Greater Positive Predictive Value Research Articles

Optimisation of Early Pregnancy Diagnosis andResynchronisation in Beef Cows.

The objectives of this study were (1) to investigate the effects of the preovulatory follicle (POF) size on the accuracy of Doppler-based early pregnancy detection, and (2) to determine whether the removal of PGF2α (PGF) treatment during the resynchronisation protocol would affect fertility in beef cows. In Experiment 1, Nelore suckling cows (n = 224) were enrolled in an estradiol-progesterone-based timed artificial insemination (TAI) protocol. At TAI, cows were separated based on the range of POF diameters, as follows: ≤11.0 mm (n = 50), 11.1-12.9 mm (n = 64), 13.0-14.4 mm (n = 62) and ≥14.5 mm (n = 48). On day 22 after TAI, the corpus luteum (CL) blood flow (CLBF) of all cows was examined by colour Doppler ultrasonography to diagnose nonpregnant cows. The cows with the largest POF had the greatest positive predictive value (88.6%; 31 of 35) and diagnostic accuracy (91.7%; 44 of 48). In Experiment 2, Nelore cows (n = 233) were subjected to the same TAI protocol. Fourteen days after TAI, all cows were started on a resynchronisation protocol. Cows diagnosed as nonpregnant based on CLBF, on day 22, received 0.5 mg estradiol cypionate intramuscular (im) and were assigned to receive either 150 μg of PGF (PGF; n = 50) or 2 mL of saline (control; n = 47). Cows treated with PGF had a P/AI of 30.0% compared with a 48.9% P/AI in controls (p = 0.06). Our findings demonstrate that the POF size affects the accuracy of a CLBF-based early pregnancy diagnosis and that the removal of PGF treatment from the resynchronisation protocol tended to increase P/AI of the second TAI.

Hypersensitivity Pneumonitis on Thin-Section Chest CT Scans: Diagnostic Performance of the ATS/JRS/ALAT versus ACCP Imaging Guidelines.

Purpose To compare the diagnostic performance of the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) versus the American College of Chest Physicians (ACCP) imaging classifications for hypersensitivity pneumonitis (HP). Materials and Methods Patients in the institutional review board-approved Interstitial Lung Disease (ILD) registry referred for multidisciplinary discussion (MDD) at the authors' institution (January 1, 2006-April 1, 2021) were included in this retrospective study when ILD was diagnosed at MDD. MDD diagnoses included HP, connective tissue disease-ILD, and idiopathic pulmonary fibrosis. Retrospective review of thin-section CT images was performed in consensus by two cardiothoracic radiologists blinded to the diagnosis. Diagnostic patterns were determined for thin-section CT images using both classifications. Discordance rates were determined. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were assessed using MDD diagnosis as the reference standard. Results A total of 297 patients were included in the study: 200 (67%) with HP, 49 (16%) with connective tissue disease-ILD, and 48 (16%) with idiopathic pulmonary fibrosis at MDD. The discordance rate between the two classifications was 21%. Assuming low HP prevalence (10%), ATS/JRS/ALAT classification outperformed ACCP classification, with greater accuracy (92.3% vs 87.6%) and greater positive predictive value (60.7% vs 42.9%). Assuming high prevalence (50%), accuracy and negative predictive value were superior using ACCP classification (81.7% vs 79.7% and 77.7% vs 72.6%, respectively), and positive predictive value was superior using ATS/JRS/ALAT classification (93.3% vs 87.1%). Conclusion Accuracy of the ATS/JRS/ALAT and ACCP HP classifications was greater in settings with low and high HP prevalence, respectively. Diagnostic performance of both classifications was discordant in a minority of cases. Keywords: CT, Thorax, Hypersensitivity Pneumonitis, Interstitial Lung Disease Supplemental material is available for this article. © RSNA, 2024.

