Lower Diagnostic Odds Ratio Research Articles

Radiological predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

BackgroundPatients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH.ObjectiveTo conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features.MethodsEmbase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis.ResultsOverall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH.ConclusionCallosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction.

The challenge of applying digital image processing software on intraoral radiographs for osteoporosis risk assessment.

The purpose of this study was to evaluate rater agreement and the accuracy of a semi-automated software and its fully automated tool for osteoporosis risk assessment in intraoral radiographs. A total of 567 intraoral radiographs was selected retrospectively from women aged 75-80 years participating in a large population-based study (SUPERB) based in Gothenburg, Sweden. Five raters assessed participants' risk of osteoporosis in the intraoral radiographs using a semi-automated software. Assessments were repeated after 4 weeks on 121 radiographs (20%) randomly selected from the original 567. Radiographs were also assessed by the softwares' fully automated tool for analysis. Overall interrater agreement for the five raters was 0.37 (95% CI 0.32-0.41), and for the five raters with the fully automated tool included as 'sixth rater' the overall Kappa was 0.34 (0.30-0.38). Intrarater agreement varied from moderate to substantial according to the Landis and Koch interpretation scale. Diagnostic accuracy was calculated in relation to reference standard for osteoporosis diagnosis which is T-score values for spine, total hip and femoral neck and presented in form of sensitivities, specificities, predictive values, likelihood ratios and odds ratios. All raters' mean sensitivity, including the fully automated tool, was 40,4% (range 14,3%-57,6%). Corresponding values for specificity was 69,5% (range 59,7%-90,4%). The diagnostic odds ratios ranged between 1 and 2.7. The low diagnostic odds ratio and agreement between raters in osteoporosis risk assessment using the software for analysis of the trabecular pattern in intraoral radiographs shows that more work needs to be done to optimise the automation of trabecular pattern analysis in intraoral radiographs.

Efficacy of chemiluminescence in the diagnosis and screening of oral cancer and precancer: a systematic review and meta-analysis

IntroductionEarly detection of potentially malignant oral cavity disorders is critical for a good prognosis, and it is unclear whether the use of chemiluminescence as an adjunctive diagnostic screening method improves diagnostic accuracy. ObjectiveThis systematic review and meta-analysis was performed to assess the accuracy of chemiluminescence for diagnosis of oral cancer and precancerous lesions. MethodsSixteen prospective and retrospective studies from PubMed, Cochrane database, SCOPUS, Web of Science, Embase, and Google Scholar were reviewed. Oral mucosal disorder, as detected by chemiluminescence, was compared with oral mucosal disorder detected by toluidine blue or visual examination. True-positive, true-negative, false-positive, and false-negative rates were extracted for each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool (ver. 2). ResultsSensitivity, specificity, negative predictive value, and diagnostic odds ratio (DOR) of the use of toluidine blue were 0.832 (95% confidence interval [CI] 0.692–0.917), 0.429 (95% CI 0.217–0.672), 0.747 (95% CI 0.607–0.849), and 4.061 (95% CI 1.528–10.796; I2=9.128%), respectively. The area under the summary receiver operating characteristic (SROC) curve was 0.743. Compared with toluidine blue, as used in 12 studies, chemiluminescence had a higher sensitivity (0.831 vs. 0.694); it had a lower specificity (0.415 vs. 0.734), negative predictive value (0.674 vs. 0.729), and DOR (3.891 vs. 7.705). Compared with clinical examination, as used in three studies, chemiluminescence had lower DOR (4.576 vs. 5.499) and area under the curve (0.818 vs. 0.91). ConclusionAlthough chemiluminescence itself has good sensitivity for diagnostic work-up of oral cancer and precancer, the diagnostic accuracy of chemiluminescence is comparable to or worse than toluidine blue and clinical examination. Diagnostic accuracy was therefore insufficient for reliable use of chemiluminescence alone.

NI-04 WHICH RADIOLOGICAL IMAGING IS BEST TO DISCRIMINATE RADIATION NECROSIS FROM TUMOR PROGRESSION? - SUBANALYSIS OF SYSTEMATIC REVIEW FOR RADIOLOGICAL DIAGNOSIS OF RADIATION NECROSIS

