High Positive Likelihood Ratio Research Articles

How to Distinguish Marfan Syndrome from Marfanoid Habitus in a Physical Examination-Comparison of External Features in Patients with Marfan Syndrome and Marfanoid Habitus.

Marfan Syndrome (MFS) is a systemic disorder caused by mutations in fibrillin-1. The most common cause of mortality in MFS is dissection and rupture of the aorta. Due to a highly variable and age-dependent clinical spectrum, the diagnosis of MFS still remains sophisticated. The aim of the study was to determine if there exist phenotypic features that can play the role of “red flags” in cases of MFS suspicion. The study population included 306 patients (199 children and 107 adults) who were referred to the Department of Pediatric Cardiology due to suspicion of MFS. All patients underwent complete clinical evaluation in order to confirm the diagnosis of MFS according to the modified Ghent criteria. MFS was diagnosed in 109 patients and marfanoid habitus in 168 patients. The study excluded 29 patients with other hereditary thoracic aneurysm syndromes. Comparative analysis between patients with Marfan syndrome and marfanoid habitus was performed. Symptoms with high prevalence and high positive likelihood ratio were identified (pectus carinatum, reduced elbow extension, hindfoot deformity, gothic palate, downslanting palpebral fissures, lens subluxation, myopia ≥ 3 dioptres remarkably high stature). The differentiation between patients with MFS and marfanoid body habitus is not possible by only assessing external body features; however, “red flags” could be helpful in the screening phase.

Drain Amylase Concentrations at 3 h After Gastrectomy Enhance Early Prediction of Postoperative Peripancreatic Inflammatory Fluid Collection

Despite numerous studies of peripancreatic inflammatory fluid collection (PIFC) that report on the relevance of the drain amylase concentration (D-AMY), early prediction using this assay is problematic. This study aimed to investigate the clinical significance of measuring the D-AMY at 3h after gastrectomy (POD0) for gastric cancer. This retrospective analysis included consecutive patients who underwent gastrectomy combined with peripancreatic lymph node dissection. The predictive value of D-AMY on POD0 and postoperative day 1 (POD1) for clinically relevant PIFC was evaluated together or individually. Analyses were performed in 204 patients. Twenty (9.8%) patients experienced PIFC. D-AMY cutoffs of 721IU/L on POD0 and 1695IU/L on POD1 were determined using the receiver operating characteristic curve analysis for predicting PIFC. The D-AMY on POD0 had higher sensitivity (80%) but lower specificity (66.3%) for prediction of PIFC, compared with those of D-AMY on POD1 (65%, 89.1%, respectively). When combination marker analysis was performed, the highest risk group (D-AMY ≥ the cutoff values of POD0 and POD1) were associated with an elevated rate of occurrence (44%) and a high positive likelihood ratio (7.36) compared with those of the single cutoff group. The lowest risk group (D-AMY < the cutoff values on POD0 and POD1) was associated with a low rate of occurrence (2.5%) and low negative likelihood ratio (0.24) compared with those of the single cutoff group. Combined measurements of D-AMYs on POD0 and POD1 enhanced early prediction of PIFC after gastrectomy.

A Hierarchical Bayesian Latent Class Model for the Diagnostic Performance of Mini-Mental State Examination and Montreal Cognitive Assessment in Screening Mild Cognitive Impairment Due to Alzheimer's Disease.