Evaluating the diagnostic accuracy of 3D contrast-enhanced magnetic resonance angiography versus digital subtraction angiography in spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas (SDAVFs) often go undiagnosed, leading to irreversible spinal cord dysfunction. Although digital subtraction angiography (DSA) is the gold standard for diagnosing SDAVF, DSA is invasive and operator dependent, with associated risks. MR angiography (MRA) is a promising alternative. This study aimed to evaluate the performance of MRA as an equal alternative to DSA in investigating, diagnosing, and localizing SDAVF. Prospectively collected data from a single neurosurgeon at a large tertiary academic center were searched for SDAVFs. Eligibility criteria included any patient with a surgically proven SDAVF in whom preoperative DSA, MRA, or both had been obtained. The eligible patients formed a consecutive series, in which they were divided into DSA and MRA groups. DSA and MRA were the index tests that were compared to the surgical SDAVF outcome, which was the reference standard. Accurate diagnosis was considered to have occurred when the imaging report matched the operative diagnosis to the correct spinal level. Comparisons used a two-sample t-test for continuous variables and Fisher-Freeman-Halton's exact test for categorical variables, with p < 0.05 specifying significance. Univariate, bivariate, and multivariate analyses were conducted to investigate group associations with DSA and MRA accuracy. Positive predictive value, sensitivity, and accuracy were calculated. A total of 27 patients with a mean age of 63 years underwent surgery for SDAVF. There were 19 male (70.4%) and 8 female (29.6%) patients, and the mean duration of symptoms at the time of surgery was 14 months (range 2-48 months). Seventeen patients (63%) presented with bowel or bladder incontinence. Bivariate analysis of the DSA and MRA groups further revealed no significant relationships between the characteristics and accuracy of SDAVF diagnosis. MRA was found to be more sensitive and accurate (100% and 73.3%) than DSA (85.7% and 69.2%), with a subanalysis of the patients with both preoperative MRA and DSA showing that MRA had a greater positive predictive value (78.6 vs 72.7), sensitivity (100 vs 72.7), and accuracy (78.6 vs 57.1) than DSA. In surgically proven cases of SDAVFs, the authors determined that MRA was more accurate than DSA for SDAVF diagnosis and localization to the corresponding vertebral level. Incomplete catheterization at each vertebral level may result in the failure of DSA to detect SDAVF.

Evaluation of Algorithms Using Automated Health Plan Data to Identify Breast Cancer Recurrences.

We updated algorithms to identify breast cancer recurrences from administrative data, extending previously developed methods. In this validation study, we evaluated pairs of breast cancer recurrence algorithms (vs. individual algorithms) to identify recurrences. We generated algorithm combinations that categorized discordant algorithm results as no recurrence [High Specificity and PPV (positive predictive value) Combination] or recurrence (High Sensitivity Combination). We compared individual and combined algorithm results to manually abstracted recurrence outcomes from a sample of 600 people with incident stage I-IIIA breast cancer diagnosed between 2004 and 2015. We used Cox regression to evaluate risk factors associated with age- and stage-adjusted recurrence rates using different recurrence definitions, weighted by inverse sampling probabilities. Among 600 people, we identified 117 recurrences using the High Specificity and PPV Combination, 505 using the High Sensitivity Combination, and 118 using manual abstraction. The High Specificity and PPV Combination had good specificity [98%, 95% confidence interval (CI): 97-99] and PPV (72%, 95% CI: 63-80) but modest sensitivity (64%, 95% CI: 44-80). The High Sensitivity Combination had good sensitivity (80%, 95% CI: 49-94) and specificity (83%, 95% CI: 80-86) but low PPV (29%, 95% CI: 25-34). Recurrence rates using combined algorithms were similar in magnitude for most risk factors. By combining algorithms, we identified breast cancer recurrences with greater PPV than individual algorithms, without additional review of discordant records. Researchers should consider tradeoffs between accuracy and manual chart abstraction resources when using previously developed algorithms. We provided guidance for future studies that use breast cancer recurrence algorithms with or without supplemental manual chart abstraction.

Is Likert better than PI-RADS at predicting prostate cancer on MRI and can a mathematical algorithm achieve similar results?

