A hierarchical regression approach to meta-analysis of diagnostic test accuracy evaluations

Combination of urinary biomarkers can predict cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis

INTRODUCTION

Acute kidney injury (AKI) develops in 20-50% of patients undergoing cardiac surgery (CS). We aimed to assess the predictive value of urinary biomarkers (UBs) for predicting CS-associated AKI. We also aimed to investigate the accuracy of the combination of UB measurements and their incorporation in predictive models to guide physicians in identifying patients developing CS-associated AKI.

METHODS

All clinical studies reporting on the diagnostic accuracy of individual or combined UBs were eligible for inclusion. We searched three databases (MEDLINE, EMBASE, and CENTRAL) without any filters or restrictions on the 11th of November, 2022 and reperformed our search on the 3rd of November 2024. Random and mixed effects models were used for meta-analysis. The main effect measure was the area under the Receiver Operating Characteristics curve (AUC). Our primary outcome was the predictive values of each individual UB at different time point measurements to identify patients developing acute kidney injury (KDIGO). As a secondary outcome, we calculated the performance of combinations of UBs and clinical models enhanced by UBs.

RESULTS

We screened 13,908 records and included 95 articles (both randomised and non-randomised studies) in the analysis. The predictive value of UBs measured in the intraoperative and early postoperative period was at maximum acceptable, with the highest AUCs of 0.74 [95% CI 0.68, 0.81], 0.73 [0.65, 0.82] and 0.74 [0.72, 0.77] for predicting severe CS-AKI, respectively. To predict all stages of CS-AKI, UBs measured in the intraoperative and early postoperative period yielded AUCs of 0.75 [0.67, 0.82] and 0.73 [0.54, 0.92]. To identify all and severe cases of acute kidney injury, combinations of UB measurements had AUCs of 0.82 [0.75, 0.88] and 0.85 [0.79, 0.91], respectively.

CONCLUSION

The combination of urinary biomarkers measurements leads to good accuracy.

GLIM Achieves Best Diagnostic Performance in Non-Cancer Patients with Low BMI: A Hierarchical Bayesian Latent-Class Meta-Analysis

CONTEXT

Global Leadership Initiative on Malnutrition (GLIM) and Patient-Generated Subjective Global Assessment (PG-SGA) are commonly used nutrition assessment tools, whose performance does not reach a consensus due to different and imperfect reference standards.

OBJECTIVE

This study aimed to evaluate and compare the diagnostic accuracy of GLIM and PG-SGA, using a hierarchical Bayesian latent class model, in the absence of a gold standard.

DATA SOURCES

A systematic search was undertaken in PubMed, Embase, and Web of Science from inception to October 2022. Diagnostic test studies comparing (1) the GLIM and/or (2) PG-SGA with "semi-gold" standard assessment tools for malnutrition were included.

DATA EXTRACTION

Two authors independently extracted data on sensitivity, specificity, and other key characteristics. The methodological quality of each included study was appraised according to the criteria in the Quality Assessment of Diagnostic Accuracy Studies-2.

DATA ANALYSIS

A total of 45 studies, comprising 20 876 individuals evaluated for GLIM and 11 575 for PG-SGA, were included. The pooled sensitivity was 0.833 (95% CI 0.744 to 0.896) for GLIM and 0.874 (0.797 to 0.925) for PG-SGA, while the pooled specificity was 0.837 (0.780 to 0.882) for GLIM and 0.778 (0.707 to 0.836) for PG-SGA. GLIM showed slightly better performance than PG-SGA, with a higher diagnostic odds ratio (25.791 vs 24.396). The diagnostic performance of GLIM was most effective in non-cancer patients with an average body mass index (BMI) of <24 kg/m2, followed by non-cancer patients with an average age of ≥60 years. PG-SGA was most powerful in cancer patients with an average age of <60 years, followed by cancer patients with an average BMI of <24 kg/m2.

CONCLUSION

Both GLIM and PG-SGA had moderately high diagnostic capabilities. GLIM was most effective in non-cancer patients with a low BMI, while PG-SGA was more applicable in cancer patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022380409.

A systematic review and meta-analysis of the diagnostic test accuracy of diffusion weighted imaging and apparent diffusion coefficient in differentiating active from inactive perianal fistula

INTRODUCTION

This systematic review and meta-analysis evaluated the diagnostic accuracy of MRI-based apparent diffusion coefficient (ADC) and diffusion-weighted imaging (DWI) for differentiating active from inactive perianal fistulas.

METHODS

The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024596604). The review included five databases (MEDLINE, Cochrane Library, PubMed, Science Direct, and Google Scholar). Meta-analyses were performed on studies reporting ADC values and other sequences using STATA software with the "Midas" command.

RESULTS

Of 21 studies included in the review, 12 were meta-analyzed, encompassing 1007 patients (77.5 % male) with 1092 fistulas and 321 abscesses. Six studies reported ADC values for active vs. inactive fistulas, with a pooled sensitivity of 83 % (95%CI 68-92), specificity of 75 % (95%CI 60-85), and AUC of 0.85 (95%CI 0.81-0.87). Pooled ADC cut-offs ranged from 1.105 to 1.109 × 10⁻³ mm2/s. The T2WI + DWI sequence demonstrated the highest diagnostic accuracy, with a pooled sensitivity of 99 % (95%CI 90-100), specificity of 97 % (95%CI 79-100), and an AUC of 1.

CONCLUSION

ADC alone is inadequate for reliably distinguishing active from inactive fistulas. T2WI combined with DWI offers superior diagnostic performance, surpassing contrast-enhanced T1WI, and is promising for non-invasive evaluation of perianal fistulas. However, several limitations, such as moderate to high risk of bias and heterogeneity, may bias this conclusion.

IMPLICATIONS FOR PRACTICE

T2WI + DWI could become the standard for assessing perianal fistulas, avoiding contrast agents, and benefiting patients contraindicated for Gadolinium-based contrast media. Variability and potential bias across studies warrant further research.

