Clinical Prediction Rule Research Articles

Risk-stratification tools for emergency department patients with syncope: A systematic review and meta-analysis of direct evidence for SAEM GRACE.

Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline. We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables. Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46. Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.

Development of an ultrasound-based clinical decision rule to rule-out diverticulitis

The concern for diverticulitis often leads to the use of computed tomography (CT) scans for diagnosis. We aim to develop an ultrasound-based clinical decision rule (CDR) to confidently rule-out the disease without requiring a CT scan. We analyzed data from a prospective study of adult emergency department (ED) patients with suspected diverticulitis who underwent both bedside ultrasound (US) and CT. Patient history, physical examination, laboratory findings, and US results were used to create a CDR via a recursive partitioning model designed to prioritize sensitivity, with a loss matrix heavily penalizing false negatives. We calculated the test characteristics for this CDR (TICS-Rule) and assessed the potential reduction in CT scans and ED length of stay. Data from 149 patients (84 female; mean age 58 ± 16) were used to develop the TICS-Rule. The final model integrates US diagnosis of simple and complicated diverticulitis, along with variables of heart rate, age, history of diverticulosis, vomiting, and leukocytosis. Negative US results and a heart rate below 100 effectively excluded diverticulitis. The sensitivity increased from 54.5% (32.2–75.6) in the US alone to 100% (84.6–100%) for complicated diverticulitis in the model. The TICS-Rule missed no cases of complicated diverticulitis but one case of simple diverticulitis. The median time from ED greeting to US interpretation was 103 min (IQR 62–169), compared to 285 min (IQR 229–372) for CT. The TICS-Rule uses a combination of negative US and heart rate less thanQ1 100 to exclude diverticulitis without the need for a CT scan. Integration of the TICS-Rule offers a promising enhancement to clinical decision-making while reducing both CT use and ED length of stay.

Alergia a la penicilina: una etiqueta que no es para siempre

Self-reported penicillin allergy is highly prevalent. Different studies estimate that 10% of the population is labeled as such.This label, confirmed or suspected, forces us to take precautions and replace the antibiotic treatment of choice (frequently beta-lactams) with other 2nd or 3rd choice alternatives with worse overall results: side effects, resistance, costs, etc.The penicillin allergy label, once placed, remains in the medical record. It is only confirmed in less than 5% of patients, either because it has been placed inappropriately or because over time the sensitivity decreases and may disappear.Penicillin Allergy Decision Rule –PEN-FAST– is a validated and simple clinical prediction rule that estimates the risk of presenting an allergic reaction. Its use, together with algorithms that involve primary care in the study and delabeling of low-risk patients, can change our clinical practice.

Current practices in diagnosing acute pulmonary embolism: a comprehensive analysis of adherence to contemporary practice guidelines.

Acute pulmonary embolism (APE) poses significant diagnostic challenges, with potentially fatal outcomes if not promptly identified and treated. Despite the availability of clinical guidelines, adherence to diagnostic strategies varies globally, impacting patient outcomes. Our aim was to investigate current practices for PE diagnosis among Polish physicians and their adherence to the contemporary 2019 European Society of Cardiology (ESC) guidelines. This cross‑sectional study, utilizing a web‑based survey developed with the Delphi methodology, included hospital‑based physicians of various specialties from Poland. The survey focused on diagnostic practices, risk stratification, and adherence to the ESC 2019 guidelines for PE. The study showed a limited use of guideline‑recommended clinical prediction rules, with predominant reliance on D‑dimer assessment and computed tomography pulmonary angiography. Risk stratification practices varied, and were often based on individual experience rather than evidence‑based strategies. The vast majority of physicians (80.5%) had never contacted a PE response team, but 88% stated that they would if it were available. Cardiologists were more likely to employ guideline‑recommended methods than other specialists. There is a need for increased adherence to guideline‑recommended diagnostic and risk stratification strategies in APE among physicians in Poland. Enhancing the availability of PE response teams and promoting guideline‑directed practices could improve diagnostic accuracy and patient outcomes.

