Modest Diagnostic Accuracy Research Articles

Clinical course and prognostic models for the conservative management of cervical radiculopathy: a prospective cohort study

PurposeTo describe the clinical course and develop prognostic models for poor recovery in patients with cervical radiculopathy who are managed conservatively.MethodsSixty-one consecutive adults with cervical radiculopathy who were referred for conservative management were included in a prospective cohort study, with 6- and 12-month follow-up assessments. Exclusion criteria were the presence of known serious pathology or spinal surgery in the past. Outcome measures were perceived recovery, neck pain intensity and disability level. Multiple imputation analyses were performed for missing values. Prognostic models were developed using multivariable logistic regression analyses, with bootstrapping techniques for internal validation.ResultsAbout 55% of participants reported to be recovered at 6 and 12 months. All multivariable models contained 2 baseline predictors. Longer symptoms duration increased the risk of poor perceived recovery, whereas the presence of paresthesia decreased this risk. A higher neck pain intensity and a longer duration of symptoms increased the risk of poor relief of neck pain. A higher disability score increased the risk of poor relief of disability, and larger active range of rotation toward the affected side decreased this risk. Following bootstrapping, the explained variance of the models varied between 0.22 and 0.30, and the median area under the curve varied between 0.75 and 0.79.ConclusionsThe clinical course of cervical radiculopathy appears to be long, with most of the reduction in symptoms occurring within the first 6 months. All prognostic models showed an adequate predictive performance with modest diagnostic accuracy and explained variance.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Improving the Diagnostic Performance of 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography in Prosthetic Heart Valve Endocarditis.

18F-Fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) was recently introduced as a new tool for the diagnosis of prosthetic heart valve endocarditis (PVE). Previous studies reporting a modest diagnostic accuracy may have been hampered by unstandardized image acquisition and assessment, and several confounders, as well. The aim of this study was to improve the diagnostic performance of FDG PET/CT in patients in whom PVE was suspected by identifying and excluding possible confounders, using both visual and standardized quantitative assessments. In this multicenter study, 160 patients with a prosthetic heart valve (median age, 62 years [43-73]; 68% male; 82 mechanical valves; 62 biological; 9 transcatheter aortic valve replacements; 7 other) who underwent FDG PET/CT for suspicion of PVE, and 77 patients with a PV (median age, 73 years [65-77]; 71% male; 26 mechanical valves; 45 biological; 6 transcatheter aortic valve replacements) who underwent FDG PET/CT for other indications (negative control group), were retrospectively included. Their scans were reassessed by 2 independent observers blinded to all clinical data, both visually and quantitatively on available European Association of Nuclear Medicine Research Ltd-standardized reconstructions. Confounders were identified by use of a logistic regression model and subsequently excluded. Visual assessment of FDG PET/CT had a sensitivity/specificity/positive predictive value/negative predictive value for PVE of 74%/91%/89%/78%, respectively. Low inflammatory activity (C-reactive protein <40 mg/L) at the time of imaging and use of surgical adhesives during prosthetic heart valve implantation were significant confounders, whereas recent valve implantation was not. After the exclusion of patients with significant confounders, diagnostic performance values of the visual assessment increased to 91%/95%/95%/91%. As a semiquantitative measure of FDG uptake, a European Association of Nuclear Medicine Research Ltd-standardized uptake value ratio of ≥2.0 was a 100% sensitive and 91% specific predictor of PVE. Both visual and quantitative assessments of FDG PET/CT have a high diagnostic accuracy in patients in whom PVE is suspected. FDG PET/CT should be implemented early in the diagnostic workup to prevent the negative confounding effects of low inflammatory activity (eg, attributable to prolonged antibiotic therapy). Recent valve implantation was not a significant predictor of false-positive interpretations, but surgical adhesives used during implantation were.

P141: Predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool

Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &amp;/or history of fever and 2 or more signs of hypoperfusion (eg. SBP&lt;90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &amp;/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index &gt;1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.

The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis.

Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic value in the management of renal colic. The review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, Embase, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were computed tomography evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer. Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary. The electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full-text review, and nine articles metall inclusion criteria. Of these, five high-quality studies (N=1,773) were included in the meta-analysis for diagnostic accuracy and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% confidence interval [CI]=67.1%-73.2%) and 75.4% (95% CI=72.5%-78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta-analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI=92.7%-95.8%). Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation. Point-of-care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5mm) stone in those presenting with renal colic.

COMPARATIVE PROGNOSTIC ACCURACY OF CARDIOGENIC SHOCK RISK PREDICTION MODELS

Despite advancements in pharmacological and procedural therapies, cardiogenic shock (CS) remains associated with high morbidity and mortality. Accurate risk stratification tools may improve our ability to select patients suitable for mechanical therapies, yet little is known about the comparative discrimination of risk prediction models for CS mortality. We compared the accuracy of established risk scores in patients with CS admitted to a tertiary care center coronary care units (CCUs). The TRACER and APPROACH registry databases were used to identify all patients admitted to a tertiary care center CCU in the province of Alberta between January 1 and December 31, 2015. CS was defined as a systolic blood pressure (SBP) < 90 mmHg for >30 minutes associated with acute kidney injury or requiring pharmacologic or mechanical support to maintain a SBP >90 mmHg. The prognostic utility of the Acute Physiology and Chronic Health Evaluation (APACHE), CardShock, Intra-aortic balloon pump (IABP) Shock II model and sepsis-related organ failure assessment (SOFA) risk scores for predicting in-hospital mortality were evaluated using receiver-operating curves (ROC). A total of 3,021 patients were included in the study, among whom 510 (16.9%) had CS. Baseline population characteristics are shown in Table 1. Patients with CS were older (64.5 vs 63.0, p=0.04), had longer hospitalizations (21.2 vs 7.6, p < 0.01), and were more likely to die (29.0% vs 2.5%, p < 0.01). The discrimination of the APACHE score (AUC 0.76, 95% CI 0.71-0.81), CardShock (AUC 0.76, 95% CI 0.72-0.81), IABP Shock II (AUC 0.73, 95% CI 0.68-0.78) and SOFA scores (AUC 0.76, 95%CI 0.72-0.81, p=0.05) for in-hospital mortality were not significantly different, shown in Figure 1. Similarly, there was no significant difference in the diagnostic performance of the scores when assessing in-CCU death (p=0.10). CS is present in a significant proportion of patients admitted to tertiary care CCUs and is associated with a substantial increase in mortality. Existing risk scores have only modest diagnostic accuracy in this patient population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The diagnostic accuracy of 1.5T magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries.

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Diagnostic efficacy of noninvasive liver fibrosis indexes in predicting portal hypertension in patients with cirrhosis.

BackgroundRecent data suggest that noninvasive liver fibrosis indexes could be useful for predicting esophageal varices (EV) in cirrhotic patients. However, thus far, the diagnostic efficacy of these indexes in predicting portal hypertension (PH) in cirrhotic patients has been poorly evaluated.AimsTo evaluate the diagnostic efficacy of noninvasive liver fibrosis indexes in the diagnosis of PH.MethodsA total of 238 cirrhotic patients underwent hepatic venous pressure gradient (HVPG) evaluation and relevant serum tests to analyze the variables associated with PH grade. Then, the diagnostic performances of seven fibrosis indexes, the aspartate aminotransferase (AST)-to-alanine aminotransferase (ALT) ratio (AAR), AST-to-platelet (PLT) ratio index (APRI), fibrosis index (FI), FIB-4, Forns index, King’s score and the Lok index, were evaluated to determine their efficacy in predicting clinically significant PH (CSPH) and severe PH (SPH). In addition, the performances of these fibrosis indexes in different subgroups were investigated.ResultsThe results of a multivariate analysis of serum markers showed that AST values, platelet (PLT) count and albumin (ALB) were associated with PH grade. Among the seven—fibrosis indexes, King’s score, APRI and the Lok index showed modest diagnostic accuracy in predicting CSPH and SPH, as indicated by AUC of 0.755 and 0.742, 0.740 and 0.742, and 0.722 and 0.717, respectively. In addition, combination of King’s score (cutoff 23.47) and Lok index (cutoff 1.30) predicted presence of CSPH, with the highest PPV (95.38%) and +LR (5.49). A subgroup analysis indicated that the noninvasive screening model may be more applicable to patients with cirrhosis of viral etiology.ConclusionsSerum liver fibrosis indexes exhibited modest diagnostic accuracy for PH in cirrhotic patients. These indexes may not be able to replace HVPG measurements for the diagnosis of PH but may be used as a first-line screening method for CSPH in liver cirrhosis patients.