Accuracy of artificial intelligence in detecting tumor bone metastases: a systematic review and meta-analysis

BACKGROUND

Bone metastases (BM) represent a prevalent complication of tumors. Early and accurate diagnosis, however, is a significant hurdle for radiologists. Recently, artificial intelligence (AI) has emerged as a valuable tool to assist radiologists in the detection of BM. This meta-analysis was undertaken to evaluate the AI diagnostic accuracy for BM.

METHODS

Two reviewers performed an exhaustive search of several databases, including Wei Pu (VIP) database, China National Knowledge Infrastructure (CNKI), Web of Science, Cochrane Library, Ovid-Embase, Ovid-Medline, Wan Fang database, and China Biology Medicine (CBM), from their inception to December 2024. This search focused on studies that developed and/or validated AI techniques for detecting BM in magnetic resonance imaging (MRI) or computed tomography (CT). A hierarchical model was used in the meta-analysis to calculate diagnostic odds ratio (DOR), negative likelihood ratio (NLR), positive likelihood ratio (PLR), area under the curve (AUC), specificity (SP), and pooled sensitivity (SE). The risk of bias and applicability were assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST), while the Transparent Reporting of a multivariable prediction model for individual prognosis or diagnosis-artificial intelligence (TRIPOD-AI) was employed for evaluating the quality of evidence.

RESULT

This review covered 20 articles, among them, 16 studies were included in the meta-analysis. The results revealed a pooled SE of 0.88 (0.82-0.92), a pooled SP of 0.89 (0.84-0.93), a pooled AUC of 0.95 (0.92-0.96), PLR of 8.1 (5.57-11.80), NLR of 0.14 (0.09-0.21) and DOR of 58 (31-109). When focusing on imaging algorithms. Based on ML, a pooled SE of 0.88 (0.77-0.92), SP 0.88 (0.82-0.92), and AUC 0.93 (0.91-0.95). Based on DL, a pooled SE of 0.89 (0.81-0.95), SP 0.89 (0.81-0.94), and AUC 0.95 (0.93-0.97).

CONCLUSION

This meta-analysis underscores the substantial diagnostic value of AI in identifying BM. Nevertheless, in-depth large-scale prospective research should be carried out for confirming AI's clinical utility in BM management.

The usefulness of serum leucine-rich alpha-2 glycoprotein as a novel biomarker in monitoring inflammatory bowel disease: a systematic review and meta-analysis

Inflammatory bowel disease (IBD) is a condition of unknown origin. It does not have a definite cure and its response to various treatments can be evaluated based on symptom-based measures, invasive procedures, or biomarker levels, highlighting the need for an accurate biomarker. Since C-reactive protein (CRP) and fecal calprotectin have their shortcomings, the need for a novel biomarker remains critical. Systematic searches of PubMed, Scopus, Web of Science, and Embase were performed In January 2024. PROSPERO number is CRD42024507383. We assessed the accuracy of leucine-rich alpha-2 glycoprotein (LRG) in identifying disease activity among patients with IBD using a bivariate diagnostic random-effects model. Fourteen studies involving 1794 individuals conducted in Japan were selected for our systematic review. The sensitivity and specificity of LRG levels for detecting disease activity were analyzed in patients with IBD and in two subgroups (ulcerative colitis and Crohn's disease). The synthesized sensitivity and specificity were 75.4% [95% confidence interval (CI), 68.9-80.9%] and 77.3% (95% CI, 69.9-83.2%), respectively, in patients with IBD, 73.1% (95% CI, 62.7-81.5%) and 81.9% (95% CI, 73.9-87.8%), respectively, in patients with CD, and the secondary analysis of the ulcerative colitis subgroup showed a pooled sensitivity and specificity of 72.8 and 59.7%, respectively. Our systematic review and meta-analysis demonstrated that LRG could be useful in detecting IBD activity. It is superior for detecting disease activity, especially in patients with normal CRP levels. The LRG was more accurate in monitoring disease activity in patients with CD than in patients with IBD.

Accuracy of Ionizing-Radiation-Based and Non-Ionizing Imaging Assessments for the Diagnosis of Periodontitis: Systematic Review and Meta-Analysis

AIMS

To evaluate the diagnostic accuracy of periapical, bitewing or panoramic radiographs (standard 2D radiographs) in detecting and monitoring periodontitis (PICO 1) and to assess the clinical relevance of alternative and emerging diagnostic methods (e.g., cone-beam computed tomography [CBCT], magnetic resonance imaging [MRI], ultrasound imaging [USG]) compared to standard 2D radiographs or clinical/intra-surgical examination in the diagnosis and surveillance of the disease (PICO 2).

MATERIALS AND METHODS

A systematic literature search was conducted through MEDLINE EMBASE, Scopus and Cochrane Library. When feasible (n > 2 comparable studies), a meta-analysis of diagnostic accuracy was performed.

RESULTS

For PICO 1, 26 studies met the inclusion criteria. Pooled-data analysis from three studies showed a sensitivity of 0.77 (95% confidence interval, CI: 0.66-0.85), specificity of 0.76 (95% CI: 0.64-0.84) and accuracy of 0.82, with a diagnostic odds ratio (DOR) of 137.99 (95% CI: 6.99-368.90). For PICO 2, 51 articles were included dealing with different techniques. The meta-analysis for CBCT (three studies) showed a pooled sensitivity and specificity of 0.98 (95% CI: 0.96-1.00) and 0.98 (95% CI: 0.95-1.00), respectively, and a diagnostic accuracy of 0.99 in the detection of furcation involvement compared to intra-surgical measurements.

CONCLUSIONS

Standard 2D radiographs appear to have adequate diagnostic accuracy for periodontitis, while CBCT is highly sensitive and specific to detect and classify furcation involvement. The role of non-ionizing techniques (MRI and USG) in diagnosing periodontitis remains under investigation.