The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are low costing and noninvasive neuropsychological tests in screening Mild Cognitive Impairment (MCI) due to Alzheimer's disease (AD). There is no consensus on which test performs better in detecting MCI due to AD based on the different imperfect reference standards. Therefore, we conducted a meta-analysis to assess the diagnostic performance of MMSE and MoCA for screening MCI due to AD in the absence of a gold standard. Six electronic databases were searched for relevant studies until April, 2022. A hierarchical Bayesian latent class model was used to estimate the pooled sensitivity and specificity of MoCA and MMSE in the absence of a gold standard. 90 eligible studies covering 21273 individuals for MMSE, 26631 individuals for MoCA were included in this meta-analysis. The pooled sensitivity was 0.71(95%CI: 0.67-0.74) for MMSE and 0.85(95%CI: 0.83-0.88) for MoCA, while the pooled specificity was 0.71(95%CI: 0.68-0.74) for MMSE and 0.79(95%CI: 0.76-0.81) for MoCA. MoCA was useful to "rule in" and "rule out" the diagnosis of MCI due to AD with higher positive likelihood ratio (4.07; 95%CI: 3.60-4.62) and lower negative likelihood ratio (0.18; 95%CI: 0.16-0.22). Moreover, the diagnostic odds ratio of MoCA was 22.08(95%CI: 17.24-28.29), which showed significantly favorable diagnostic performance. It suggests that MoCA has greater diagnostic performance than MMSE for differentiating MCI due to AD when the gold standard is absent. However, these results should be taken with caution given the heterogeneity observed.

Cirrhosis of Wilson's disease: High and low cutoff using acoustic radiation force impulse (ARFI) -Comparison and combination with serum fibrosis index.

Acoustic Radiation Force Impulse (ARFI), Fibrosis-4(FIB-4) and Aspartate transaminase to platelet ratio index (APRI) are valuable non-invasive methods to evaluate fibrosis in hepatitis virus. Yet, they are rarely used in Wilson's disease. Evaluate the diagnostic efficacy of ARFI, FIB-4, APRI, combined detection in cirrhosis with WD, and speculate the optimal high, low cutoff. This retrospective study was authorized by hospital ethics Committee (number:2021MCZQ02). 102 patients with WD completed ARFI and laboratory examination on the same day. The intraclass correlation coeffcient (ICC) of ARFI among three sonographers was 0.896 (95%CI:0.859-0.925, p = 0.000). The stage of liver involvement was classified into 5 categories according to clinical manifestations, laboratory examination, and liver morphologic characteristics: I, normal; II, biochemical abnormal only; III, abnormal liver morphologic features without sighs of cirrhosis; IV, clinical and imaging sighs of compensateded cirrhosis (Child-Pugh A); V, decompensated cirrhosis (Child-Pugh B and C). This stage system served as the reference standard. The diagnostic efficacy was analyzed by Logistic regression, ROC curve. The optimal low cut-off with high sensitivity (SE) and low negative likelihood ratio (NLR) and high cut-off with high specificity (SP) and positive likelihood ratio (PLR) were derived. The diagnostic value of ARFI (0.85, 95%CI:0.77-0.92, p = 0.000) in distiguishing cirrhosis with WD was higher than FIB-4 (0.59, 95%CI: 0.47-0.70, p = 0.127), APRI (0.70, 95%CI: 0.59-0.81, p = 0.000). The low, high cut-off of ARFI for excluding, diagnosing cirrhosis with WD was 1.47 m/s(SE: 98%, NLR:0.09), 2.11 m/s(SP:98%, PLR:27.4), 37 (36%) patients could be spared a liver biopsy. When ARFI was 1.47∼2.11 m/s, liver biopsy was recommended. After combined with ARFI, the AUROC of FIB-4, APRI were increased respectively (p < 0.001), there were not different between ARFI and combined detection(p > 0.05). ARFI could replace some unnecessary liver biopsy according to high diagnostic efficacy for identifying cirrhosis of WD. The combined detection can also be used as an important model to predict cirrhosis in WD.

Usefulness of serum BUN or BUN/creatinine ratio as markers for citrin deficiency in positive cases of newborn screening

Citrin deficiency belongs to a group of urea cycle disorders that can be identified during newborn screening by measuring citrulline, phenylalanine, methionine, and galactose levels. Early diagnosis of citrin deficiency is beneficial as disease-specific interventions such as permission of food preference and/or supplementation of medium-chain triglyceride can prevent metabolic decompensation. However, there are currently no laboratory tests for the diagnosis of citrin deficiency in routine clinical practice. Our retrospective study investigated the diagnostic characteristics of citrin deficiency during infancy at secondary newborn screening. The present study included 10 patients with citrin deficiency and 35 controls without the condition. The positive likelihood ratios for serum levels of blood urea nitrogen (BUN) levels were 6.8 at the first visit, 3.2 at age ≤ 60 days, and 17.5 at age ≤ 100 days. The serum BUN/creatinine ratio also showed a high positive likelihood ratio (3.9 at first visit, 16.0 at age ≤ 60 days, and 24.5 at age ≤ 100 days). Therefore, the serum BUN or BUN/creatinine ratio may help to identify patients with citrin deficiency during newborn screening. Further studies are required to confirm its diagnostic accuracy in a larger cohort and elucidate the underlying mechanisms involved.