Use of copeptin for rapid rule-out of acute myocardial infarction.

Copeptin is currently understood as a quantitative marker of endogenous stress. It rises rapidly in multiple acute disorders including acute myocardial infarction. As a single variable, it has only modest diagnostic accuracy for acute myocardial infarction. However, the use of copeptin within a dual-marker strategy together with conventional cardiac troponin increases the diagnostic accuracy and particularly the negative predictive value of cardiac troponin alone for acute myocardial infarction. The rapid rule-out of acute myocardial infarction is the only application in acute cardiac care mature enough to merit consideration for routine clinical care. However, the dual-marker approach seems to provide only very small incremental value when used in combination with sensitive or high-sensitivity cardiac troponin assays. This review aims to update and educate regarding the potential and the procedural details, as well as the caveats and challenges of using copeptin in clinical practice.

Stenotic flow reserve derived from quantitative coronary angiography has modest but incremental value in predicting functionally significant coronary stenosis as evaluated by fractional flow reserve.

Stenotic flow reserve (SFR) derived from quantitative coronary angiography (QCA) has been correlated with myocardial ischaemia as determined by pharmacological stress echocardiography. However, the diagnostic accuracy of SFR in predicting functionally significant coronary stenosis as assessed by the gold standard, fractional flow reserve (FFR), has not been previously characterised. Patients who underwent coronary angiography and FFR assessment between January 2010 and February 2012 in a single tertiary centre were retrospectively assessed. QCA parameters such as minimal lumen diameter (MLD), lesion length, diameter stenosis (DS), SFR, turbulent resistance (TR) and Poiseuille resistance (PR) were assessed. Significant FFR was defined as FFR ≤0.8. The diagnostic accuracy of QCA parameters to predict significant FFR was assessed by independent t-test and receiver operator characteristic (ROC) curve. Statistical significance was defined as P value of <0.05. The study included 272 patients (age: 64±11, 70% males) and 415 vessels. There were 180 (43%) vessels which were FFR significant. The mean FFR value for all vessels was 0.81±0.11. On comparison of AUC for predicting significant FFR, SFR (AUC =0.76) had the highest diagnostic accuracy compared to PR (AUC =0.75), % DS (AUC =0.73), TR (AUC =0.69), MLD (AUC =0.71) and DS >50% (AUC =0.64). Using a retrospectively determined optimal cut-off value of 3.51, the sensitivity of stenotic-flow-reserve was modest at 56% with good specificity of 81%. DS >50% had a sensitivity of 47% and specificity of 82% in predicting significant FFR. There was incremental predictive value when SFR was added to DS >50% on integrated discrimination improvement index (IDI =0.103, P<0.001) and net reclassification index (NRI =0.72, P<0.001). SFR has modest diagnostic accuracy for predicting significant FFR but adds incremental predictive value to DS >50% for predicting significant FFR.

Impact of Patient Preparation on the Diagnostic Performance of 18F-FDG PET in Cardiac Sarcoidosis