Prognostic accuracy of point-of-care ultrasound in patients with pulseless electrical activity: a systematic review and meta-analysis

BACKGROUND

The prognosis for pulseless electrical activity (PEA) is typically poor; however, patients with cardiac activity observed on point-of-care ultrasound (POCUS) tend to have better outcomes compared to those without. This systematic review and meta-analysis were conducted to assess the prognostic accuracy of cardiac activity detected by POCUS in predicting resuscitation outcomes in patients experiencing PEA.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify relevant studies. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio, and the area under the summary receiver operating characteristic curve (SROC) were calculated using the bivariate model.

RESULTS

Eighteen studies comprising 1202 patients were included in the meta-analysis. Cardiac activity observed on POCUS demonstrated a pooled sensitivity of 0.86 (95% CI 0.67-0.95) and specificity of 0.64 (95% CI 0.51-0.75) for predicting return of spontaneous circulation, a pooled sensitivity of 0.89 (95% CI 0.80-0.94) and specificity of 0.73 (95% CI 0.63-0.81) for survival to admission (SHA), and a pooled sensitivity of 0.79 (95% CI 0.58-0.91) and specificity of 0.58 (95% CI 0.47-0.68) for survival to discharge. The highest area under the SROC, 0.89 (95% CI 0.86-0.92), was observed for SHA.

CONCLUSIONS

Our study suggests that POCUS may serve as a vital component of a multimodal approach for early termination of resuscitation.

Evaluating Rabies Test Accuracy: A Systematic Review and Meta-Analysis of Human and Canine Diagnostic Methods

Background/Objectives: Rabies is almost invariably fatal once clinical symptoms manifest. Timely and accurate diagnosis is essential for effective treatment and prevention. Dogs are the principal reservoirs of the virus, particularly in developing nations, highlighting the importance of precise diagnostic and control measures to prevent human cases. This systematic review and meta-analysis assessed the accuracy of laboratory tests for diagnosing rabies in humans and dogs. Methods: The PubMed database was searched for published studies on rabies diagnosis between 1990 and 2024. Following PRISMA statement recommendations, we included 60 studies that met the selection criteria. Results: The results demonstrated the effectiveness of immunological tests like the Enzyme-Linked Immunosorbent Assay (ELISA) and molecular tests such as Reverse Transcription Polymerase Chain Reaction (RT-PCR) for both humans and dogs. In this study, the Direct Fluorescent Antibody Test (DFAT) exhibited lower diagnostic performance, with an area under the curve for false positive rates (AUCFPR = 0.887). In contrast, ELISA (AUCFPR = 0.909) and RT-PCR (AUCFPR = 0.905) provided more consistent results. Notably, the Rapid Immunochromatographic Test (RIT) showed the best performance (AUCFPR = 0.949), highlighting its superior diagnostic capabilities compared to DFAT. Conclusions: These findings underscore the need to modernize rabies diagnostic protocols by incorporating advanced methodologies to improve diagnostic accuracy, reduce transmission, and decrease mortality rates.

Patency Capsule and Cross-Sectional Imaging for Predicting Capsule Endoscopy Retention: A Systematic Review and Meta-Analysis

AIMS

Small bowel capsule endoscopy, which has been widely used to evaluate small bowel disease, has a risk of capsule retention (CR). The present systematic review and meta-analysis evaluated the accuracy of patency capsule (PC) and cross-sectional imaging (CSI) for predicting CR.

METHODS

Databases, including MEDLINE/PubMed, EMBASE, Web of Science and the Cochrane library, were searched for articles through August 15, 2023, that investigated the diagnostic accuracy of PC or CSI for predicting CR. Pooled sensitivity and specificity were calculated using a bivariate random-effects model. The false-negative rates of PC and CSI were separately analyzed and compared using a single-proportion meta-analysis based on random-effects modeling.

RESULTS

Twenty-three articles (covering 3273 patients) including 17 assessing PC (involving 3051 patients), 4 assessing CSI (involving 140 patients), and 2 assessing both PC and CSI (involving 82 patients) were identified. CSI had a pooled sensitivity and specificity for predicting CR of 54% (95% confidence interval [CI], 21-84%) and 88% (95% CI, 67-97%), respectively, whereas PC had a pooled sensitivity and specificity for predicting CR of 75% (95% CI, 43-92%) and 94% (95% CI, 90-96%), respectively. PC showed a significantly higher specificity (P = 0.05) and lower pooled false-negative rate than CSI (2.7% [95% CI, 1.3-5.4%] vs. 12.8% [95% CI, 6.1-25.0%]; P = 0.001).

CONCLUSIONS

PC showed demonstrated comparable sensitivity, significantly higher specificity, and significantly lower false-negative rate than CSI. PC may be a more reliable modality for predicting CR than CSI.

Diagnostic accuracy of cell-free fetal DNA in maternal blood in detecting chromosomal anomalies in twin pregnancy: systematic review and meta-analysis

OBJECTIVE

To report the diagnostic accuracy of cell-free fetal DNA (cfDNA) in maternal blood in detecting fetal chromosomal anomalies in twin pregnancy.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane databases were searched from inception to November 2023. The inclusion criteria were twin pregnancy undergoing cfDNA screening for trisomies 21, 18 and 13, monosomy X and/or other sex-chromosome aneuploidies (SCA). The index test was cfDNA screening. The reference standard was pre- or postnatal karyotyping (in the case of a positive cfDNA result) or neonatal phenotypic assessment (in case of a negative cfDNA result). The quality of included studies was assessed using the revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Summary estimates of diagnostic accuracy were computed using a bivariate random-effects model.

RESULTS

Thirty-five studies were included in the systematic review and meta-analysis. cfDNA had a high accuracy in detecting trisomy 21 in twin pregnancy, with a sensitivity of 98.8% (95% CI, 96.5-100%) and specificity of 100% (95% CI, 99.9-100%). Sensitivity and specificity were 94.9% (95% CI, 75.9-99.1%) and 100% (95% CI, 99.9-100%), respectively, for trisomy 18 and 84.6% (95% CI, 54.6-98.1%) and 100% (95% CI, 99.9-100%), respectively, for trisomy 13. We could not compute the diagnostic accuracy of cfDNA in detecting monosomy X, owing to an absence of positive cases, while cfDNA had a sensitivity of 100% (95% CI, 71.5-100%) and specificity of 99.8% (95% CI, 99.7-99.9%) for other SCA. The accuracy of cfDNA in detecting the common trisomies was similar in dichorionic and monochorionic twin pregnancies.