Prostate Imaging Reporting & Data System (PI-RADS) is an internationally recognized system to quantify risk of prostate cancer on magnetic resonance imaging (MRI). However, studies have suggested methods to improve predictive accuracy. To assess two different methods that aim to improve the accuracy of PI-RADS scores: a subjective Likert score given by experienced reporters, and an objective Calculated Adjustment of PI-RADS Equivocal Score (CAPES). Five experienced reporters in a quaternary referral unit used a standardized reporting template to prospectively collect PI-RADS and Likert scores for 1467 multiparametric MRI (mpMRI) scans between January 2021 and June 2022. Histology results were recorded for patients who underwent trans-perineal biopsy. The CAPES tool was retrospectively applied to the cases scoring PI-RADS 3. A theoretical standardized biopsy protocol (assuming all patients scoring ≥3 were referred for biopsy) was used to compare the three scoring systems for sensitivity, specificity, and positive predictive value (PPV). Across all reporters, significantly fewer equivocal "3" scores were given using Likert (15.7%) or CAPES (2.2%) compared to PI-RADS (24.1%). Assuming a protocol where all patients scoring ≥3 were biopsied, Likert had a higher specificity (69.0% vs. 54.4%), sensitivity (98.3% vs. 97.7%), and PPV (49.9% vs. 40.3%) than PI-RADS for identifying ISUP ≥2 cancer. The CAPES tool had an even higher specificity (81.4%) and PPV (61.2%) with only a slightly lower sensitivity (93.4%) resulting in 37.1% (n = 316) fewer biopsies than PI-RADS, and 22.4% (n = 155) fewer biopsies than Likert across 1467 patients. Compared to PI-RADS scoring, Likert scoring or CAPES can result in fewer equivocal scores, greater PPV, and fewer unnecessary biopsies.

Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations

Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. To improve diagnosis, we developed machine learning models that integrate cardiac troponin concentrations at presentation or on serial testing with clinical features and compute the Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) score (0–100) that corresponds to an individual’s probability of myocardial infarction. The models were trained on data from 10,038 patients (48% women), and their performance was externally validated using data from 10,286 patients (35% women) from seven cohorts. CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.947–0.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30 days (0.1 versus 0.5 and 1.8%) and 1 year (0.3 versus 2.8 and 4.2%; P < 0.001 for both) from patient presentation. CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers.

Statistical consequences of staging exploration and confirmation

A number of methodologists have recently argued that it is inadvisable or even improper to use the same data for exploration (discovering effects) and for confirmation (validating the existence of effects). This has led to suggestions of a two-phased strategy: running an exploratory study (Phase 1) and then performing a Phase 2 validation/confirmation study (ideally pre-registered) that tests just the strongest effect(s) to emerge from Phase 1. Using simulations we ask a simple question: how does this phased strategy compare with the simpler alternative of running “one big study” that combines exploration and confirmation? At any given alpha level, two figures of merit trade off against each other, with the 2-phased strategy offering lower power and greater positive predictive value (PPV). However, a closer comparison of the results show that the “big study” option is strictly dominant in the sense that for any given alpha level used in the two-phased strategy, there is some alpha level for which the “big study” approach yields better power and better PPV. Bonferroni correction for multiple comparisons does not affect this result. The implications and their important limitations are discussed.

CytoBas: Precision component-resolved diagnostics for allergy using flow cytometric staining of basophils with recombinant allergen tetramers.