F-FDG PET/CT is a valuable diagnostic tool in the evaluation of cardiac sarcoidosis. Appropriate patient preparation is important because the diagnostic accuracy of this procedure depends on adequate suppression of physiologic glucose uptake. This systematic review and meta-analysis aims to assess the effect of different patient preparations on the diagnostic accuracy of F-FDG PET/CT in cardiac sarcoidosis. We searched the PubMed/MEDLINE, Embase, and Cinicaltrials.gov databases. Sixteen studies (n = 559) were identified to be suitable for this systemic review. Studies were stratified according to fasting duration and means of physiologic suppression of F-FDG by cardiac tissue, which involves the use of heparin infusion or high-fat, low-carbohydrate diet before imaging. Study quality was assessed using the QUADAS-2 tool. Forest plots of sensitivity and specificity were calculated in Review Manager 5.3, and a random-effects hierarchical summary receiver operating characteristic model was created using MetaDiSc. Meta-regression was performed to investigate sources of heterogeneity. PET/CT had an overall Specificity of 0.75 (95% confidence interval [CI], 0.69-0.80) and specificity of 0.81 (95% CI, 0.76-0.85) for the diagnosis of cardiac sarcoidosis. This modest diagnostic accuracy was attributed to the inclusion of large single study in which a short fasting duration before scanning likely influenced its sensitivity. Its exclusion resulted in an overall sensitivity of 0.81 (95% CI, 0.76-0.86) and specificity of 0.82 (95% CI, 0.77-0.86). Meta-regression showed that the diagnostic odds ratio was significantly affected by fasting time and heparin administration before scanning (P = 0.01, 0.02) but not with high-fat, low-carbohydrate diet (P = 0.17). F-FDG PET/CT plays an integral role in the diagnosis of cardiac sarcoidosis. Diagnostic accuracy is affected by fasting duration and means of cardiomyocyte glucose uptake suppression before scanning.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study.

BackgroundAspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis.Material/MethodsAll patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy.ResultsA total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506–0.6 and 0.539–0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601–0.664 and 0.596–0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627–0.69 and 0.607–0.692, respectively.ConclusionsAPRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.

Does cognitive performance map to categorical diagnoses of schizophrenia, schizoaffective disorder and bipolar disorder? A discriminant functions analysis

ObjectivesDespite known overlaps in the pattern of cognitive impairments in individuals with bipolar disorder (BD), schizophrenia (SZ) and schizoaffective disorder (SZA), few studies have examined the extent to which cognitive performance validates traditional diagnostic boundaries in these groups. MethodIndividuals with SZ (n=49), schizoaffective disorder (n=33) and BD (n=35) completed a battery of cognitive tests measuring the domains of processing speed, immediate memory, semantic memory, learning, working memory, executive function and sustained attention. ResultsA discriminant functions analysis revealed a significant function comprising semantic memory, immediate memory and processing speed that maximally separated patients with SZ from those with BD. Initial classification scores on the basis of this function showed modest diagnostic accuracy, owing in part to the misclassification of SZA patients as having SZ. When SZA patients were removed from the model, a second cross-validated classifier yielded slightly improved diagnostic accuracy and a single function solution, of which semantic memory loaded most heavily. ConclusionsA cluster of non-executive cognitive processes appears to have some validity in mapping onto traditional nosological boundaries. However, since semantic memory performance was the primary driver of the discrimination between BD and SZ, it is possible that performance differences between the disorders in this cognitive domain in particular, index separate underlying aetiologies.

Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematicreview.

BackgroundPatients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking echocardiography (STE) has proved to have diagnostic value in acute coronary syndrome it is not commonly incorporated in everyday practice.The purpose of the present systematic review was to assess the diagnostic accuracy of left ventricular (LV) longitudinal function by STE to predict significant coronary artery stenosis (CAD+) or not (CAD-) verified by coronary angiography in patients with chest pain suspected to be of cardiac ischemic origin.Methods4 electronic databases; Embase, Medline, Cochrane and PubMed ahead-of print were searched for per 19.05.14. Only full-sized articles including > 40 patients were selected.ResultsA total of 166 citations were identified, 16 full-size articles were assessed of which 6 were found eligible for this review. Of 781 patients included 397 (60 %) had CAD+. The overall weighted mean global longitudinal strain (GLS) was −17.2 % (SD = 2.6) among CAD+ vs. -19.2 % (SD = 2.8) in CAD- patients. Mean area under curve in 4 studies for predicting CAD+ ranged from 0.68 to 0.80. The study cut-off levels for prediction of CAD+ in the ROC analysis varied between −17.4 % and −19.7 % with sensitivity from 51 % to 81 % and specificity between 58 % and 81 %. In 1 study GLS obtained during dobutamine stress echocardiography (DSE) had the best accuracy. Regional strain measurements were not uniform, but may have potential in detecting CAD.ConclusionsGLS measurements at rest only have modest diagnostic accuracy in predicting CAD+ among patients presenting with acute or chronic chest pain. The results from regional strain, layer specific strain and DSE need to be verified in larger studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12880-015-0067-y) contains supplementary material, which is available to authorized users.