CONCLUSIONS

cfDNA has high diagnostic accuracy in detecting trisomies 21 and 18 in twin pregnancy, irrespective of chorionicity. Estimation of diagnostic accuracy for trisomy 13 and other SCA was limited by the small number of affected cases and the difficulty associated with detecting false-negative cases of other SCA, and thus requires confirmation in larger studies. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Prediction of good neurological outcome after return of circulation following paediatric cardiac arrest: A systematic review and meta-analysis

AIM

To evaluate the ability of blood-biomarkers, clinical examination, electrophysiology, or neuroimaging, assessed within 14 days from return of circulation to predict good neurological outcome in children following out- or in-hospital cardiac arrest.

METHODS

Medline, EMBASE and Cochrane Trials databases were searched (2010-2023). Sensitivity and false positive rates (FPR) for good neurological outcome (defined as either 'no, mild, moderate disability or minimal change from baseline') in paediatric survivors were calculated for each predictor. Risk of bias was assessed using the QUIPS tool.

RESULTS

Thirty-five studies (2974 children) were included. The presence of any of the following had a FPR < 30% for predicting good neurological outcome with moderate (50-75%) or high (>75%) sensitivity: bilateral reactive pupillary light response within 12 h; motor component ≥ 4 on the Glasgow Coma Scale score at 6 h; bilateral somatosensory evoked potentials at 24-72 h; sleep spindles, and continuous cortical activity on electroencephalography within 24 h; or a normal brain MRI at 4-6d. Early (≤12 h) normal lactate levels (<2mmol/L) or normal s100b, NSE or MBP levels predicted good neurological outcome with FPR rate < 30% and low (<50%) sensitivity. All studies had moderate to high risk of bias with timing of measurement, definition of test, use of multi-modal tests, or outcome assessment heterogeneity.

CONCLUSIONS

Clinical examination, electrophysiology, neuroimaging or blood-biomarkers as individual tests can predict good neurological outcome after cardiac arrest in children. However, evidence is often low quality and studies are heterogeneous. Use of a standardised, multimodal, prognostic algorithm should be studied and is likely of added value over single modality testing.

Ability of pulse oximetry-derived indices to predict hypotension after spinal anesthesia for cesarean delivery: A systematic review and meta-analysis

Cesarean deliveries are often performed under spinal anesthesia because of the reduced risk of complications compared with that of general anesthesia. However, hypotension frequently occurs and adversely affects both the mother and fetus. Indices, such as the perfusion index (PI) and pleth variability index (PVI), which are derived from pulse oximetry have been used in numerous studies to predict hypotension after spinal anesthesia. However, their predictive abilities remain controversial. This study aimed to investigate the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia in patients undergoing cesarean deliveries. To this end, we conducted a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, European Union Clinical Trials Register, World Health Organization International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry databases from inception until June 15, 2023. We included retrospective and prospective observational studies and randomized controlled trials that assessed the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia during cesarean delivery. We did not restrict our search to specific languages. Of the 19 studies, involving 1437 patients, 17 assessed the PI in 1,311 patients, and 5 assessed the PVI in 344 patients. The summary sensitivity and specificity of the PI were 0.75 (95% confidence interval [CI]: 0.69-0.80) and 0.64 (95%CI: 0.48-0.77), respectively, while those of the PVI were 0.63 (95%CI: 0.47-0.76) and 0.76 (95%CI: 0.64-0.84), respectively. The area under the summary receiver operating characteristic curve was approximately 0.75 for both indexes. Baseline PI and PVI have a moderate predictive ability for hypotension after spinal anesthesia in patients undergoing cesarean delivery.

Changes in pulse pressure variation induced by passive leg raising test to predict preload responsiveness in mechanically ventilated patients with low tidal volume in ICU: a systematic review and meta-analysis

BACKGROUND

Pulse pressure variation (PPV) is limited in low tidal volume mechanical ventilation. We conducted this systematic review and meta-analysis to evaluate whether passive leg raising (PLR)-induced changes in PPV can reliably predict preload/fluid responsiveness in mechanically ventilated patients with low tidal volume in the intensive care unit.

METHODS

PubMed, Embase, and Cochrane databases were screened for diagnostic research relevant to the predictability of PPV change after PLR in low-tidal volume mechanically ventilated patients. The QUADAS-2 scale was used to assess the risk of bias of the included studies. In-between study heterogeneity was assessed through the I2 indicator. Publication bias was assessed by the Deeks' funnel plot asymmetry test. Summary receiving operating characteristic curve (SROC), pooled sensitivity, and specificity were calculated.

RESULTS

Five studies with a total of 474 patients were included in this meta-analysis. The SROC of the absolute PPV change resulted in an area under the curve of 0.91 (95% CI 0.88-0.93), with overall pooled sensitivity and specificity of 0.88 (95% CI 0.82-0.91) and 0.83 (95% CI 0.76-0.89), respectively. The diagnostic odds ratio was 35 (95% CI 19-67). The mean and median cutoff values of PLR-induced absolute change in absolute PPV were both -2 points and ranged from -2.5 to -1 points. Overall, there was no significant heterogeneity with I2 = 0%. There was no significant publication bias. Fagan's nomogram showed that with a pre-test probability of 50%, the post-test probability reached 84% and 17% for the positive and negative tests, respectively.

CONCLUSIONS

PLR-induced change in absolute PPV has good diagnostic performance in predicting preload/fluid responsiveness in ICU patients on mechanical ventilation with low tidal volume. Trial registration PROSPERO (CRD42024496901). Registered on 15 January 2024.

Evaluating the diagnostic accuracy of androgen measurement in polycystic ovary syndrome: a systematic review and diagnostic meta-analysis to inform evidence-based guidelines

BACKGROUND

Biochemical hyperandrogenism is a hallmark and diagnostic feature of polycystic ovary syndrome (PCOS). However, the most accurate androgen measurement for assessing biochemical hyperandrogenism in PCOS diagnosis remains uncertain.