The Use of Thoracic Ultrasound to Predict Transudative and Exudative Pleural Effusion.

Objectives: Pleural effusion is a common reason for hospital admission with thoracentesis often required to diagnose an underlying cause. This study aimed to determine if the imaging characteristics of TUS effectively differentiates between transudative and exudative pleural fluid. Methods: Patients undergoing TUS with pleural fluid analysis were retrospectively identified at a single center between July 2016 and March 2018. TUS images were interpreted and characterized by established criteria. We determined diagnostic performance characteristics of image criteria to distinguish transudative from exudative pleural effusions. Results: 166 patients underwent thoracentesis for fluid analysis of which 48% had a known malignancy. 74% of the pleural effusions were characterized as exudative by Light's Criteria. TUS demonstrated anechoic effusions in 118 (71%) of samples. The presences of septations on TUS was highly specific in for exudative effusions (95.2%) with high positive predictive values (89.5%) and likelihood ratio (2.85). No TUS characteristics, even when adjusting for patient characteristics such as heart failure or malignancy, were sensitive for exudative effusions. Conclusions: Among our cohort, anechoic images did not allow reliable differentiation between transudative and exudative fluid. Presence of complex septated or complex homogenous appearance was high specific and predictive of exudative fluid.

Detection of circulating rare cells benefitted the diagnosis of malignant solitary pulmonary nodules.

Solitary pulmonary nodules (SPNs) are challenging in differentiating between benignancy and malignancy. Therefore, more effective non-invasive biomarkers are urgently needed. The purpose of this investigation was to examine whether circulating rare cells (CRCs) could facilitate the differentiation between benign and malignant SPNs as well as its sensitivity and specificity. 164 patients diagnosed with SPNs, 24 healthy volunteers, and 25 patients diagnosed with advanced-stage lung cancer were included. CT/PET-CT images, serum tumor markers, and biopsy results were collected. The CRCs were examined using subtraction enrichment and immunostaining-fluorescence in situ hybridization (SE-iFISH) and their relationship with malignant or benign SPNs was analyzed. The total CRC numbers from patients with malignant SPNs diagnosed by biopsy were significantly greater compared to those with benign SPNs (P < 0.0001), but not significantly different from patients with advanced lung cancer (P > 0.05). The total CRCs, with a cut-off value of 21.5 units, showed 67.6% sensitivity and 73.3% specificity [area under curve (AUC) 95% CI, 0.778 (0.666-0.889)] in discriminating benign and malignant SPNs and the triploid CRCs exhibited a high positive likelihood ratio of 8.4, which suggested that CRCs appeared to have a distinct advantage in discriminating benign and malignant SPNs compared to CT/PET-CT images and serum tumor markers and could be a potential screening indicator for lung cancer in the high-risk population. SE-iFISH could effectively detect CRCs including circulating tumor cells (CTCs) and circulating tumor-derived endothelial cells (CTECs) and the detection of CRCs could benefit the differentiation of patients with benign and malignant SPNs.