Accuracy of intravascular ultrasound and optical coherence tomography in identifying functionally significant coronary stenosis according to vessel diameter: A meta-analysis of 2,581 patients and 2,807 lesions

Accuracy of intracoronary imaging to discriminate functionally significant coronary stenosis according to vessel diameter remains to be defined. PubMed, Scopus, and Google Scholar were systematically searched for studies assessing diagnostic accuracy (area under the receiver operating characteristic curve [AUC], the primary end point) and sensitivity and specificity (the secondary end points) of minimal luminal area (MLA) or of minimal luminal diameter (MLD) derived from intravascular ultrasound (IVUS) or optical coherence tomography (OCT) to detect functionally significant stenosis as determined with fractional flow reserve (FFR). Fifteen studies were included, 2 with 110 patients analyzing only left main (LM), 5 with 224 patients and 306 lesions using OCT, and 9 with 1532 patients and 1681 lesions with IVUS. Median MLA for the OCT studies was 1.96 mm(2) (1.85-1.98 mm(2)), 2.9 mm(2) (2.7-3.1 mm(2)) for MLA of all lesions assessed with IVUS, 2.8 mm(2) (2.7-2.9 mm(2)) for lesions with an angiographic diameter >3 mm, 2.4 mm(2) (2.4-2.5 mm(2)) for lesions <3 mm, and 5.4 mm(2) (5.1-5.6 mm(2)) for LM lesions. For OCT-MLA, AUC was 0.80 (0.74-0.86), with a sensitivity of 0.81 (0.74-0.87) and specificity of 0.77 (0.71-0.83), whereas OCT-MLD had an AUC of 0.85 (0.79-0.91), sensitivity of 0.74 (0.69-0.78), and specificity of 0.70 (0.68-0.73). For IVUS-MLA, AUC was 0.78 (0.75-0.81) for all lesions, 0.78 (0.73-0.84) for vessels with a diameter >3 mm, and 0.79 (0.70-0.89) for those with a diameter <3 mm. Left main AUC was 0.97 (0.93-1). Intravascular ultrasound and OCT had modest diagnostic accuracy for identification hemodynamically significant lesions, also with specific cutoff for different diameters. Invasive imaging for assessment of LM severity demonstrated excellent correlation with FFR. What is already known about this subject? Fractional flow reserve represents the criterion standard to evaluate the prognostic value of coronary stenosis, whereas its relationship with IVUS and OCT remains to be assessed. What does this study add? Despite improvement, IVUS and OCT do not predict functional stenosis, even with dedicated cutoff, apart from LM disease. How might this impact on clinical practice? The recent guidelines of myocardial revascularization have stressed the crucial role of FFR before performing percutaneous coronary intervention on LM, whereas intravascular imaging is often exploited to drive revascularization. The present analysis stresses the point that LM percutaneous coronary intervention may be driven only by intravascular imaging, given the high accuracy for significant ischemic lesions, whereas for other vessels, these 2 techniques mirror 2 different aspects.

Disorders of the cauda equina.

Cauda equina syndrome is an important neurologic disorder characterized by lower back pain, sciatica, perineal numbness, and sphincter dysfunction. This article reviews the anatomy, clinical presentation, evaluation, and treatment of cauda equina dysfunction, focusing on diskogenic cauda equina syndrome. Assessment of suspected cauda equina syndrome is hampered by modest diagnostic accuracy of any one clinical feature. Although urgent operation for diskogenic cauda equina syndrome is standard practice, most data about timing of intervention comes from small case series; however, randomized trials are very unlikely given the ethical implications of delaying surgical intervention. In the absence of high-quality data indicating otherwise, urgent evaluation and intervention are required for diskogenic cauda equina syndrome. Other etiologies of cauda equina dysfunction including neoplastic, infectious, and iatrogenic causes must also be considered, especially in the setting of normal neuroimaging studies.