OBJECTIVE AND RATIONALE

This systematic review aimed to assess different androgen measures [including total testosterone (TT), calculated free testosterone (cFT), free androgen index (FAI), androstenedione (A4), dehydroepiandrosterone sulfate (DHEAS), and dihydrotestosterone (DHT)] for accuracy in diagnosing biochemical hyperandrogenism in women with PCOS, to inform the 2023 International PCOS Evidence-based Guidelines.

SEARCH METHODS

To update evidence from the 2018 International PCOS Guidelines, a systematic search from 3 July 2017 to 23 June 2023 was conducted across Medline (Ovid), CINAHL, all EBM, EMBASE, and PsycInfo for articles evaluating androgens in the diagnosis of biochemical hyperandrogenism. The revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the risk of bias and applicability. A diagnostic test accuracy meta-analysis was performed using STATA 18 software. Summary sensitivity and specificity were calculated with 95% CIs using the bivariate model, while the hierarchical summary receiver operating characteristics (ROC) model was used to produce a summary ROC curve.

OUTCOMES

Of 23 studies reviewed, 18 were included in the meta-analysis, with data from 2857 participants (1650 with PCOS and 1207 controls). For diagnosing biochemical hyperandrogenism in PCOS, the pooled sensitivity, specificity, and AUC with 95% CI were for TT: 0.74 (0.63-0.82), 0.86 (0.77-0.91), and 0.87 (0.84-0.90); cFT: 0.89 (0.69-0.96), 0.83 (0.79-0.86), and 0.85 (0.81-0.88); FAI: 0.78 (0.70-0.83), 0.85 (0.76-0.90), and 0.87 (0.84-0.90); A4: 0.75 (0.60-0.86), 0.71 (0.51-0.85), and 0.80 (0.76-0.83); and DHEAS: 0.75 (0.61-0.85), 0.67 (0.48-0.81), and 0.77 (0.73-0.81), respectively. In subgroup analyses, liquid chromatography with tandem mass spectrometry (LC-MS/MS) had superior sensitivity for measuring cFT, FAI, A4, and DHEAS, and superior specificity for measuring TT, cFT, and FAI, compared to the direct immunoassay method.

WIDER IMPLICATIONS

Our results directly informed the 2023 International PCOS Guideline recommendations to use TT and FT as the first-line laboratory tests to assess biochemical hyperandrogenism in the diagnosis of PCOS. cFT should be assessed by equilibrium dialysis or ammonium sulfate precipitation, or calculated using FAI. If TT or cFT are not elevated, A4 and DHEAS could also be considered, noting their poorer specificity. Laboratories should utilize LC-MS/MS for androgen measurement given its high accuracy. Future studies should focus on establishing optimal normative cut-off values in large, unselected, and ethnically diverse cohorts of women.

REGISTRATION NUMBER

The review protocol was prepublished in the 2023 PCOS Guideline Technical Report (https://www.monash.edu/__data/assets/pdf_file/0010/3379591/TechnicalReport-2023.pdf).

Accuracy of cell-free fetal DNA in detecting chromosomal anomalies in women experiencing miscarriage: systematic review and meta-analysis

OBJECTIVE

To report the diagnostic accuracy of cell-free fetal DNA (cfDNA) in detecting fetal chromosomal anomalies in women experiencing miscarriage.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane databases were searched from inception to June 2024. The inclusion criteria were women experiencing miscarriage (defined as pregnancy loss before 20 weeks of gestation) who underwent cfDNA screening for trisomies 21, 18 and 13, other autosomal aneuploidies, sex-chromosome aneuploidies and/or copy-number variants (CNVs). The index test was cfDNA screening for each of the chromosomal anomalies listed. The reference standard was cytogenetic analysis of pregnancy tissue. The quality of the studies was assessed using the revised tool for the quality assessment of diagnostic accuracy studies. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were computed using the hierarchical summary receiver-operating-characteristics model.

RESULTS

Seven studies (887 women) were included in the systematic review and meta-analysis. cfDNA had a sensitivity and specificity of 100% (95% CI, 81.5-100%) and 100% (95% CI, 99.1-100%), respectively, for trisomy 21, 100% (95% CI, 54.1-100%) and 100% (95% CI, 99.0-100%), respectively, for trisomy 18, and 88.9% (95% CI, 51.8-99.7%) and 100% (95% CI, 99.1-100%), respectively, for trisomy 13. The respective values for other autosomal trisomies were 75.8% (95% CI, 65.7-84.2%) and 99.4% (95% CI, 97.9-99.9%), while those for CNVs were 60.0% (95% CI, 14.7-94.7%) and 100% (95% CI, 97.4-100%). Failure of cfDNA testing was reported in 7.3% (95% CI, 5.7-9.2%) of cases.

CONCLUSION

cfDNA has high diagnostic accuracy in detecting fetal trisomies 21, 18 and 13 in women experiencing miscarriage, while its accuracy for other autosomal aneuploidies and CNVs is only moderate. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating the accuracy of a nutritional screening tool for patients with digestive system tumors: A hierarchical Bayesian latent class meta-analysis

BACKGROUND

Cancer, particularly tumors of the digestive system, presents a major global health challenge. The incidence and mortality rates of these cancers are increasing, and many patients face significant nutritional risks, which are often overlooked in clinical practice. This oversight can lead to serious health consequences, underscoring the need for effective nutritional assessment tools to improve clinical outcomes. Although several nutritional risk screening tools exist, their specific utility for patients with gastrointestinal tumors remains unclear. This study aimed to address this gap by systematically evaluating the performance of various nutritional screening tools in this patient population.

METHODS

A systematic search of six databases was conducted to identify studies that met predefined inclusion and exclusion criteria. Diagnostic test metrics such as sensitivity, specificity, and likelihood ratios (positive and negative) were estimated using a hierarchical summary receiver operating characteristic model. This approach was used to compare the accuracy of different nutritional screening scales.

