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Giant Bladder Calculus in an Adult- A Persistent Problem in the Developing World: A Case Report
Introduction: Giant urinary bladder calculus in an adult is an uncommon entity. The number of patients with giant bladder calculi has decreased over recent years owing to wider availability of healthcare and better diagnostic modalities.Case Report: We present a case of a young adult without any history of recurrent urinary tract infections or bladder outlet obstruction with giant vesical calculus who presented to the emergency department with gross hematuria, abdominal pain, and dysuria. Investigations revealed a large calculus in the urinary bladder, and suprapubic cystolithotomy was performed. A large stone of 6.5Ă6Ă5.5 centimeters, weighing 125 grams, was removed. On follow-up, the patient was free of any symptoms and cystoscopy was normal.Conclusion: Urinary outflow obstruction must be ruled out in all patients with giant vesical calculus. Patients without any predisposing condition should be treated as a separate entity and evaluated accordingly. Multiple surgical treatment modalities are available for bladder calculus patients. Treatment is personalised as per size of stone, number of stones, and associated comorbidities
Approaches to describing inter-rater reliability of the overall clinical appearance of febrile infants and toddlers in the emergency department
Objectives. To measure inter-rater agreement of overall clinical appearance of febrile children aged less than 24 months and to compare methods for doing so.Study Design and Setting. We performed an observational study of inter-rater reliability of the assessment of febrile children in a county hospital emergency department serving a mixed urban and rural population. Two emergency medicine healthcare providers independently evaluated the overall clinical appearance of children less than 24 months of age who had presented for fever. They recorded the initial âgestaltâ assessment of whether or not the child was ill appearing or if they were unsure. They then repeated this assessment after examining the child. Each rater was blinded to the otherâs assessment. Our primary analysis was graphical. We also calculated Cohenâs Îș, Gwetâs agreement coefficient and other measures of agreement and weighted variants of these. We examined the effect of time between exams and patient and provider characteristics on inter-rater agreement.Results. We analyzed 159 of the 173 patients enrolled. Median age was 9.5 months (lower and upper quartiles 4.9â14.6), 99/159 (62%) were boys and 22/159 (14%) were admitted. Overall 118/159 (74%) and 119/159 (75%) were classified as well appearing on initial âgestaltâ impression by both examiners. Summary statistics varied from 0.223 for weighted Îș to 0.635 for Gwetâs AC2. Inter rater agreement was affected by the time interval between the evaluations and the age of the child but not by the experience levels of the rater pairs. Classifications of ânot ill appearingâ were more reliable than others.Conclusion. The inter-rater reliability of emergency providersâ assessment of overall clinical appearance was adequate when described graphically and by Gwetâs AC. Different summary statistics yield different results for the same dataset