Comparison of the Diagnostic Power of Computed Tomography Coronary Angiography and Exercise Electrocardiography as a First Screening Test in Real-World Practice: Is It Ready for Clinical Use?

Exercise electrocardiography (XECG) is a widely used noninvasive test for screening coronary artery disease that is endorsed by current clinical guidelines. However, its clinical use is limited by its modest diagnostic accuracy. Coronary computed tomographic angiography (CCTA) has emerged as a new tool for screening coronary artery disease. In this issue, CCTA performed better diagnostically than XECG when invasive coronary angiography was used as the diagnostic standard. In addition, invasive coronary angiography was chosen based on CCTA, rather than XECG. Although this study suffers from the lack of an appropriate diagnostic standard, the clinical course identified implies that clinical practice might be influenced by sophisticated anatomical imaging to a considerably greater extent than by a simple physiological assessment. (Korean J Med 2014;87:163-164)

Neuroanatomical pattern classification in a population-based sample of first-episode schizophrenia

Recent neuroanatomical pattern classification studies have attempted to individually classify cases with psychotic disorders using morphometric MRI data in an automated fashion. However, this approach has not been tested in population-based samples, in which variable patterns of comorbidity and disease course are typically found. We aimed to evaluate the diagnostic accuracy (DA) of the above technique to discriminate between incident cases of first-episode schizophrenia identified in a circumscribed geographical region over a limited period of time, in comparison with next-door healthy controls. Sixty-two cases of first-episode schizophrenia or schizophreniform disorder and 62 age, gender and educationally-matched controls underwent 1.5 T MRI scanning at baseline, and were naturalistically followed-up over 1 year. T1-weighted images were used to train a high-dimensional multivariate classifier, and to generate both spatial maps of the discriminative morphological patterns between groups and ROC curves. The spatial map discriminating first-episode schizophrenia patients from healthy controls revealed a complex pattern of regional volumetric abnormalities in the former group, affecting fronto-temporal-occipital gray and white matter regions bilaterally, including the inferior fronto-occipital fasciculus, as well as the third and lateral ventricles. However, an overall modest DA (73.4%) was observed for the individual discrimination between first-episode schizophrenia patients and controls, and the classifier failed to predict 1-year prognosis (remitting versus non-remitting course) of first-episode schizophrenia (DA=58.3%). In conclusion, using a "real world" sample recruited with epidemiological methods, the application of a neuroanatomical pattern classifier afforded only modest DA to classify first-episode schizophrenia subjects and next-door healthy controls, and poor discriminative power to predict the 1-year prognosis of first-episode schizophrenia.

Diagnostic role of whole-body [18F]-FDG positron emission tomography in patients with symptoms suspicious for malignancy after heart transplantation

Increased rates of malignancies and infections occur in transplant patients under immunosuppression, but the resultant clinical symptoms, and results of physical examination, chest X-ray, abdominal ultrasonography and laboratory findings are frequently difficult to interpret or inconclusive. The aim of the present study was to investigate the usefulness of whole-body [(18)F]-FDG PET for investigation of heart transplant patients suffering from suspicious symptoms, with a previously ambiguous diagnosis. Seventeen consecutive patients (8 women; 48 ± 22 years) with non-specific symptoms (lymphadenopathy, fever of unknown origin or recurrent febrile temperatures, weight loss, abdominal pain, night sweating, cough or generally reduced physical condition) were evaluated retrospectively. All patients underwent whole-body [(18)F]-FDG examinations by PET (7 patients) or PET/CT (10 patients) at 8 ± 6 (range 0.1 to 21) years after orthotopic heart transplantation (OHT). During a follow-up of 28 ± 25 months, results of bone marrow biopsies, and histologic and/or microbiologic findings were registered and retrospectively compared with the PET results. PET revealed the cause of non-specific symptoms in 9 of 17 patients; there were 5 cases of lymphoproliferative disease (PTLD), 2 carcinomas and 2 cases of infection. Four patients were rated false positive, 1 patient false negative and 3 patients were correctly rated as negative. Sensitivity, specificity and positive and negative predictive values were 0.90, 0.43, 0.69 and 0.75, respectively, giving an overall diagnostic accuracy of 0.71. A non-invasive strategy of using whole-body [(18)F]-FDG PET or PET/CT in heart transplant recipients with non-specific unexplained symptoms may offer diagnostic stratification for malignancy and infections with a high sensitivity and modest diagnostic accuracy. These findings require prospective confirmation.