RESULTS

A total of 33 eligible studies were included in this meta-analysis, assessing six nutritional screening tools: the Malnutrition Universal Screening Tool, Malnutrition Screening Tool, Nutritional Risk Screening 2002, Mini Nutritional Assessment-Short Form, Nutritional Risk Index, and Patient-Generated Subjective Global Assessment. Among these, the Patient-Generated Subjective Global Assessment demonstrated the highest performance, with a sensitivity of 0.911 (95% confidence interval: 0.866-0.942) and a specificity of 0.805 (95% confidence interval: 0.674-0.891), outperforming the other screening tools.

CONCLUSIONS

This study confirms the effectiveness of the Patient-Generated Subjective Global Assessment in identifying malnutrition risk among patients with digestive system tumors. However, as this research focused on a Chinese population, future studies should encompass a broader geographic scope and work toward standardized assessment criteria to enhance the global validation and refinement of nutritional screening tools.

Diagnostic performance of biomarkers for differentiating active tuberculosis from latent tuberculosis: a systematic review and Bayesian network meta-analysis

Background

PCR and culture tests are used together to confirm the diagnosis of active tuberculosis (TB). Due to the long culture period, if the PCR test is negative, it takes a significant amount of time for the culture result to be available. Interferon-γ release assays (IGRAs), which are widely used to diagnose TB or latent tuberculosis infection (LTBI), cannot effectively discriminate TB from LTBI. The purpose of this study is to analyze the diagnostic performance of various markers for differentiating between TB from LTBI.

Methods

PubMed-Medline, EMBASE, Cochrane Library, and Web of Science were searched up to the end of May 2024, without restrictions on publication date and population. Articles describing the diagnostic value of at least one biomarker for differentiating between TB and LTBI were included. The QUADAS-2 tool was used to assess study quality. Two independent researchers assessed the articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The network meta-analysis (NMA) was performed for diagnostic tools of 11 groups used to differentiate TB from LTBI.

Results

Out of 164 identified articles, 159 reports were included in the systematic review and 58 in the meta-analysis. Seventy results from 58 reports accounting for 9,291 participants were included. When measuring interleukin-2 (IL-2) after stimulation with latency antigen, the most significant odds ratio was shown in terms of sensitivity, specificity, positive predictive value and negative predictive value. The values were 9.46, 18.5, 11.30, and 9.61, respectively.

Conclusion

This study shows that the IL-2 level after stimulation with latent antigen is a potential biomarker for differentiating TB from LTBI.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024542996.

Diagnostic efficacy of aldosterone-to-renin ratio to screen primary aldosteronism in hypertension: a systemic review and meta-analysis

Background

The aldosterone-to-renin ratio (ARR) is commonly used for screening primary aldosteronism (PA) in patients with difficult-to-control hypertension. Various thresholds have been proposed for the confirmatory tests, leading to inconsistency in the results.

Objectives

This study aimed to elucidate the performance of ARR screening in hypertensive patients.

Design

Systemic review and meta-analysis.

Data sources and methods

PubMed, Embase, and the Cochrane Library were systematically searched from inception to January 2024. Studies that used the ARR to screen for PA and provided a comprehensive probability panel specifically focusing on hypertensive individuals were considered for enrollment. Pooled diagnostic efficacy was evaluated, and subgroup analyses and meta-regression were conducted based on different demographic and clinical parameters.

Results

Eighteen observational studies encompassing 7150 participants were included in the meta-analysis. The overall prevalence of PA in the hypertensive cohort was 15.2%, and pooled sensitivity and specificity were 81.6% and 93.3%, respectively, resulting in a diagnostic odds ratio of 62.0. Fagan's nomogram showed that a positive ARR increased the post-test probability to 80% from a pre-test probability of 25%. Summary receiver operating characteristic curve analysis revealed an area under the curve of 94.7%. Notably, analysis of variability demonstrated that the diagnostic performance was consistent across either ARR based on plasma renin activity or direct renin concentration, geographic region, sex, mean age, potassium level, and systolic blood pressure.

Conclusion

ARR was validated as a viable screening methodology for PA in hypertensive individuals. Moreover, its diagnostic efficacy remained unchanged across diverse clinical contexts. Future studies are warranted to refine ARR methodologies and enhance diagnostic accuracy.

Trial registration

PROSPERO ID number CRD42023493680.

Infographics

Performance of PA screening by ARR. ARR, aldosterone-to-renin ratio; BP, blood pressure; DRC, direct renin concentration; hsROC, hierarchical summary receiver operating characteristic; PA, primary aldosteronism; PRA, plasma renin activity.

The American Society for Microbiology collaboration with the CDC Laboratory Medicine Best Practices initiative for evidence-based laboratory medicine

SUMMARYClinical medicine has embraced the use of evidence for patient treatment decisions; however, the evaluation strategy for evidence in laboratory medicine practices has lagged. It was not until the end of the 20th century that the Institute of Medicine (IOM), now the National Academy of Medicine, and the Centers for Disease Control and Prevention, Division of Laboratory Systems (CDC DLS), focused on laboratory tests and how testing processes can be designed to benefit patient care. In collaboration with CDC DLS, the American Society for Microbiology (ASM) used an evidence review method developed by the CDC DLS to develop a program for creating laboratory testing guidelines and practices. The CDC DLS method is called the Laboratory Medicine Best Practices (LMBP) initiative and uses the A-6 cycle method. Adaptations made by ASM are called Evidence-based Laboratory Medicine Practice Guidelines (EBLMPG). This review details how the ASM Systematic Review (SR) Processes were developed and executed collaboratively with CDC's DLS. The review also describes the ASM transition from LMBP to the organization's current EBLMPG, maintaining a commitment to working with agencies in the U.S. Department of Health and Human Services and other partners to ensure that EBLMPG evidence is readily understood and consistently used.

