key: cord-0820343-1qwlb654
authors: Carrion, D. M.; Mantica, G.; Antón-Juanilla M, M.; Pang, K. H.; Tappero, S.; Rodriguez-Serrano, A.; Parodi, S.; Crespo-Atín, V.; Cansino, R.; Terrone, C.; Nikles, S.; Gomez Rivas, J.; Esperto, F.
title: Assessment of trends and clinical presentation in the emergency department of patients with renal colic during the COVID-19 pandemic era
date: 2020-11-19
journal: nan
DOI: 10.1016/j.acuroe.2020.11.004
sha: 96e3c7d0257945de2d99f219253c3d96c5749fb1
doc_id: 820343
cord_uid: 1qwlb654

Introduction We hypothesized that the recent COVID-19 pandemic may lead to a delay in renal colic patients presenting to the Emergency Department due to the fear of getting infected. This delay may lead to a more severe clinical condition at presentation with possible complications for the patients. Material and methods Retrospective review of data collected from three institutions from Spain and Italy. Patients who presented to Emergency Department with unilateral or bilateral renal colic caused by imaging confirmed urolithiasis during the 45 days before and after each national lockdown were included. Data collected included patients’ demographics, biochemical urine and blood tests, radiological tests, signs, symptoms and the therapeutic management. Analysis was performed between two groups, Group A: patients presenting prior to the national lockdown date; and Group B: patients presenting after the national lockdown date. Results A total of 397 patients presented to Emergency Department with radiology confirmed urolithiasis and were included in the study. The number of patients presenting to Emergency Department with renal/ureteric colic was 285 (71.8%) patients in Group A and 112 (28.2%) patients in Group B (p<0.001). The number of patients reporting a delay in presentation was 135 (47.4%) in Group A and 63 (56.3%) in Group B (p=0.11). At presentation, there were no statistical differences between Group A and Group B regarding the serum creatinine level, C reactive protein, white blood cell count, fever, oliguria, flank pain and hydronephrosis. In addition, no significant differences were observed with the length of stay, Urology department admission requirement and type of therapy. Conclusion Data from our study showed a significant reduction in presentations to Emergency Department for renal colic after the lockdown in Spain and Italy. However, we did not find any significant difference with the length of stay, Urology department admission requirement and type of therapy.

On 31 While hospitals were overloaded with COVID-19 patients, there has been a decrease in presentation to the Emergency Department (ED) with non-severely symptomatic, or non-life-threatening conditions, such as acute uncomplicated renal colic. [3] [4] [5] [6] In the urological field, in some centers a significant reduction in access to some acute urological conditions, in particular for renal colic has been reported. [7] [8] While it is plausible that the lockdown may greatly decrease some pathologies such as trauma or infections, it is questionable that it can reduce the incidence of renal colic. The severity of renal colic and its associated complications vary, and ED may be presented with lowcomplexity cases resulting in abuse of hospital resources, that could have otherwise been managed by general practitioners. However, during the worse days of lockdown due to COVID-19 spread, there may be a worrisome delay in presentations due to patients' fear of getting infected in hospitals.

We aim to evaluate the impact of the COVID-19 pandemic on the number of patients attending ED with renal colic, possible delays in presentation and the severity of clinical condition in Institutions from two of the most affected European countries, Italy and Spain. We hypothesized that the recent COVID-19 pandemic may lead to a delay in renal colic patients presenting to ED due to the fear of J o u r n a l P r e -p r o o f getting infected. This delay may lead to a more severe clinical condition at presentation with possible complications for the patients and adding further burden on the healthcare systems both in terms of costs and hospital bed occupancy. These data could be of fundamental importance for "urological counseling" in view of possible further pandemic peaks in different European countries in the coming months.

After Institutional Review Board approval (HULP: PI-4188) data were retrospectively collected from three institutions from two European countries (Genova, Italy and Madrid and Bilbao, Spain).

The study period included 45 days preceding the official date of the lockdown (9 th March 2020, Italy and 13 th March 2020, Spain) and 45 days following the lockdown date: Italy, from 24 th January to 25 th April; Spain, 28 th January to 29 th April.

Patients who presented to ED with unilateral or bilateral renal colic caused by imaging confirmed urolithiasis during the 45 days before and after each national lockdown were included. Exclusion criteria were patients with flank pain not caused by urolithiasis, patients with Chronic Kidney Disease (CKD) > grade II according to "Kidney Disease: Improving Global Outcomes" (KIDGO) guidelines [9] and patients with a solitary kidney.

Data collected included patients' demographics, biochemical urine and blood tests (creatinine, C-Reactive Protein [CPR], Procalcitonin, white blood cell count [WBC] , urinalysis), radiological tests (CT-scan; ultrasonography and abdominal X-Ray), signs, symptoms, clinical parameters (temperature, urine output) and the therapeutic management (admission to the ED for less or more than 24 hours, admission to urology department, admission to the intensive care unit, ureteral stent placement, nephrostomy placement, ureteroscopy).