BackgroundDiagnostic tests for allergy rely on detecting allergen‐specific IgE. Component‐resolved diagnostics incorporate multiple defined allergen components to improve the quality of diagnosis and patient care.ObjectiveTo develop a new approach for determining sensitization to specific allergen components that utilizes fluorescent protein tetramers for direct staining of IgE on blood basophils by flow cytometry.MethodsRecombinant forms of Lol p 1 and Lol p 5 proteins from ryegrass pollen (RGP) and Api m 1 from honeybee venom (BV) were produced, biotinylated, and tetramerized with streptavidin‐fluorochrome conjugates. Blood samples from 50 RGP‐allergic, 41 BV‐allergic, and 26 controls were incubated with fluorescent protein tetramers for flow cytometric evaluation of basophil allergen binding and activation.ResultsAllergen tetramers bound to and activated basophils from relevant allergic patients but not controls. Direct fluorescence staining of Api m 1 and Lol p 1 tetramers had greater positive predictive values than basophil activation for BV and RGP allergy, respectively, as defined with receiver operator characteristics (ROC) curves. Staining intensities of allergen tetramers correlated with allergen‐specific IgE levels in serum. Inclusion of multiple allergens coupled with distinct fluorochromes in a single‐tube assay enabled rapid detection of sensitization to both Lol p 1 and Lol p 5 in RGP‐allergic patients and discriminated between controls, BV‐allergic, and RGP‐allergic patients.ConclusionOur novel flow cytometric assay, termed CytoBas, enables rapid and reliable detection of clinically relevant allergic sensitization. The intensity of fluorescent allergen tetramer staining of basophils has a high positive predictive value for disease, and the assay can be multiplexed for a component‐resolved and differential diagnostic test for allergy.

Abstract 13919: Race and Gender Specific High Sensitivity Troponin-t Cutoff Values Improve Detection in Patients’ With Ischemic Heart Disease

Introduction: Death rates from acute coronary syndrome events (ASCE) are 30% higher in African Americans than in Caucasians. A potential reason for this disparity is the underdiagnosis of ACSE due to race-specific differences in blood levels of cardiac troponin-T (cTnT), the biomarker of choice for the exclusion of myocardial injury. Hypothesis: Race- and gender-specific high-sensitivity cTnT (hs-cTnT) cutoff values will improve the detection of myocardial injury. Methods: Emergency Department encounters at the University of Chicago from June 2018 through April 2019 with at least 1 hs-cTnT value were included. Race- and gender-specific 99 th percentiles for hs-cTnT were determined for patients without a history of hypertension, heart failure, coronary artery disease, diabetes, or chronic kidney disease, and used as the threshold for a positive result. These threshold values were compared against manufacturer’s recommended gender-only values (male ≥ 22 ng/dL, female ≥ 14 ng/dL). Confusion matrices were used to calculate test characteristics. The presence of ischemic heart disease was determined by the corresponding International Statistical Classification of Diseases. Results: Among 10,934 included encounters, 89.9% were African American. The 99 th percentile values for African American were lower than for matched white counterparts. Race and gender specific cutoffs had higher specificity (83.1% vs 75.2%), greater positive predictive value (91.9% vs 90.7%), and lower false negative rates (16.9% vs. 24.8%) compared with traditional gender-only cutoff values. During the 10 months of data collection, race- and gender-specific cutoffs would have correctly identified 215 additional encounters as having ischemic heart disease, all of them African Americans. The net reclassification rate was +7.91%. Conclusions: Using race-specific, in addition to traditional gender-specific, hs-cTnT cutoff values resulted in higher specificity, greater positive predictive value, and lower false negative rates. Nearly 8% of patients with eventual diagnosis of ischemic heart disease would have been correctly reclassified using race- and gender-specific cutoffs. These findings suggest that race- and gender-specific cutoffs should be further explored.

Abstract 17409: Improved Diagnosis of Coronary Artery Disease Using Cardiac CT Compared With Exercise Stress Testing in an Urban Public Hospital Patient Population