Diagnostic Yield of High-resolution Esophageal Manometry With Chicago Classification Version 3.0 in Thai Patients

Background/AimsHigh-resolution manometry with the Chicago classification scheme has been introduced in clinical practice as a gold standard for esophageal motility test. This study aims to evaluate the diagnostic yield of high-resolution manometry in Thai patients.MethodsAll available high-resolution esophageal manometry (HREM) studies performed during the study period were retrospectively reviewed and interpreted according to the Chicago classification version 3.0. The main esophageal symptoms and coexisting factors were correlated with the HREM findings.ResultsOf the 201 patients, nearly half (49.8%) were documented to have dysphagia. The second most common condition was refractory reflux symptoms (17.4%). More than 70.0% of dysphagia patients showed abnormal esophageal motility, contrary to globus patients who mostly had normal test findings (65.4%). Dysphagia still was the most often correlated condition with major esophageal motility disorders (88.7%), particularly the elderly patients who have coexisting weight loss. Endoscopic and/or surgical procedures were revealed for the highest rate among patients with dysphagia but no one in the globus group needed this intervention. The sensitivity and specificity of dysphagia for major esophageal motility disorders were 70.0% and 67.0%. A much lower sensitivity and higher specificity were found in other non-dysphagia symptoms, especially nausea/vomiting or belching (3.0% or 89.0%). The highest positive likelihood ratio (2.10) to detect major abnormalities was also observed in dysphagia.ConclusionEsophageal manometry provided the highest yield in dysphagia; it was not a strongly beneficial test in patients presenting with non-dysphagia to identify clinically relevant esophageal motor disorders.

Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study.

To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE). We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives. A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

An Evaluation of the Performance of Five Burnout Screening Tools: A Multicentre Study in Anaesthesiology, Intensive Care, and Ancillary Staff.

Burnout is an important occupational hazard and early detection is paramount in preventing negative sequelae in physicians, patients, and healthcare systems. Several screening tools have been developed to replace lengthy diagnostic tools for large-scale screening, however, comprehensive head–to–head evaluation for performance and accuracy are lacking. The primary objective of this study was to compare the diagnostic performance of five burnout screening tools, including a novel rapid burnout screening tool (RBST). This was a cross-sectional study involving 493 hospital staff (anaesthesiology and intensive care doctors, nurses, and ancillary staff) at the COVID-19 frontline across four hospitals in Singapore between December 2020 and April 2021. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used as the reference standard. Five burnout screening tools, the single-item MBI measure of burnout (SI-MBI), dual-item MBI (DI-MBI), abbreviated MBI (aMBI), Single Item Burnout Question (SIBOQ), and the RBST, were administered via a 36-item online survey. Tools were administered simultaneously and responses were anonymised. Burnout prevalence was 19.9%. The RBST and the SI-MBI had the two highest accuracies (87.8% and 81.9% respectively) and AUROC scores (0.86, 95% CI: 0.83–0.89 and 0.86, 95% CI: 0.82–0.89 respectively). However, the accuracy of the RBST was significantly higher than the SI-MBI (p < 0.0001), and it had the highest positive likelihood ratio (+LR = 7.59, 95% CI 5.65–10.21). Brief screening tools detect burnout albeit with a wide range of accuracy. This can strain support services and resources. The RBST is a free screening tool that can detect burnout with a high degree of accuracy.