A presentation after 24 hours of the onset of symptoms was considered a delay. The duration of delay was estimated from the time of experiencing symptoms to the day of presentation. Where data on delay was missing, patients were phone called and asked to reply to a short interview evaluating possible delays and its causes. Categorical variables were analyzed with Chi-squared test. All statistical tests were two sided with the significance level set at 0.05.

A total of 397 patients presented to ED with radiology confirmed urolithiasis and were included in the study (Table 1) At presentation, there were no statistical differences between Group A and Group B regarding the serum creatinine level, CRP, WBC, fever, oliguria, flank pain and hydronephrosis. None of the patients were on medical expulsive therapy (MET) prior to presentation. In addition, no significant differences were observed with regards to the length of stay, Urology department admission requirement and type of therapy (ureteric stenting vs nephrostomy insertion vs MET) ( Table 2 ).

Here we report the incidence of urolithiasis and its associated clinical parameters at presentation and treatment outcomes 45 days before and after the date of lockdown in three major referral centers from two European countries that were severely affected by COVID-19. We hypothesized that the lockdown and COVID-19 outbreak would result in a delay presentation of renal colic possibly secondary to fear of getting infected, leading to a more severe condition and potential complications. However, in our current analysis we did not identify any significant delays in presentation and the clinical outcome did not differ between the 45-day period before and after the lockdown date. We observed a decrease in number of ED presentations following lockdown, 112 (28.2%) versus 285 (71.8%) prior to lockdown. The reduction in urolithiasis in the COVID-19 period was also observed in Antonucci et al's study [8] which compared the number of ED admission in Rome between March and April 2020 with the same period in 2019 and identified a 48.8% reduction. Fear of acquiring COVID-19 is considered one of the key factors for avoiding or delaying ED visits. [6, 10] . Another explanation could be that patients contacted emergency medical J o u r n a l P r e -p r o o f services via telephone, and due to the overloaded ambulance and ED services, patients were advised to stay home with over the counter analgesics and only attending ED if they presented with fever or uncontrolled pain. [11] [12] [13] [14] More patients delayed their presentation during the COVID-19 era (Group B), 56.3% versus 47.4% (Group A), but this did not reach statistical significance. A reason why a delay in presentation was not observed in this cohort of patients is possibly due to the nature of renal colic. Renal colic can cause immense pain, described as worse than childbirth [15] and may be difficult to tolerate.

The presenting age was significantly higher in the post lockdown group which could be explained with fear of having a more serious condition and a lower pain threshold in older patients. There were no statistical differences in presenting clinical parameters including signs and symptoms, vitals, WBC, CRP, serum creatinine levels, stone location, hydronephrosis. In addition, the surgical intervention and type of intervention such as ureteric stenting, nephrostomy insertion or primary ureteroscopy did not differ amongst the two groups. Our finding is different to Antonucci et al [8] , who showed that the patients admitted to ED between March and April 2020 had more complications, more frequently needing hospitalization and early stone removal was preferred over urinary drainage compared with the same period in 2019. This could be explained by the different time periods studied. We compared 45 days before and after the lockdown date during the COVID- We identified more COVID-19 positive patients in the post-lockdown group and this might be due to the increase in swab tests performed. In particular, swab testing in ED was mandatory in Italy 

The potential limitation of our study is the relatively low number of patients. This could be expected because the three centres involved in this study were greatly impacted by the high number of COVID-19 patients that reduced the overall number of ED admissions.

Data from our study showed a significant reduction of presentations to ED for renal colic after the lockdown in Spain and Italy. Patients' fear to get infected, telematic triage and further public health plans may be responsible for this trend. However, we did not identify any significant difference with the length of stay, Urology department admission requirement and type of therapy.

Bibliografía Table 1 -Demographics, baseline biochemical and radiological findings at presentation of 397 patients attending the emergency department for renal colic. Legend: BMI: body mass index; CCI: Charlson comorbidity index; CRP: C reactive protein; WBC: white blood cells; IQR: interquartile range; SD: standard deviation J o u r n a l P r e -p r o o f Legend: ICU: intensive care unit.

Pre-COVID era Post-COVID era p-value

Obstructive stone location Lower ureter Middle ureter Upper ureter 60

Stone size, mean (SD) Stone size categorized, n (%) < 5 mm 5-9 mm > 9 mm

Patients, n (%) 397 285 (71,8) 112 (28,2) < 0,001 Delay from symptoms, n (%)Mean delay (SD) Median delay (IQR) 198 (49, 9) 135 (47,4) 63 (56,3) 0,11 3, 3 (3,9) 2,9 (3,5) 4,1 (4,5) 0,24 2 (1-4