Standard 1.5-T MRI of endometrial carcinomas: modest agreement between radiologists

To evaluate pelvic magnetic resonance imaging (MRI) interobserver agreement for the detection of deep myometrial invasion, cervical stroma invasion and lymph node metastases in endometrial carcinoma patients in relation to surgical staging. Fifty-seven patients with histologically confirmed endometrial carcinoma were prospectively included in a study of preoperative 1.5-T MRI. Four radiologists, blinded to patient data, independently reviewed the images for the presence of deep myometrial invasion, cervical stroma invasion and lymph node metastases. Kappa coefficients for interobserver agreement and diagnostic performances for each observer were calculated using final surgical staging results (FIGO 09) as reference standard. Overall agreement among all observers was moderate for cervical stroma invasion (κ = 0.50 [95% CI 0.27-0.73]) and lymph node metastases (κ = 0.56 [0.09-0.80]) and fair for deep myometrial invasion (κ = 0.39 [0.26-0.55]). Sensitivity (specificity) values for the four observers were 72-92% (44-63%) for deep myometrial invasion, 38-63% (82-94%) for cervical stroma invasion and 25-38% (90-100%) for lymph node metastases. Conventional MRI showed only modest interobserver agreement and diagnostic accuracy for detection of deep myometrial invasion, cervical stroma invasion and lymph node metastases. Improved methods are needed for preoperative imaging in the staging of endometrial carcinomas. MRI is an important tool for preoperative endometrial cancer staging. • Staging agreement based on pelvic MRI was modest among different observers. • Preoperative MRI alone was suboptimal in identifying high-risk patients. • Improved imaging and biomarkers may refine preoperative risk stratification in endometrial cancer.

Accuracy of soluble human leukocyte antigen-G for predicting pregnancy among women undergoing infertility treatment: meta-analysis

There have been concerns about validity and accuracy of the measurement of sHLA-G in embryo culture supernatants. In this systematic review, we quantified the diagnostic accuracy of sHLA-G for predicting the ability to achieve clinical pregnancy in women who are undergoing infertility treatment. Medline and Embase were searched up to 7 September 2007, for full English and non-English articles concerning cohort studies evaluating sHLA-G in embryo culture for predicting clinical pregnancy in women undergoing IVF and ICSI. Eleven studies including 1813 patients met our inclusion criteria. In the individual studies, sensitivity ranged from 0.01 to 0.97, specificity from 0.18 to 0.98, the positive likelihood ratio from 0.34 to 3.21 and the negative likelihood ratio from 0.08 to 1.01. These values were highly heterogeneous with, in each case, I(2) values of >75%, and P-values for the Q statistic of <0.001, arguing against generating a pooled estimate for these diagnostic test properties. The diagnostic odds ratios (DORs) ranged from 0.92 to 24.82 in the individual studies with an I(2) value of 49% indicating moderate heterogeneity. Therefore, the meta-analysis combined the logs of the DORs, which are derived from sensitivity and specificity. A random-effects model yielded a summary DOR of 4.38 (95% CI, 2.93-6.55), consistent with modest diagnostic accuracy. Interestingly, an a priori defined subgroup analysis restricted to six studies with good quality embryos showed a better diagnostic performance with a DOR of 12.67 (95% CI, 3.66-43.80) to predict the ability to achieve clinical pregnancy in women undergoing infertility treatment. Further research is needed with single-embryo culture, single-embryo transfer and highly sensitive detection techniques to determine the potential application of measuring sHLA-G in culture supernatant.