Editors' Note: Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage

In their analysis of 451 consecutive adults with nontraumatic, spontaneous intracranial hemorrhage (ICH), Dr. Faigle et al. derived and internally validated a simple score for predicting critical care needs. This INTRINSIC score was also externally validated in a separate population and was found to have high sensitivity and specificity for identifying whether a patient with acute ICH may require transfer to an intensive care unit. Dr. Patel et al. comment on the limitations of scoring systems such as this, with an outcome of “intensive care interventions” being a subjective endpoint. The investigators acknowledge that interinstitutional practice variability may limit the transportability of their findings; however, the model was externally validated in a center remote from their own practice. Dr. Foroush et al. note that the estimated positive likelihood ratios (PLRs) for each cut point in the INTRINSIC score render it less useful at higher cut points. Dr. Faigle recognizes that high PLRs may not be possible for individual cut points and reference several examples of scoring systems (e.g., RACE score and LAMS), which are presently in use for stroke triage which do not meet the PLR standards cited by Dr. Foroush et al. Examining the cut point of individual scores may not provide as meaningful a measure as compared with a continuous composite score. On a separate note, readers may find that the score has considerable overlap with the traditional ICH score, which is predictive of early mortality. Both scores assign points for ICH volume, presence of intraventricular hemorrhage, and Glasgow Coma Scale. However, the INTRINSIC score is unique in that it may prove useful for early triage of patients with unclear dispositions after hospital arrival. In their analysis of 451 consecutive adults with nontraumatic, spontaneous intracranial hemorrhage (ICH), Dr. Faigle et al. derived and internally validated a simple score for predicting critical care needs. This INTRINSIC score was also externally validated in a separate population and was found to have high sensitivity and specificity for identifying whether a patient with acute ICH may require transfer to an intensive care unit. Dr. Patel et al. comment on the limitations of scoring systems such as this, with an outcome of “intensive care interventions” being a subjective endpoint. The investigators acknowledge that interinstitutional practice variability may limit the transportability of their findings; however, the model was externally validated in a center remote from their own practice. Dr. Foroush et al. note that the estimated positive likelihood ratios (PLRs) for each cut point in the INTRINSIC score render it less useful at higher cut points. Dr. Faigle recognizes that high PLRs may not be possible for individual cut points and reference several examples of scoring systems (e.g., RACE score and LAMS), which are presently in use for stroke triage which do not meet the PLR standards cited by Dr. Foroush et al. Examining the cut point of individual scores may not provide as meaningful a measure as compared with a continuous composite score. On a separate note, readers may find that the score has considerable overlap with the traditional ICH score, which is predictive of early mortality. Both scores assign points for ICH volume, presence of intraventricular hemorrhage, and Glasgow Coma Scale. However, the INTRINSIC score is unique in that it may prove useful for early triage of patients with unclear dispositions after hospital arrival.

Reader Response: Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage

We read with interest the article by Faigle et al.1 and wish to comment on its applicability in clinical practice. The article presents a tool designed to identify patients with intracerebral hemorrhage who do not need admission to an intensive care unit (ICU). The tool should have a high positive likelihood ratio (PLR > 10) to identify this group of patients.2 We calculated the likelihood ratios from Table 4.

Forecasting Erroneous Neural Machine Translation of Disease Symptoms: Development of Bayesian Probabilistic Classifiers for Cross-Lingual Health Translation.

Background: Machine translation (MT) technologies have increasing applications in healthcare. Despite their convenience, cost-effectiveness, and constantly improved accuracy, research shows that the use of MT tools in medical or healthcare settings poses risks to vulnerable populations. Objectives: We aimed to develop machine learning classifiers (MNB and RVM) to forecast nuanced yet significant MT errors of clinical symptoms in Chinese neural MT outputs. Methods: We screened human translations of MSD Manuals for information on self-diagnosis of infectious diseases and produced their matching neural MT outputs for subsequent pairwise quality assessment by trained bilingual health researchers. Different feature optimisation and normalisation techniques were used to identify the best feature set. Results: The RVM classifier using optimised, normalised (L2 normalisation) semantic features achieved the highest sensitivity, specificity, AUC, and accuracy. MNB achieved similar high performance using the same optimised semantic feature set. The best probability threshold of the best performing RVM classifier was found at 0.6, with a very high positive likelihood ratio (LR+) of 27.82 (95% CI: 3.99, 193.76), and a low negative likelihood ratio (LR−) of 0.19 (95% CI: 0.08, 046), suggesting the high diagnostic utility of our model to predict the probabilities of erroneous MT of disease symptoms to help reverse potential inaccurate self-diagnosis of diseases among vulnerable people without adequate medical knowledge or an ability to ascertain the reliability of MT outputs. Conclusion: Our study demonstrated the viability, flexibility, and efficiency of introducing machine learning models to help promote risk-aware use of MT technologies to achieve optimal, safer digital health outcomes for vulnerable people.