BACKGROUNDIt is challenging to discriminate radiation necrosis from tumor progression, especially in malignant glioma. Therefore many radiological imaging studies have been reported. In this study, we performed a systematic review of radiological diagnosis for radiation necrosis and analyzed the best radiological imaging for malignant glioma.METHODSWe divided diagnostic approaches into two categories as follows-CT and MRI (conventional radiological imaging studies), and SPECT and PET (nuclear medicine studies). Our librarians conducted a comprehensive systematic search on Pub Med, Cochrane Library, and the Japan Medical Society up to March 2015. The searching keywords included radiation necrosis, recurrence, imaging modalities such as MRI, diagnosis, and differential. In a meta-analysis, diagnostic odds ratio (DOR) was calculated. A subanalysis was performed, dividing into tumor types, gliomas and metastatic brain tumors.RESULTSOf 188 and 239 records extracted from the database, 20 and 26 studies were included in the meta-analysis after exclusion of case reports and studies with incompatible content and insufficient information. Gd-enhanced MRI exhibited the lowest sensitivity (63%) and DOR (2.2). On the other hand, combined multiple imaging studies including MRS and perfusion image displayed the highest sensitivity (96%) and DOR (5.9). In the subanalysis for glioma, Gd-enhanced MRI and 18F-FDG-PET revealed low DORs (1.7 and 2.3). Conversely, 18F-FET-PET and combined multiple imaging studies showed high DORs (6.8 and 5.9).CONCLUSIONSGd-enhanced MRI had low diagnostic ability for differentiation of radiation necrosis. In glioma patients, 18F-FDG-PET was not useful to discriminate radiation necrosis from tumor progression. Combined multiparametric imaging including lesional metabolism and blood flow could enhance diagnostic accuracy and be useful to differentiate radiation necrosis from tumor progression even in glioma patients.

The diagnostic accuracy of bleeding assessment tools for the identification of patients with mild bleeding disorders: A systematic review.

The bleeding assessment tool (BAT) has been developed to standardize and interpret bleeding history for mild bleeding disorders. However, a critical appraisal addressing the quality and results of validation studies is lacking. We performed a systematic review of diagnostic studies assessing the performance of the BAT in patients referred for evaluation of bleeding symptoms. The electronic database PubMed was searched from inception through July 27, 2017. Eligible publications were original studies that assessed and validated the diagnostic accuracy of bleeding questionnaires for identification of adults with mild bleeding disorders. For each study, sensitivity, specificity and diagnostic odds ratio (DOR) were calculated. Quality was assessed using the Quality Assessment of Diagnostic studies-2 tool. To assess the influence of specific study characteristics on DOR, univariate meta-regression analyses were performed. Nine studies were included. Five studies investigating the ISTH-BAT or other bleeding questionnaires had a moderate to low DOR. Four studies investigating Vicenza-based BATs had a high DOR, with high specificity (>90%) and sensitivity of 59%-85%. Study characteristics such as case-control design, retrospective data collection and differences in reference standard were associated with optimistic estimates of diagnostic performance. Three of four studies with a high DOR had these study characteristics. Studies with good methodological quality mainly had a low DOR. The main advantage of the BAT is that it offers a complete and structured interview. However, the BAT is of limited diagnostic value to the workup of patients referred for bleeding evaluation in clinical practice.

Maternal Blood Biomarkers of Placentation toPredict Low-Birth-Weight Newborns: A Meta-Analysis.

The development of methods for pre-delivery prediction of low-birth-weight newborns would be clinically advantageous because low birth weight contributes to a high infant mortality rate. This study was performed to examine whether maternal blood biomarkers of placentation can be used to predict low-birth-weight newborns. Ten databases, including PubMed/Medline, were searched. Any English language study that provided all of the true- and false-positive and true- and false-negative results of this prediction was included in the analysis. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies. Bivariate diagnostic meta-analysis was performed to construct hierarchical summary receiver operating characteristic curves. Based on relatively good quality studies, alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and pregnancy-associated plasma protein A (PAPP-A) (n= 73, 19, and 7, respectively) showed low sensitivity and specificity and low diagnostic odds ratio. The informational usability was categorized as "no exclusion or confirmation" (i.e., positive likelihood ratio <10 and negative likelihood ratio >0.1). The diagnostic accuracy of AFP and hCG or PAPP-A was categorized as low (i.e., 0.5 ≤ area under the curve ≤0.7) or could not be categorized (i.e., area under the curve <0.5). There is no evidence that maternal blood levels of AFP, hCG, or PAPP-A used as a single predictor are useful to predict low-birth-weight newborns.

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes.

RecommendationsClassification/diagnosis Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate). Osteomyelitis For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high). Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate). A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate). A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak). Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate). Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low). Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate). When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate). Assessing severity At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate). At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low). Microbiological considerations Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high). Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low). Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low). Surgical treatment Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low). Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low). Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low). Antimicrobial therapy While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low) Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate). A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high). Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low). Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high). For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate). We suggest not using any adjunctive treatments for diabetic foot infection (weak; low). When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).

Diagnostic value of neutrophil gelatinase-associated lipocalin for early diagnosis of cardiac surgery-associated acute kidney injury: a meta-analysis.