Diagnostic performance of artificial intelligence-aided caries detection on bitewing radiographs: a systematic review and meta-analysis

The accuracy of artificial intelligence-aided (AI) caries diagnosis can vary considerably depending on numerous factors. This review aimed to assess the diagnostic accuracy of AI models for caries detection and classification on bitewing radiographs. Publications after 2010 were screened in five databases. A customized risk of bias (RoB) assessment tool was developed and applied to the 14 articles that met the inclusion criteria out of 935 references. Dataset sizes ranged from 112 to 3686 radiographs. While 86 % of the studies reported a model with an accuracy of ≥80 %, most exhibited unclear or high risk of bias. Three studies compared the model's diagnostic performance to dentists, in which the models consistently showed higher average sensitivity. Five studies were included in a bivariate diagnostic random-effects meta-analysis for overall caries detection. The diagnostic odds ratio was 55.8 (95 % CI= 28.8 - 108.3), and the summary sensitivity and specificity were 0.87 (0.76 - 0.94) and 0.89 (0.75 - 0.960), respectively. Independent meta-analyses for dentin and enamel caries detection were conducted and showed sensitivities of 0.84 (0.80 - 0.87) and 0.71 (0.66 - 0.75), respectively. Despite the promising diagnostic performance of AI models, the lack of high-quality, adequately reported, and externally validated studies highlight current challenges and future research needs.

Accuracy of brain natriuretic peptide and N-terminal brain natriuretic peptide for detecting paediatric pulmonary hypertension: a systematic review and meta-analysis

OBJECTIVE

Pulmonary hypertension (PH) is a life-threatening disease, especially in paediatric population. Symptoms of paediatric PH are non-specific. Accurate detection of paediatric PH is helpful for early treatment and mortality reduction. Therefore, we assessed the overall performance of brain natriuretic peptide (BNP) and N-terminal brain natriuretic peptide (NT-proBNP) for diagnosing PH in paediatric population.

METHODS

PubMed, Web of Science, Cochrane Library and Embase databases were screened since their respective inceptions until August 2023. A bivariate random model and a hierarchical summary receiver operating characteristic model were used together to evaluate and summarize the overall performance of BNP and NT-proBNP for diagnosing paediatric PH.

RESULTS

Eighteen studies using BNP/NT-proBNP were assessed, comprising 1127 samples. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the curve (AUROC) of BNP/NT-proBNP were separately as 0.81, 0.87, 6.33, 0.21, 29.50 and 0.91, suggesting a good diagnostic performance of BNP/NT-proBNP for detecting PH in paediatric population. For BNP, the pooled sensitivity, specificity, PLR, NLR, DOR and AUROC were 0.83, 0.89, 7.76, 0.19, 40.90 and 0.93, indicating the diagnostic accuracy of BNP for paediatric PH patients was good. For NT-proBNP, the pooled sensitivity, specificity, PLR, NLR, DOR and AUROC were 0.81, 0.86, 5.59, 0.22, 24.96 and 0.90, showing that NT-proBNP could provide a good value for detecting paediatric PH.

CONCLUSIONS

Both BNP and NT-proBNP are good markers for differentiating paediatric PH patients from non-PH individuals.

Diagnostic accuracy of artificial intelligence for approximal caries on bitewing radiographs: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to investigate the diagnostic accuracy of Artificial Intelligence (AI) for approximal carious lesions on bitewing radiographs.

METHODS

This study included randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) reporting on the diagnostic accuracy of AI for approximal carious lesions on bitewing radiographs. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. A systematic search was conducted on November 4, 2023, in PubMed, Cochrane, and Embase databases and an updated search was performed on August 28, 2024. The primary outcomes assessed were sensitivity, specificity, and overall accuracy. Sensitivity and specificity were pooled using a bivariate model.

RESULTS

Of the 2,442 studies identified, 21 met the inclusion criteria. The pooled sensitivity and specificity of AI were 0.94 (confidence interval (CI): ± 0.78-0.99) and 0.91 (CI: ± 0.84-0.95), respectively. The positive predictive value (PPV) ranged from 0.15 to 0.87, indicating a moderate capacity for identifying true positives among decayed teeth. The negative predictive value (NPV) ranged from 0.79 to 1.00, demonstrating a high ability to exclude healthy teeth. The diagnostic odds ratio was high, indicating strong overall diagnostic performance.

CONCLUSIONS

AI models demonstrate clinically acceptable diagnostic accuracy for approximal caries on bitewing radiographs. Although AI can be valuable for preliminary screening, positive findings should be verified by dental experts to prevent unnecessary treatments and ensure timely diagnosis. AI models are highly reliable in excluding healthy approximal surfaces.

CLINICAL SIGNIFICANCE

AI can assist dentists in detecting approximal caries on bitewing radiographs. However, expert supervision is required to prevent iatrogenic damage and ensure timely diagnosis.

Overall Accuracy of the Modified Duke Criteria-A Systematic Review and Meta-analysis

BACKGROUND

 Rapid and accurate diagnosis of infective endocarditis (IE) allows timely management of this life-threatening disease and improves outcome. The Duke criteria have traditionally been the clinical method for diagnosing IE. These criteria were reformulated at different timepoints. We aimed to evaluate the real accuracy of the modified Duke criteria based on several studies that concluded the diagnosis of IE.

METHODS

 Three databases were assessed. Studies were considered for inclusion if they reported the use of modified Duke criteria as the initial approach and the confirmation of the diagnosis with the gold standard methods. The meta-analysis of diagnostic test accuracy was performed after fitting the hierarchical summary receiver operating characteristic model (HSROC) with bivariate model and displaying the summarized measures of sensitivity and specificity, and positive and negative likelihood ratios.

RESULTS

 A total of 11 studies were included. Accuracy in the included studies ranged from 62.3 to 92.2%, sensitivity ranged from 58.3 to 84.0%, and specificity ranged from 50.0 to 100%. The combined overall sensitivity and specificity were 85% (95% CI: 0.77-0.90) and 98% (95% CI: 0.89-0.99), respectively. The positive likelihood ratio was 40.2 (95% CI: 7.26-220.74) and the negative likelihood ratio was 0.15 (95% CI: 0.01-0.23).