Clinical Decision Rules: A Starting Place in Medical Education, Not a Destination

Clinical Decision Rules: A Starting Place in Medical Education, Not a Destination

338 Inter-Rater Reliability and Acceptability of a Clinical Prediction Rule for Opioid-Associated Out-of-Hospital Cardiac Arrest

338 Inter-Rater Reliability and Acceptability of a Clinical Prediction Rule for Opioid-Associated Out-of-Hospital Cardiac Arrest

A cross-sectional analysis of four common clinical decision rules for pulmonary embolism, Mashhad, Iran.

Pulmonary embolism (PE) is a potentially fatal condition. Several non-invasive clinical decision rules (CDRs) were developed for the safe exclusion of PE. All CDRs used to safely rule out PE have been created and tested within hospital or acute care environments. However, CDRs that are designed in one specific setting may not perform as effectively when used in a different setting. In this study, we aimed to compare the performance of four common CDRs; Wells Score, Simplified Wells Score, revised Geneva Score, and simplified revised Geneva Score. This was a cross-sectional study in which patients suspected of PE presenting to Imam Reza Hospital or Ghaem Hospital were recruited from September 23, 2013, to March 19, 2016 in Mashhad, Iran. The specificity, sensitivity, and accuracy were utilized as metrics to compare the CDRs in our region. Two hundred and forty patients were included in the study. The mean age of patients was 57.91±19.97 years, and 54.16% of them (n=130) were female. 120 patients were confirmed to have PE with CT angiography. Wells score showed the highest sensitivity (90.4%) and revised Geneva score represented the highest specificity (84.9%). The highest accuracy belongs to the simplified Wells score (62.3%). In this study, we demonstrated that the Wells criteria with its high sensitivity, can be used as a score for screening, and the revised Geneva score with its high specificity, can be used in the second stage for healthy people who have been diagnosed as unhealthy by the Wells score.

Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest

AimPrehospital termination of resuscitation (ToR) rules are used to predict medical futility in adult out-of-hospital cardiac arrest (OHCA), however, the available evidence for pediatric patients is limited. The primary aim of this study is to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic OHCA patients. MethodsWe analyzed a retrospective cohort of pediatric OHCA patients within the CARES database over a 10-year period (2013–2022). We split the dataset into training and test datasets and fit logistic regressions with Least Absolute Shrinkage and Selection Operator (LASSO) to select predictor variables and estimate predictive test characteristics for the primary outcome of death and a secondary composite outcome of death or survival to hospital discharge with unfavorable neurologic status. ResultsWe analyzed a sample of 21,240 children where 2,326 (11.0%) survived to hospital discharge, and 1,894 (8.9%) survived to hospital discharge with favorable neurologic status. We derived a PToR rule for death demonstrating a specificity of 99.1% and a positive predictive value (PPV) of 99.8% and a PToR rule for death or survival with poor neurologic status with a specificity of 99.7% and PPV of 99.9% within the test dataset. ConclusionWe derived a clinical prediction rule with high specificity and positive predictive value in prehospital settings utilizing Advanced Life Support (ALS) providers which may inform termination of resuscitation considerations in pediatric patients. Further prospective and validation studies will be necessary to define the appropriateness and applicability of these PToR criteria for routine use.

Predicting mortality in geriatric patients with fever in the emergency departments: a prospective validation study

ObjectiveEmergency physicians are always faced with the challenge of choosing the appropriate disposition for elderly patients in order to ensure an acceptable care plan and effective use of resources. A clinical decision rule, Geriatric Fever Score (GFS) has been proposed but not validated to help ED physicians with decision-making. This rule employs leukocytosis, severe coma, and thrombocytopenia as predictors of 30-day mortality. Through our study determines the performance of this clinical prediction rule in a prospective study in a setting different from where it was developed.Method and materialsIn this prospective cohort study in a 1200-bed tertiary care, patients older than 65 years old who visited the ED with fever were enrolled. All elements of the rule were collected and the total score was calculated for each patient. Patients were also categorized as low risk (score 0–1) or high risk (score ≥ 2). Thirty-day follow-up was performed to determine the patient outcome (survival or mortality).ResultsA total of 296 patients were included in our final analysis. The mortality rate was 33.1% for patients with a Score of 0, 42.1% for a score of 1, 57.1% for a score of 2, and 100% for a score of 3. When divided into two risk groups, patients’ mortality rates were as follows: low risk group 37.9% and high-risk group 40.5%.ConclusionOur study showed that elderly patients who present to ED with fever and have a score of 2 or higher on the Geriatric Fever Score are at higher risk of mortality at 30 days.