Introduction: Heart disease remains the leading cause of death in the United States, with the disease burden particularly high in various racial and ethnic groups. In serving an underserved population comprised largely of Hispanic and African American individuals, it is crucial for an urban public hospital to diagnose heart disease in a resource-efficient and cost-effective manner. The greater positive predictive value of cardiac CT relative to exercise stress testing presents the opportunity for such hospitals to optimize resource utilization in identifying patients with coronary artery disease (CAD). Hypothesis: The positive predictive value of cardiac CT in diagnosing CAD is greater than that of exercise stress testing in the patient population served by an urban public hospital. Methods: Patients at Harbor-UCLA Medical Center (Torrance, California) were identified for inclusion in this observational study on the basis of a positive (i.e., abnormal) exercise stress test result or a positive cardiac CT result, during the period between January 2015 and September 2019. These patients were subsequently referred for invasive coronary artery angiography, with the diagnosis of obstructive CAD established by an indication for revascularization via percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Data were analyzed using a two-tailed Z-test for two proportions. Results: Seventy-six catheterization laboratory results were analyzed. Fifteen subjects with an abnormal exercise stress test result, out of a total of 41 (36.6%), had an indication for PCI or CABG. Twenty-five cardiac CT imaging subjects, out of a total of 35 (71.4%), had an indication for PCI or CABG. The proportion of positive cardiac CT results with an indication for PCI or CABG was significantly higher than the abnormal exercise stress test proportion (p=0.0024). Conclusions: Among urban public hospital patients who were referred for invasive coronary artery angiography, it was determined that cardiac CT provides a greater positive predictive value in the diagnosis of obstructive CAD than exercise stress testing. This result may help guide the optimal allocation of diagnostic resources in an urban public hospital.

Abstract 16479: A Comparison of Rates of Significant Coronary Artery Disease Found on Invasive Coronary Angiography in Patients Who Underwent Nuclear Stress Testing or CT Coronary Angiography as a Workup for Acute Coronary Syndrome

Introduction: Chest pain syndromes are one of the most common causes of hospital admission. The correct diagnosis as cardiac [acute coronary syndromes (ACS)] with associated morbidity and mortality, or non-cardiac has important medical and legal consequences. Appropriate and timely diagnosis of these conditions is essential, yet limited literature exists comparing two common diagnostic tools, CT coronary angiography (CTCA) and nuclear stress testing (NST) in the acute inpatient setting. Methods: We conducted a retrospective analysis to determine rates of ischemia and intervention needed in patients without ischemic cardiac history, who were evaluated for ACS with NST or CTCA and who subsequently underwent invasive coronary angiography (IA) with iFR and angioplasty as appropriate. Results: We identified 121 CTCA cases and 45 NST cases. There were no significant difference in age, rates of hypertension, diabetes mellitus, renal disease, aspirin or statin use. However, there were more male patients in the CTCA group and higher mean GRACE scores and creatinine on admission in the NST group. Patients who underwent CTCA were found to have higher rates of significant coronary artery disease defined as iFR &lt; 0.9 or ≥70% stenosis on IA (63% vs 44%), and shorter mean length of stay (4.5 vs 6.5 days). Rates of artifact were higher in the NST group (64% vs 24%) and CTCA demonstrated higher specificity (90% vs 28%) and greater positive predictive value (92% vs. 41%) than NST. (Table 1) Conclusions: Our study found that CTCA compared to NST in admitted patients being evaluated for chest pain syndromes was associated with lower rates of reported artifact, shorter length of stay, higher rates of IA confirmed significant coronary disease, and higher specificity and positive predictive value for needed intervention when evaluated with IA. While limited by its single center analysis, our study demonstrates the potential value of CTCA in a real-world population which merits further study.

Mid-upper arm circumference as a screening tool for identifying adolescents with thinness.

To evaluate the performance of mid-upper arm circumference (MUAC) to identify thinness in the late adolescence period (aged 15-19 years) in Ethiopia. We conducted a school-based cross-sectional study. The receiver operating characteristics curve was used to examine the validity of MUAC compared with BMI Z-score to identify adolescents with thinness (BMI Z-score <-2 sd). Fifteen high schools (grade 9-12) located in Addis Ababa, Ethiopia. A total of 851 adolescent (456 males and 395 females) were included in the study. The prevalence of thinness and severe thinness among high-school adolescents in Addis Ababa was 9·5 % (95 % CI 7·7, 11·7 %). The overall AUC for MUAC against BMI Z-score <-2 SD was 0·91 (95 % CI 0·88, 0·93). The optimal MUAC cut-offs to identify thinness were 23·3 cm for males and 22·6 cm for females. These cut-off points give high sensitivity and specificity for both males (a sensitivity of 87·9 % and a specificity of 75·9 %) and females (a sensitivity of 100 % and a specificity 88·2 %). MUAC has a comparable level of accuracy with BMI Z-score to identify thinness in adolescents aged 15-19 years. Hence, MUAC could be used as an alternative tool for surveillance and screening of thinness among adolescents aged 15-19 years. The optimum cut-off proposed by this study may incorrectly include a large number of adolescents when used in a relatively well-nourished population. In this situation, it would be necessary to choose a cut-off with greater positive predictive value.