Bruch Membrane Opening Minimum Rim Width and Retinal Nerve Fiber Layer Helps Differentiate Compressive Optic Neuropathy From Glaucoma

To compare optical coherence tomography-measured Bruch membrane opening minimum rim width (MRW), peripapillary retinal nerve fiber layer (pRNFL) measurements, and MRW:pRNFL ratios in eyes with compressive optic neuropathy (CON) and glaucoma and controls, and evaluate the ability of these parameters to differentiate CON from glaucoma. Prospective, cross-sectional study. Setting: Single-center tertiary hospital and outpatient clinic. One hundred fifteen eyes of 77 participants, 34 with CON from chiasmal lesions, 21 with glaucoma, and 22 healthy controls. Optical coherence tomography-measured MRW, pRNFL, and MRW:pRNFL ratios for each optic disc sector and global average. MRW, pRNFL, and MRW:pRNFL ratios compared using generalized estimated equations. Area under the receiver operating characteristic curve and positive and negative likelihood ratios were calculated. MRW and pRNFL measurements were significantly reduced in CON and glaucoma compared with controls. In glaucoma, MRW was thinner than in CON in the global, inferotemporal, superonasal, inferonasal, and vertical average measurements, but a significant overlap was observed in many parameters. MRW:pRNFL ratios increased the ability to discriminate between CON and glaucoma, as shown by the high area under the receiver operating characteristic curve, high positive likelihood ratios, and low negative likelihood ratios, especially in the nasal disc sector and the nasal and temporal average. MRW measurements alone cannot reliably distinguish CON from glaucoma, but the combination of MRW, pRNFL, and MRW:pRNFL ratios significantly improves accuracy. When comparing the 2 conditions, MRW:pRNFL ratios yielded higher area under the receiver operating characteristic curve and positive and negative likelihood ratios, suggesting this parameter may be helpful in clinical practice.

Somatosensory Tinnitus Diagnosis: Diagnostic Value of Existing Criteria.

Tinnitus can be influenced by changes in somatosensory afference from the cervical spine or temporomandibular area, then called somatosensory or somatic tinnitus (ST). In 2018, a new set of diagnostic criteria for ST was agreed upon by a large group of ST experts. Currently, however, it still requires extensive and specific expertise to diagnose ST correctly. The next step in the development of easily applicable diagnostic criteria is to assess the diagnostic value of each individual criterion. The aim of this study was, therefore, to further investigate the diagnostic value of these criteria, validate them empirically, and identify their sensitivity and specificity. An online survey, questioning the presence of 12 diagnostic criteria for ST in a convenience sample of participants with tinnitus, was launched on the online forum Tinnitus Talk, managed by Tinnitus Hub. Participants were divided into three groups: a group with no somatic influence, a group with some somatic influence and a group with large somatic influence on their tinnitus. Chi-square tests were used to calculate differences between these groups. Afterward, sensitivity, specificity, positive and negative likelihood ratios (LR), and pre- and posttest probabilities were calculated for each ST diagnostic criterion. For this analysis, all patients with some and large somatic influence were compared as one group to the group with no somatic influence. In total, 8221 participants filled out the online survey. As expected, the diagnostic criteria for ST are more prevalent in the groups with somatic influence, but the criterium of tinnitus modulation also often occurs in the group with no somatic influence. The simultaneous onset or increase and decrease of both tinnitus and pain complaints have the highest positive LR (6.29 and 10.72, respectively), next to the influence of certain postures on the tinnitus (+LR: 6.04). To rule out ST, the absence of neck pain or tension in the neck extensor muscles are most suited, as they decrease the posttest probability to 18% and 19%, respectively. The simultaneous onset or increase and decrease of tinnitus and neck or jaw pain and the influence of certain postures are most suited to use as a single criterion for identifying patients with a somatic influence on their tinnitus. On the other hand, the absence of neck pain or tension in the neck extensor muscles is valid criterion to rule out a somatic influence. Additional analysis is needed to identify clusters of symptoms and criteria to further aid ST diagnosis.

Screening for congenital heart disease in a Singapore neonatal unit.