Physical therapy in burn care: Development of clinical prediction rules to determine the efficacy of low-level laser therapy

This study aimed to demonstrate the benefits of low-level laser therapy (LLLT) on burn healing and to investigate whether patients' age, burn wound size, wound stage, and total burned surface area influence the burn wound healing response to LLLT. This was a quasi-experimental study with a single-group design that included eighty male and female patients with partial-thickness burn wounds recruited from burn units. The participants were placed in a single intervention group receiving LLLT. The duration of the intervention was six weeks, divided into 18 sessions (three sessions per week). The statistical analysis was conducted using version 25 of the SPSS statistical package for Windows. The results showed a statistically significant negative relationship between wound improvement from LLLT and age (p < 0.05) and between total body surface area (TBSA) and wound improvement (p < 0.05). Additionally, a statistically significant positive relationship was found between initial wound size and wound improvement (p < 0.05). There was no statistically significant relationship between wound improvement and wound stage (p > 0.05). The current study revealed that age, TBSA, and initial wound size can predict the efficacy of low-level laser treatment for burn wounds.

Interpretable Machine Learning Models for Predicting Critical Outcomes in Patients with Suspected Urinary Tract Infection with Positive Urine Culture.

(1) Background: Urinary tract infection (UTI) is a leading cause of emergency department visits and hospital admissions. Despite many studies identifying UTI-related risk factors for bacteremia or sepsis, a significant gap remains in developing predictive models for in-hospital mortality or the necessity for emergent intensive care unit admission in the emergency department. This study aimed to construct interpretable machine learning models capable of identifying patients at high risk for critical outcomes. (2) Methods: This was a retrospective study of adult patients with urinary tract infection (UTI), extracted from the Medical Information Mart for Intensive Care IV Emergency Department (MIMIC-IV-ED) database. The critical outcome is defined as either in-hospital mortality or transfer to an intensive care unit within 12 h. ED visits were randomly partitioned into a 70%/30% split for training and validation. The extreme gradient boosting (XGBoost), random forest (RF), and support vector machine (SVM) algorithms were constructed using variables selected from the stepwise logistic regression model. The XGBoost model was then compared to the traditional model and clinical decision rules (CDRs) on the validation data using the area under the curve (AUC). (3) Results: There were 3622 visits among 3235 unique patients diagnosed with UTI. Of the 2535 patients in the training group, 836 (33%) experienced critical outcomes, and of the 1087 patients in the validation group, 358 (32.9%) did. The AUCs for different machine learning models were as follows: XGBoost, 0.833; RF, 0.814; and SVM, 0.799. The XGBoost model performed better than others. (4) Conclusions: Machine learning models outperformed existing traditional CDRs for predicting critical outcomes of ED patients with UTI. Future research should prospectively evaluate the effectiveness of this approach and integrate it into clinical practice.

Chest Pain in Primary Care: A Systematic Review of Risk Stratification Tools to Rule Out Acute Coronary Syndrome.

