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.
Retrospective observational derivation cohort; prospective observational validation cohort.
Urban tertiary care emergency department and suburban freestanding community emergency department.
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).
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.
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.
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.
www.clinicaltrials.gov NCT01352676.
为符合 CT 检查条件的输尿管结石患者建立并验证一种基于客观临床数据的预测规则。我们假设，患有输尿管结石的高概率患者其患有急性重要的其他疾病的概率较低。
回顾性观察性推导队列；前瞻性观察性验证队列。
城市三级保健急诊室和郊区独立社区急诊室。
接受疑似单纯性肾结石非对比 CT 检查的成年人。推导队列由 2005 年 4 月至 2010 年 11 月期间进行 CT 检查的随机患者组成（1040 例）；验证队列包括 2011 年 5 月至 2013 年 1 月连续前瞻性纳入的患者（491 例）。
在推导阶段，根据记录中的医疗信息推导可能与输尿管结石相关的先验因素，推导过程不参考已分类的 CT 报告，然后根据诊断对其进行单独分类。采用多变量逻辑回归确定与输尿管结石最相关的前五个因素，并为这些因素分配整数点，以创建一个评分系统，该系统分为输尿管结石低、中、高概率。在前瞻性阶段，该评分根据 CT 结果进行观察性推导，并与输尿管结石的患病率和症状的重要替代原因进行比较。
推导样本包括 1040 例记录，其中五个因素最能预测输尿管结石：男性、疼痛持续时间短、非黑人种族、恶心或呕吐，以及镜下血尿，得出 0-13 分（STONE 评分）。在 491 例前瞻性验证患者中进行了验证。在推导和验证队列中，低概率（评分 0-5）组输尿管结石的检出率分别为 8.3%和 9.2%，中概率（评分 6-9）组为 51.6%和 51.3%，高概率（评分 10-13）组为 89.6%和 88.6%。在高评分组中，推导队列中有 0.3%和验证队列中有 1.6%的患者有急性重要的其他发现。
STONE 评分可可靠地预测单纯性输尿管结石的存在和发生急性重要的其他疾病的可能性较低。将其纳入未来的研究可能有助于限制辐射暴露和过度使用影像学检查。
www.clinicaltrials.gov NCT01352676。