Congenital heart disease (CHD) is a leading cause of infant mortality. The aim of this study was to evaluate the efficacy of a neonatal screening programme for CHD before the introduction of pulse oximetry. This was a retrospective review of live births in the period 2003-2012. Cases of CHD were detected through prenatal ultrasonography and/or postnatal examination, and confirmed using two-dimensional echocardiography. Data was rigorously checked against multiple sources. The antenatal detection rate, sensitivity, specificity, predictive values and likelihood ratios of the screening programme were analysed for all cases of CHD and critical CHD. The incidence of CHD was 9.7 per 1,000 live births. The commonest CHD was ventricular septal defect (54.8%). The antenatal detection rate was three times higher in the critical CHD group (64.0%) compared to the group as a whole (21.1%). The sensitivity and specificity of screening was 64.5% and 99.7% for all CHD, and 92.9% and 99.1% for the critical CHD group, respectively. The positive likelihood ratio was 215 and 103, while the negative likelihood ratio was 0.36 and 0.07 for all CHD and critical CHD, respectively. The CHD screening programme had excellent specificity but limited sensitivity. The high positive likelihood ratios indicate that where sufficient risk factors for CHD are present, a positive result effectively confirms the presence of CHD. The low negative likelihood ratio for critical CHD indicates that, where prior suspicion for critical CHD is low, a negative result is reassuring.

Diagnostic accuracy of physical examination findings for midfacial and mandibular fractures

ObjectivesTo assess the diagnostic accuracy of physical examination findings used to identify patients at risk for midfacial or mandibular fractures. Materials and MethodsA five-year retrospective cohort was constructed from all emergency department patients with a midfacial or mandibular trauma. The sensitivity, specificity, pre-test probability, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio data was calculated for 19 and 14 physical examination findings for midfacial and mandibular fractures respectively. Computed Tomography and panoramic radiography were used as index tests. ResultsA total of 1484 patients were identified among whom 40.4% midfacial and 33.4% mandibular fractures were diagnosed. Overall, specificity was found to be higher than sensitivity. Regarding midfacial fractures, high specificity was found for raccoon eyes, malar eminence flattening and all the findings that are related to palpation, the nasal, ocular and intra-oral assessment. Malar eminence flattening, external nasal deformity, nasal septum hematoma, change of globe position and palpable step-off had ad high positive predictive value and positive likelihood ratio. Regarding mandibular fractures high specificity was found for mouth opening restriction, auditory canal bleeding, intra-oral assessment related findings, palpable step-off, inferior alveolar nerve paresthesia, the angular compression test and chin axial pressure test. ConclusionsThe diagnostic accuracy of relevant physical examination findings were identified for the prediction of midfacial and mandibular fractures.

Validation of Methicillin-Resistant Staphylococcus aureus (MRSA) Risk Factors in Predicting MRSA Community-Acquired Pneumonia at an Academic Medical Center.

Background: The 2019 Infectious Diseases Society of America community-acquired pneumonia (CAP) guidelines recommend antimethicillin- resistant Staphylococcus aureus (MRSA) therapy in patients with CAP based on previously identified risk factors for MRSA with an emphasis on local epidemiology and institutional validation of risk. Thus, we sought to assess the ability of guideline-recognized risk factors to predict MRSA CAP at our institution. Methods: This was a single-center, retrospective cohort study from January 2016 to March 2020. Patients were included if they were >18 years old, diagnosed with CAP, and had a MRSA nasal screen and respiratory culture obtained on admission. Patients were excluded if CAP diagnosis was not met, respiratory cultures were not obtained within 48 hours of antibiotic initiation, or they had cystic fibrosis. Sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios (LR) were calculated using Vasser Stats 2019. Pre/post-test odds and pre/post-test probabilities were calculated using Excel 2019. Results: Of 705 screened patients, 221 were included. MRSA prevalence in CAP patients at our institution was 3.6%. History of MRSA isolated from a respiratory specimen had high specificity (98%), high positive LR of 20 (95% CI 5.3-74.8), and high post-test probability of 42.8%. Receipt of IV antibiotics during hospitalization within the past 90 days had a positive LR of 1.9 (95% CI 0.74-4.84). A positive MRSA nasal screen on admission had a positive LR of 6.9 (95% CI 4.0-12.1), negative LR 0.28 (95% CI 0.08-0.93), positive post-test probability of 20.7%, and negative post-test probability of 1.04%. Conclusion: Our study utilized institutional data to validate guideline recognized risk factors for MRSA CAP specifically at our institution. Risk factors including history of MRSA isolated from a respiratory specimen, and positive post-admission MRSA nasal screen were validated as significant risk factors; receipt of IV antibiotics during hospitalization within the past 90 days was not shown to be a risk factor for MRSA CAP based on our institutional data. Validated risk factors may help providers discern which patients with CAP at our institution would benefit most from empiric MRSA treatment.