Chest pain frequently poses a diagnostic challenge for general practitioners (GPs). Utilizing risk stratification tools might help GPs to rule out acute coronary syndrome (ACS) and make appropriate referral decisions. We conducted a systematic review of studies evaluating risk stratification tools for chest pain in primary care settings, both with and without troponin assays. Our aims were to assess the performance of tools for ruling out ACS and to provide a comprehensive review of the current evidence. We searched PubMed and Embase for articles up to October 9, 2023 concerning adult patients with acute chest pain in primary care settings, for whom risk stratification tools (clinical decision rules [CDRs] and/or single biomarker tests) were used. To identify eligible studies, a combination of active learning and backward snowballing was applied. Screening, data extraction, and quality assessment (following the Quality Assessment of Diagnostic Accuracy Studies-2 tool) were performed independently by 2 researchers. Of the 1,204 studies screened, 14 were included in the final review. Nine studies validated 7 different CDRs without troponin. Sensitivities ranged from 75.0% to 97.0%, and negative predictive values (NPV) ranged from 82.4% to 99.7%. None of the CDRs outperformed the unaided judgment of GP's. Five studies reported on strategies using troponin measurements. Studies using high-sensitivity troponin showed highest diagnostic accuracy with sensitivity 83.3% to 100% and NPV 98.8% to 100%. Clinical decision rules without troponin and the use of conventional troponin showed insufficient sensitivity to rule out ACS in primary care and are not recommended as standalone tools. High-sensitivity troponin strategies are promising, but studies are limited. Further prospective validation in primary care is needed before implementation.

Clinical prediction rules for surgical site infection after minor surgery in general practice.

Surgical site infection (SSI) after dermatological surgery is associated with poor outcomes. Developing clinical prediction rules based on the predicted probability of infection might encourage guided prophylaxis and judicious prescribing. The purpose of this study was to develop a clinical prediction rule based on identified risk factors for SSI in a large general practice patient cohort. We examined a large, pooled dataset from four randomised controlled trials performed in a regional centre of North Queensland, Australia. Multivariable logistic regression identified a prediction model. Bootstrapping was used for internal validation. A scoring system was based on predicted probabilities of infection. The final prediction rule included age >55years and the anatomical site, histology and complexity of the excision. The area under the curve was 0.704. Our prediction rule encourages judicious use of prophylaxis in clinical practice.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectivesof this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24hr, 30days, and 1year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

A Multicentre Prospective Cohort Study to Identify High-Risk Transient Ischemic Attack/Minor Stroke Patients Benefitting from Echocardiography

BackgroundWe aimed to derive a clinical decision rule to identify patients with transient ischemic attack (TIA) or minor stroke most likely to benefit from echocardiography. MethodsThis multicentre prospective cohort study enrolled adults diagnosed with TIA/minor stroke in the emergency department who underwent echocardiograms within 90 days, from 13 Canadian academic emergency departments from October 2006 to May 2017. Our outcome was clinically significant echocardiogram findings. ResultsIn 7149 eligible patients, a clinically significant finding was found in 556 (7.8%). There were a further 2421 (33.9%) with potentially significant findings. History of heart failure (adjusted odds ratio [OR], 3.9) or coronary artery disease (OR, 2.7) were the factors most strongly associated with clinically significant echocardiogram findings, whereas young age, male sex, valvular heart disease, and infarct (any age) on neuroimaging were modestly associated (OR, 1.3-1.9). The model combining these predictors into a score (range: 0-15), had a C-statistic of 0.67 (95% confidence interval [CI], 0.65-0.70). A cut point of 6 points or more classified 6.6% of cases as high likelihood, defined as > 15% for clinically significant echocardiogram findings. ConclusionsEchocardiography is a very useful test in the investigations of patients with TIA/minor stroke. We identified high-risk clinical features—combined to create a clinical decision rule—to identify which patients with TIA/minor stroke are likely to have clinically significant echocardiogram findings requiring an immediate change in management. These patients should have echocardiography prioritized, whereas others may continue to have echocardiography conducted in a less urgent fashion.

Development and application of a serious adverse events risk model for concurrent chemoradiotherapy in patients with nasopharyngeal carcinoma.