The use of a second core needle biopsy to predict response to neoadjuvant chemotherapy in breast cancer patients, especially in the HER2-positive population

BackgroundEarly and accurate assessment of the response to neoadjuvant chemotherapy offers the potential to optimize treatment to obtain improved responses. We aimed to predict the response to neoadjuvant chemotherapy using a second breast core needle biopsy after a median of 2 cycles of neoadjuvant chemotherapy. MethodsWe evaluated 805 consecutive patients undergoing neoadjuvant chemotherapy who had a second core needle biopsy between 2013 and 2017. The second core needle biopsy was performed after a median of 2 cycles of neoadjuvant chemotherapy. Pathologic response was evaluated after completion of all the chemotherapy cycles. Diagnostic values were compared and evaluated between the second core needle biopsy and contrast-enhanced magnetic resonance imaging in both the whole and the human epidermal growth factor receptor 2–positive populations. ResultsOverall, 653 patients were eligible and underwent a median of 6 chemotherapy cycles. The second core needle biopsy predicted residual breast cancer earlier than the final contrast-enhanced magnetic resonance imaging, with a greater positive predictive value (positive predictive value: 0.856 vs 0.802, P = .028). Multivariate analysis revealed that a estrogen receptor status, human epidermal growth factor receptor 2 positivity, findings on the final contrast-enhanced magnetic resonance imaging and the pathologic findings of the second core needle biopsy pathology were independent predictive factors for treatment response. The superiority in diagnostic value of a second core needle biopsy pathology in human epidermal growth factor receptor 2–positive patients was consistent with that in the whole population, with a positive predictive value of 0.785 (95% confidence interval: 0.707–0.847). The second core needle biopsy predicted the response to neoadjuvant chemotherapy as early as after 2 cycles, but the accuracy increased from 0.744 to 0.872 if the procedure was performed after more cycles (P = .002). ConclusionThe second core needle biopsy predicted the response to neoadjuvant chemotherapy after 2 cycles quite well, especially in human epidermal growth factor receptor 2–positive patients. The ability of the prediction of response improved if the second biopsy was performed after 3 or 4 cycles.

The association of bioimpedance analysis parameters with the outcomes of critically ill patients.

The association between bioimpedance analysis (BIA) parameters and the outcomes of critically ill patients was explored through a retrospective investigation. The study enrolled patients in the intensive care units of our hospital who had a record of BIA measurements as well as disease severity scores assessed by Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA). The associations between clinical conditions, outcomes and BIA parameters were analysed. The relationship between individual bioimpedance values and the current frequencies fit well to a natural logarithmic function, providing a regression coefficient S value. Other parameters obtained from the BIA measurements included phase angle (PA), the ratio of bioimpedance at high and low frequencies (IR), extracellular water (ECW), intracellular water (ICW) and total body water (TBW). Among 201 enrolled patients, the 90-day in-hospital mortality was 35.8%. Compared to the survivors at 7-days, for the non-survivors, the IR, S value, ratio of ECW/weight and ratio of ECW/TBW were higher, and the PA was lower (P<0.05). Compared to the survivors at 90-days, for the non-survivors, the IR, S value and ratio of ECW/weight were higher, and the PA was lower (P<0.05). Multinomial logistic regression analysis results showed that only SAPS II and S value were independent risk factors for 7-day and 90-day death (P<0.01). When analysed by ROC, the AUC of the S value for predicting 7-day and 90-day death was non-significantly lower than SAPS II (S vs. SAPS II, 0.729 vs. 0.747 (7-day); 0.701 vs. 0.779 (90-day), P>0.05). Importantly, both the 7-day and the 90-day mortality in patients with S values ≤-25.5 were 0; for the others, the mortality increased with the rise of S value. For patients with SAPS II ≤33, the mortality varied minimally; and for patients with SAPS II >55, the mortality was 100%. The S value and SAPS II are independent risk factors for 7-day and 90-day death in critically ill patients; the former may have a greater negative predictive value, while the latter may have a greater positive predictive value.

Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury

Background and purposeCervical spine injury is common in the setting of blunt trauma and there is consensus that cervical spine CT (CSCT) is the image modality of choice for initial evaluation for blunt trauma related injuries of the cervical spine. However, there is disagreement in the literature with regards to further evaluation of blunt trauma patients with cervical spine MRI (CSMRI) after negative CSCT when there is persistent clinical concern for occult trauma related injury. The purpose of this study is to examine the utility of CSMRI for detection of occult injury in blunt trauma patients after negative CSCT. Materials and methodsWe reviewed records for 7,301 patients admitted for blunt trauma (November 2007–December 2013) and identified 259 who underwent CSMRI after a negative CSCT. These CSMRIs were reviewed to determine the number and type of significant CT occult injuries identified and clinical indications that led to CSMRI acquisition. Results and conclusionsCSMRI detected significant injuries following negative CSCT in 31% (81/259) of patients. There were 15 cord contusions/infarcts, 9 bone contusions/fractures, 7 spinal canal hemorrhages and 66 soft tissue injuries. Upper extremity neurological deficit had greatest positive predictive value (PPV) for detection of CT-occult injury on CSMRI of 43% (23/53), followed by equivocal CSCT findings (38%, 18/47), presence of extra-cervical injuries (34%, 20/58), midline cervical tenderness (20%, 17/85), and isolated lower extremity neurological deficit (0%, 0/16). CSMRI is recommended following negative CSCT in the evaluation of blunt cervical spine trauma when appropriate clinical concerns are present.

Detection of hiatal hernias: comparison of high-resolution manometry and physician reported in an obese-predominant population

BackgroundThe diagnosis of a hiatal hernia (HH) can be made by barium oesophagram or upper endoscopy. Data regarding the ability of high-resolution manometry (HRM) with oesophageal pressure topography (OPT) to...

Sonographic Features of Diffuse Hashimoto Thyroiditis: Determining Sensitivity of Features and Predictors of Malignancy

Objective The objective of this study was to determine the sensitivity and accuracy of five sonographic features of Hashimoto thyroiditis (HT) in histologically confirmed cases. In addition, to determine if sonographic features can serve as a predictor of underlying malignancy. Methods A cohort of 101 patients who underwent thyroidectomy for malignancy or other clinical conditions with histologically confirmed HT and a pre-operative thyroid ultrasound examination were included. A retrospective analysis of sonographic features and radiology reports was conducted and comparative statistical analysis completed. Results Among the cohort of 101 patients, 84% demonstrated sonographic evidence of HT. The following features were used for the identification of HT: Diffuse hypoechoic echogenicity, parenchymal heterogeneity, hypoechoic micronodularity, echogenic septations, and hypervascularity. There was a female predominance (9:1) with an average age of 50 years. Among the studied sonographic features of HT, parenchymal heterogeneity was the most sensitive (88.2%) and hypervascularity was the least sensitive (17.7%). Approximately 44% of the study cohort had malignancy; papillary thyroid carcinoma was by far the most common, accounting for 89% of all malignancies. Hypoechoic micronodularity was the feature with the greatest positive predictive value (PPV) for malignancy. Nodal metastasis was less common in patients with sonographically evident HT. Conclusion HT is the most common cause of hypothyroidism in iodine sufficient areas of the world. Parenchymal heterogeneity and diffuse hypoechogenicity were the most sensitive sonographic features of HT. Hypoechoic micronodularity demonstrated the greatest PPV for malignancy.