Performance of Different Criteria Sets for Inflammatory Back Pain in Radiographic and Nonradiographic Axial Spondyloarthritis

Introduction: It is important to recognise inflammatory back pain (IBP) for early diagnosis of ankylosing spondylitis (AS). The aims of this study were to develop a valid, reliable Bengali IBP tool and to assess the performance of different IBP criteria sets, including Calin, Berlin set 8a and 7b, and new Assessment of SpondyloArthritis International Society (ASAS) expert criteria, in radiographic axial spondyloarthritis (axSpA) and nonradiographic axSpA. Method: This case-control study was performed in three phases. The first phase involved development of an IBP tool by adding the fifth parameter of ASAS expert criteria to the National Health and Nutrition Examination Survey (NHANES) 2009–2010 arthritis questionnaires; the second phase assessed reliability by test-retest statistics among 87 participants at a 5-day interval. Finally, according to the imaging arm of ASAS axSpA classification criteria, 50 patients with axSpA were included as cases while 50 patients with chronic mechanical back pain (MBP) were included as a control. Results: The presence of IBP with SpA versus patients with MBP, detected by Calin criteria, were 76.0% versus 10.0%, by Berlin 8a were 72.0% versus 6.0%, by Berlin 7b were 58.0% versus 12.0%, and by ASAS were 64.0% versus 18.0%, respectively. Results suggested the Calin criteria set has the highest sensitivity (76.0%) and Berlin set 8a has the highest specificity (78.9%) in the differentiation of IBP from MBP. Conclusion: The performance of the new ASAS criteria was analogous to the other existing criteria sets. The highest positive likelihood ratio and odds ratio were found for Berlin set 8a criteria. The Berlin set 8a criteria can still be used in primary care practice at the first screening because of high sensitivity.

Second trimester maternal serum D-dimer combined with alpha-fetoprotein and free \u03b2-subunit of human chorionic gonadotropin predict hypertensive disorders of pregnancy: a systematic review and retrospective case\u2013control study

BackgroundThis study investigated whether maternal serum D-dimer (DD) alone or DD combined with alpha-fetoprotein (AFP) and free β-subunit of human chorionic gonadotropin (free β-hCG) in the second trimester could be used to predict hypertensive disorders of pregnancy (HDP).Materials and methodsIn this retrospective case–control study, the data of gravidas patients who delivered at hospital were divided into the following groups: control (n = 136), gestational hypertension (GH, n = 126), preeclampsia (PE, n = 53), and severe preeclampsia (SPE, n = 41). Receiver operator characteristic (ROC) curves were used to evaluate the diagnostic value of maternal serum DD, AFP, and free β-hCG levels for HDP.ResultsDD levels of the GH, PE, and SPE groups were significantly higher than that of the control group (P < 0.001). The order of effectiveness for models predicting HDP was as follows: DD + AFP + free β-hCG > DD > DD + AFP > DD + free β-hCG > AFP + free β-hCG > AFP > free β-hCG. For predicting different types of HDP, DD alone had the best diagnostic value for SPE, followed by PE and GH. DD alone had a sensitivity of 100% with a 0% false negative rate and had the highest positive likelihood ratio (+ LR) for SPE. DD alone in combination with AFP alone, free β-hCG alone and AFP + free β-hCG could reduce false positive rate and improve + LR.ConclusionDD is possible the best individual predictive marker for predicting HDP. Levels of DD alone in the second trimester were positively correlated with the progression of elevated blood pressure in the third trimester, demonstrating the predicting the occurrence of HDP. The risk calculation model constructed with DD + free β-hCG + AFP had the greatest diagnostic value for SPE.