The objective of this study was to construct a concise prediction model for serious adverse events (SAEs) in order to assess the likelihood of SAE occurrence among hospitalized patients undergoing concurrent chemoradiotherapy. An electronic database of a Cancer Centre was utilized to conduct a cross-sectional review survey. Our research involved the recruitment of 239 patients who were undergoing concurrent chemoradiotherapy in the Department of Nasopharynx and Radiotherapy. The clinical prediction rule was derived using logistic regression analysis, with SAE serving as the primary outcome. Internal verification was conducted. The occurrence rate of SAE in the derivation cohort was 59.4%. The ultimate model used had 3 variables, namely cystatin C, C-reactive protein, and serum amyloid A. The model exhibited an area under the curve of 0.626 (95% CI: 0.555-0.696; P < .001). The model accurately predicts the occurrence of SAE, and the variable data can be easily obtained, and the assessment technique is straightforward.

Acute pulmonary embolism pretest probability estimation by d-dimer test, our modified, new ECG score and clinical prediction rules

ObjectivesWe investigated whether a sufficiently sensitive D-dimer test could exclude acute pulmonary embolism (acPE) as a stand-alone diagnostic test and compared our previously published, modified ECG score with the Wells and Geneva scores in the estimation of acPE pretest probability. MethodsWe retrospectively evaluated 345 patients who underwent chest CT angiography (CTA) for the suspicion of acPE. The pretest probability of acPE was assessed in 120 D-dimer negative [DD (−)] and 225 D-dimer positive [DD (+)] patients. ResultsChest CTA verified acPE in 57/345 (16.5 %) patients and in 1/120 (0.8 %) DD (−) patient. In DD (−) patients the test accuracy (TA) and specificity (SP) of the ECG score (98 %, 99 %) were better than those of the Wells score (92.5 %, 92.4 %) (p = 0.063 and p < 0.05 respectively) and the Geneva score (76.7 %, 76.5 %) (p < 0.001 for both), the Wells score TA and SP were greater than those of the Geneva score (p < 0.001 for both). In DD (+) patients the SPs, TAs and positive predictive values (PPV) of the ECG score (94 %, 78.6 %, 69 %) and the Wells score (91.8 %, 75.1 %, 48 %) were greater than those of the Geneva score (71.3 %, 64.9 %, 38.2 %) (p < 0.001 for both SP and TA respectively, and p < 0.001 for PPV of the ECG score vs. the Geneva score and p < 0.05 for PPV of the Wells score vs. Geneva score), their sensitivities (SE) (36.4 %, 23.6 %) were less than that of the Geneva score (47.5 %) (p < 0.05 and p < 0.001 respectively). The ECG score's TA in a trend, its SE and PPV were significantly (p < 0.01 and p < 0.001) better than those of the Wells score. ConclusionIn contrast to the current guidelines, a stand-alone high sensitivity DD (−) test, without prediction rules, could reliably exclude acPE. Our ECG score slightly outperformed the Wells score, the ECG score and Wells score far outperformed the Geneva score in the estimation of acPE pretest probability. An acPE diagnosis with the ECG score, in addition to the supportive diagnosis with the clinical prediction rules, may further increase the chance of true DD positivity.

Development and validation of a clinical prediction rule for walking independence in hospitalized older adults with a vertebral compression fracture.

No reports on factors or Clinical prediction rules (CPRs) associated with walking independence among patients with vertebral compression fractures (VCFs) are available. Evidence regarding epidemiological walking independence rates is also sparse. Here, we sought to (i) obtain epidemiological data on the probability of inpatients with VCFs achieving walking independence, and (ii) develop and validate a CPR to determine walking independence in hospitalized patients with VCFs. We conducted a retrospective cross-sectional observational study of patients aged ≥60years who were hospitalized for VCF at four hospitals in Japan in 2019-2022. The outcome was walking independence at discharge. We performed a binomial logistic regression analysis to assess predictors of walking independence. Five independent variables were entered: age, American Society of Anesthesiologists physical status, cognitive function, Berg Balance Scale (BBS), and 10-m walking test. Among the independent variables that were significant, we converted the continuous variables to binary data by calculating cut-off values and then created the CPR. The area under the curve (AUC) was calculated as the measure of the CPR's diagnostic accuracy, and internal validation was conducted by bootstrapping. Of the 240 patients, 188 (78.3%) achieved walking independence. Cognitive function and the BBS score (with a cut-off of 45 points) were identified as significant predictors. We created a CPR using these two items (0-2 points). The CPR's AUC was 0.92 (0.874-0.967), and internal validation by bootstrapping yielded a mean AUC of 0.919 with a slope of 0.965. The walking independence rate of patients with a VCF during hospitalization was 78.3%, with cognitive function and BBS being predictors. The developed CPR performed well enough to retrospectively predict walking independence in VCF patients. The BBS cut-off value and the CPR may serve as useful indicators for clinicians to predict VCF patients' walking independence.