Abstract WMP95: Drip and Ship vs. Mothership: Conditional Probability Modelling for Patients With Suspected Large Vessel Occlusion

Introduction: For patients with suspected large vessel occlusion (LVO) stroke should we bypass alteplase treatment at Primary Stroke Centres (PSC) in favor of endovascular therapy (EVT) at Comprehensive Stroke Centres (CSC) (mothership) or transport the patient to the PSC for alteplase and then transfer to the CSC for EVT (drip and ship)? This is complicated by the inability to definitively diagnose LVO stroke without imaging. Methods: The efficacy decay of alteplase and EVT over time and the accuracy of the Los Angeles Motor Scale (LAMS) LVO screening tool were combined with various treatment times to predict the probability of good outcome (mRS 0 - 1 at 90 days) for both transport strategies for patients with LAMS ≥4. Results: The results are shown in the Figure. If the patient is closest to the CSC mothership is always superior. If treatment is fast at both centres drip and ship is superior if the centres are far apart and the patient must travel past a PSC to get to a CSC, otherwise the strategies are equivalent (Panel A). Slow treatment at the PSC increases the area where mothership is superior and eliminates drip and ship unless the time from onset to alteplase administration exceeds 4.5 hours in the mothership scenario (Panel B). Slow treatment at both centres decreases the mothership area and expands the drip and ship area (Panel C). Conclusions: Due to the uncertainty in patient diagnosis both transport options are equivalent in most scenarios. A triaging tool with greater positive predictive value would increase the size of the mothership areas. However, even with diagnosis uncertainty the importance of fast treatment times is illustrated.

Clinical, laboratory and epidemiological aspects of HPV infection in a low-income population from South Bahia, Brazil.

The aim of this study was to determine the prevalence and risk factors for human papillomavirus (HPV) infection in the Southern region of the State of Bahia, evaluating the performance of alternative complementary methods for cervical lesion detection. Cervical samples from women who attended healthcare units were collected and diagnosed by visual inspection, cervical cytology and nested polymerase chain reaction (PCR). Moreover, hemi-nested PCR was performed to detect different HPV genotypes. The prevalence of HPV infection was 47·7%, with genotype 16 detected in most cases. Infection was associated with dyspareunia and bleeding (P < 0·001, odds ratio (OR) 5·6, 95% confidence interval (CI) 2·815-11·14) and hormonal contraceptive use (P = 0·007, OR 2·33, 95% CI 1·25-4·34). There was a positive correlation between positive PCR and positive visual inspection, cervical cytology and symptoms reported. Furthermore, visual inspection was twice as specific, and had a greater positive predictive value than cytology. We showed a high prevalence of HPV infection in Southern Bahia, with HPV 16 being the most common type, and visual inspection being most effective at detecting HPV lesions, corroborating the suggestion that it can be applied in routine gynecologic examinations for low-income populations.

The Dangers of Equivocal FAST in Trauma Resuscitation

Equivocal focused abdominal sonography for trauma (FAST) examinations confound decision-making for trauma surgeons. We sought to determine whether the equivocal FAST (defined as any nonconcordant result) has a deleterious effect on trauma outcomes. A 2-year review (2014-2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST results were compared. Outcomes included resuscitation time (h), ventilation days (d), hospital length of stay (HLOS-d), ICU length-of-stay, and survival (%). In addition, skill level of the sonographer was stratified by novice (postgraduate year (PGY) years 1-3) or expert skill levels (PGY-4/fellow or attending). A total of 1,027 patients were included. Compared with concordant FAST examinations, equivocal FASTs were associated with increased HLOS (14.1 vs 10.6, P = 0.05), higher mortality (9.8 vs 3.7%, P = 0.02), decreased positive predictive value in the right upper quadrant (RUQ) (55 vs 79%, P = 0.02) and left upper quadrant (LUQ) (50 vs 83%, P < 0.01) and significantly decreased specificity in the thoracic (83 vs 98%), RUQ (80 vs 98%), LUQ (86 vs 99%), and pelvic (88 vs 98%) windows (P < 0.01 for all). A trend of greater positive predictive value in the thoracic window (100 vs 81%, P = 0.09) among PGY-4/fellow and attending providers compared with PGY levels 1-3 was observed. Equivocal FASTs portend worse outcomes than concordant FASTs because of high false-negative rates, specifically in the thoracic region and the upper quadrants. Lower thresholds for intervention are recommended.