Neutrophil gelatinase-associated lipocalin (NGAL) has been identified as one of the most sensitive and specific biomarkers for predicting cardiac surgery-associated acute kidney injury (CSA-AKI); however, variable performance characteristics have been reported. We therefore performed a diagnostic meta-analysis to investigate the diagnostic accuracy of NGAL in early (within 12 h postoperatively) diagnosis of CSA-AKI using established guidelines. The search was carried out electronically with Medline (through PubMed interface), Embase, Cochrane library, ISI Web of Science, Scopus and ClinicalTrials.gov (up to 5 September 2014), and hand-searching was also done. Two reviewers conducted study inclusion, data extractions and quality assessment of the studies independently. The diagnostic capacity of NGAL for CSA-AKI was assessed using pooled sensitivity and specificity, diagnostic odds ratio (DOR), area under the summary receiver operating characteristic curve (AUC). Meta-Disc 1.4 and STATA 12.0 were used to investigate the source of heterogeneity and to perform the meta-analysis. Twenty-four studies (33 data sets of 4066 patients) were considered, which were all of good methodological quality. The overall pooled sensitivity of NGAL for the diagnosis of AKI was 0.68 [95% confidence interval (CI), 0.65-0.70], and specificity was 0.79 (95% CI, 0.77-0.80). The overall pooled positive likelihood ratio and negative likelihood ratio were 3.98 (95% CI, 3.05-5.20) and 0.33 (95% CI, 0.24-0.45), respectively, with a DOR of 13.05 (95% CI, 7.85-21.70). The receiver operating characteristic analysis showed an AUC [standard error (SE)] of 0.86 (0.02) and with a Q*-value (SE) of 0.79 (0.02). Subgroup analysis showed that NGAL had better predictive ability in neonates/children compared with adults (DOR, 19.37; AUC, 0.89 vs DOR, 8.98; AUC, 0.83), and adults without pre-existing renal insufficiency (PRI) had higher diagnostic value than adults without PRI to predict CSA-AKI (DOR, 15.43; AUC, 0.87 vs DOR, 6.56; AUC, 0.81). Both plasma/serum and urine NGAL had the highly predictive nature for early diagnosis of CSA-AKI (DOR, 13.09; AUC, 0.85 vs DOR, 13.20; AUC, 0.88), while lower DOR and AUC values were shown (DOR, 8.31; AUC, 0.81) when measured using standardized clinical platforms, compared with research-based assays (DOR, 19.22; AUC, 0.89). I(2)-values showed substantial heterogeneity, which mainly stems from characteristics of patient population (P = 0.037). NGAL diagnostic accuracy in early detection of CSA-AKI is high, especially in neonates/children or adults with normal baseline renal function.

Discriminant indices for distinguishing thalassemia and iron deficiency in patients with microcytic anemia: a reply

Background More than 40 mathematical indices have been proposed in the hematological literature for discriminating between iron deficiency anemia and thalassemia trait in subjects with microcytic red blood cells (RBCs). None of these discriminant indices is 100% sensitive and specific and also the ranking of the discriminant indices is not consistent. Therefore, we decided to conduct the first meta-analysis of the most frequently used discriminant indices. Methods An extensive literature search yielded 99 articles dealing with 12 indices that were investigated five or more times. For each discriminant index we calculated the diagnostic odds ratio (DOR) and summary ROC analysis was done for comparing the performance of the indices. Results The ratio of microcytic to hypochromic RBCs (M/H ratio) showed the best performance, DOR=100.8. This was significantly higher than that of all other indices investigated. The RBC index scored second (DOR=47.0), closely followed by the Sirdah index (DOR=46.7) and the Ehsani index (DOR=44.7). Subsequently, there was a group of four indices with intermediate and three with lower DOR. The lowest performance (DOR=6.8) was found for the RDW (Bessman index). Overall, the indices performed better for adults than for children. Conclusions The M/H ratio outperformed all other discriminant indices for discriminating between iron deficiency anemia and thalassemia trait. Although its sensitivity and specificity are not high enough for making a definitive diagnosis, it is certainly of value for identifying those subjects with microcytic RBC in whom diagnostic tests for confirming thalassemia are indicated.

Discriminant indices for distinguishing thalassemia and iron deficiency in patients with microcytic anemia: a meta-analysis.

More than 40 mathematical indices have been proposed in the hematological literature for discriminating between iron deficiency anemia and thalassemia trait in subjects with microcytic red blood cells (RBCs). None of these discriminant indices is 100% sensitive and specific and also the ranking of the discriminant indices is not consistent. Therefore, we decided to conduct the first meta-analysis of the most frequently used discriminant indices. An extensive literature search yielded 99 articles dealing with 12 indices that were investigated five or more times. For each discriminant index we calculated the diagnostic odds ratio (DOR) and summary ROC analysis was done for comparing the performance of the indices. The ratio of microcytic to hypochromic RBCs (M/H ratio) showed the best performance, DOR=100.8. This was significantly higher than that of all other indices investigated. The RBC index scored second (DOR=47.0), closely followed by the Sirdah index (DOR=46.7) and the Ehsani index (DOR=44.7). Subsequently, there was a group of four indices with intermediate and three with lower DOR. The lowest performance (DOR=6.8) was found for the RDW (Bessman index). Overall, the indices performed better for adults than for children. The M/H ratio outperformed all other discriminant indices for discriminating between iron deficiency anemia and thalassemia trait. Although its sensitivity and specificity are not high enough for making a definitive diagnosis, it is certainly of value for identifying those subjects with microcytic RBC in whom diagnostic tests for confirming thalassemia are indicated.