Application of the Kaiser score on contrast-enhanced mammography in the differential diagnosis of breast lesions: comparison with breast magnetic resonance imaging.

The Kaiser score (KS) as a clinical decision rule has been proven capable of enhancing the diagnostic efficiency for suspicious breast lesions and obviating unnecessary benign biopsies. However, the consistency of KS in contrast-enhanced mammography (CEM-KS) and KS on magnetic resonance imaging (MRI-KS) is still unclear. This study aimed to evaluate and compare the diagnostic efficacy and agreement of CEM-KS and MRI-KS for suspicious breast lesions. This retrospective study included 207 patients from April 2019 to June 2022. The radiologists assigned a diagnostic category to all lesions using the Breast Imaging Reporting and Data System (BI-RADS). Subsequently, they were asked to assign a final diagnostic category for each lesion according to the KS. The diagnostic performance was evaluated by the area under the receiver operating characteristic curve (AUC). The agreement in terms of the kinetic curve and the KS categories for CEM and MRI were evaluated via the Cohen kappa coefficient. The AUC was higher for the CEM-KS category assignment than for the CEM-BI-RADS category assignment (0.856 vs. 0.776; P=0.047). The AUC was higher for MRI-KS than for MRI-BI-RADS (0.841 vs. 0.752; P =0.015). The AUC of CEM-KS was not significantly different from that of MRI-KS (0.856 vs. 0.841; P=0.538). The difference between the AUCs for CEM-BI-RADS and MRI-BI-RADS was not statistically significant (0.776 vs. 0.752; P=0.400). The kappa agreement for the characterization of suspicious breast lesions using CEM-KS and MRI-KS was 0.885. The KS substantially improved the diagnostic performance of suspicious breast lesions, not only in MRI but also in CEM. CEM-KS and MRI-KS showed similar diagnostic performance and almost perfect agreement for the characterization of suspicious breast lesions. Therefore, CEM holds promise as an alternative when breast MRI is not available or contraindicated.

Clinical prediction model for pediatric lymphadenopathy: enhancing diagnostic precision and treatment decision making.

Lymph node enlargement is common in children, with 90% of physiologically palpable lymph nodes. This study aimed to develop a predictive model based on clinical characteristics to enhance the diagnosis of pediatric lymphadenopathy and provide insights into biopsy outcomes. A clinical prediction rule was developed using a retrospective, cross-sectional design for patients under 15years who underwent lymph node biopsy from 2012 to 2022. Multivariable risk regression was used to analyze benign and malignant lesions, presenting results through risk difference and AUROC for each group. Predicted probabilities were applied in a logistic regression equation to classify patients' lymphadenopathy as reactive hyperplasia, benign, or malignant. Of 188 children, 70 (37.2%) had benign lymphadenopathy beyond reactive hyperplasia, and 27 (14.4%) had malignant lymphadenopathy. The predictive model included 12 characteristics such as size, location, duration, associated symptoms, and lymph node examination. Predictive accuracy was 92.2% for benign cases (AUROC = 0.92; 95% CI 0.87-0.96) and 98.6% for malignancy (AUROC = 0.98; 95% CI 0.94-0.99). Overall accuracy for predicting both benign and malignant tumors was 68.3%. The model demonstrated reasonably accurate predictions for the clinical characteristics of pediatric lymphadenopathy. It tended to overestimate malignancy but did not miss diagnoses, aiding in reducing unnecessary lymph node biopsies in benign cases.