CONCLUSION

 The analysis reveals that the modified Duke criteria have a high positive likelihood ratio, suggesting a robust correlation between a positive test result and the existence of IE, and a very good overall specificity at 98%. The latter aspect holds significant importance in order to prevent unnecessary overtreatment, given the intricacies involved in managing IE.

Serum and urine nucleic acid screening tests for BK polyomavirus-associated nephropathy in kidney and kidney-pancreas transplant recipients

BACKGROUND

BK polyomavirus-associated nephropathy (BKPyVAN) occurs when BK polyomavirus (BKPyV) affects a transplanted kidney, leading to an initial injury characterised by cytopathic damage, inflammation, and fibrosis. BKPyVAN may cause permanent loss of graft function and premature graft loss. Early detection gives clinicians an opportunity to intervene by timely reduction in immunosuppression to reduce adverse graft outcomes. Quantitative nucleic acid testing (QNAT) for detection of BKPyV DNA in blood and urine is increasingly used as a screening test as diagnosis of BKPyVAN by kidney biopsy is invasive and associated with procedural risks. In this review, we assessed the sensitivity and specificity of QNAT tests in patients with BKPyVAN.

OBJECTIVES

We assessed the diagnostic test accuracy of blood/plasma/serum BKPyV QNAT and urine BKPyV QNAT for the diagnosis of BKPyVAN after transplantation. We also investigated the following sources of heterogeneity: types and quality of studies, era of publication, various thresholds of BKPyV-DNAemia/BKPyV viruria and variability between assays as secondary objectives.

SEARCH METHODS

We searched MEDLINE (OvidSP), EMBASE (OvidSP), and BIOSIS, and requested a search of the Cochrane Register of diagnostic test accuracy studies from inception to 13 June 2023. We also searched ClinicalTrials.com and the WHO International Clinical Trials Registry Platform for ongoing trials.

SELECTION CRITERIA

We included cross-sectional or cohort studies assessing the diagnostic accuracy of two index tests (blood/plasma/serum BKPyV QNAT or urine BKPyV QNAT) for the diagnosis of BKPyVAN, as verified by the reference standard (histopathology). Both retrospective and prospective cohort studies were included. We did not include case reports and case control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out data extraction from each study. We assessed the methodological quality of the included studies by using Quality Assessment of Diagnostic-Accuracy Studies (QUADAS-2) assessment criteria. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity for the QNAT test with one positivity threshold. In cases where meta-analyses were not possible due to the small number of studies available, we detailed the descriptive evidence and used a summative approach. We explored possible sources of heterogeneity by adding covariates to meta-regression models.

MAIN RESULTS

We included 31 relevant studies with a total of 6559 participants in this review. Twenty-six studies included kidney transplant recipients, four studies included kidney and kidney-pancreas transplant recipients, and one study included kidney, kidney-pancreas and kidney-liver transplant recipients. Studies were carried out in South Asia and the Asia-Pacific region (12 studies), North America (9 studies), Europe (8 studies), and South America (2 studies).

INDEX TEST

blood/serum/plasma BKPyV QNAT The diagnostic performance of blood BKPyV QNAT using a common viral load threshold of 10,000 copies/mL was reported in 18 studies (3434 participants). Summary estimates at 10,000 copies/mL as a cut-off indicated that the pooled sensitivity was 0.86 (95% confidence interval (CI) 0.78 to 0.93) while the pooled specificity was 0.95 (95% CI 0.91 to 0.97). A limited number of studies were available to analyse the summary estimates for individual viral load thresholds other than 10,000 copies/mL. Indirect comparison of thresholds of the three different cut-off values of 1000 copies/mL (9 studies), 5000 copies/mL (6 studies), and 10,000 copies/mL (18 studies), the higher cut-off value at 10,000 copies/mL corresponded to higher specificity with lower sensitivity. The summary estimates of indirect comparison of thresholds above 10,000 copies/mL were uncertain, primarily due to a limited number of studies with wide CIs contributed to the analysis. Nonetheless, these indirect comparisons should be interpreted cautiously since differences in study design, patient populations, and methodological variations among the included studies can introduce biases. Analysis of all blood BKPyV QNAT studies, including various blood viral load thresholds (30 studies, 5658 participants, 7 thresholds), indicated that test performance remains robust, pooled sensitivity 0.90 (95% CI 0.85 to 0.94) and specificity 0.93 (95% CI 0.91 to 0.95). In the multiple cut-off model, including the various thresholds generating a single curve, the optimal cut-off was around 2000 copies/mL, sensitivity of 0.89 (95% CI 0.66 to 0.97) and specificity of 0.88 (95% CI 0.80 to 0.93). However, as most of the included studies were retrospective, and not all participants underwent the reference standard tests, this may result in a high risk of selection and verification bias.

INDEX TEST

urine BKPyV QNAT There was insufficient data to thoroughly investigate both accuracy and thresholds of urine BKPyV QNAT resulting in an imprecise estimation of its accuracy based on the available evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence to suggest the use of urine BKPyV QNAT as the primary screening tool for BKPyVAN. The summary estimates of the test sensitivity and specificity of blood/serum/plasma BKPyV QNAT test at a threshold of 10,000 copies/mL for BKPyVAN were 0.86 (95% CI 0.78 to 0.93) and 0.95 (95% CI 0.91 to 0.97), respectively. The multiple cut-off model showed that the optimal cut-off was around 2000 copies/mL, with test sensitivity of 0.89 (95% CI 0.66 to 0.97) and specificity of 0.88 (95% CI 0.80 to 0.93). While 10,000 copies/mL is the most commonly used cut-off, with good test performance characteristics and supports the current recommendations, it is important to interpret the results with caution because of low-certainty evidence.

The Diagnostic Accuracy and Cutoff Value of Phase Angle for Screening Sarcopenia: A Systematic Review and Meta-Analysis

OBJECTIVES

Phase angle (PhA) declines with age and is a reliable marker for muscle function, making it a potential screening indicator for sarcopenia. However, studies examined the reliability and validity of PhA for detecting sarcopenia, yielding inconsistent results. This meta-analysis aimed to evaluate the accuracy and cutoff value of PhA for screening sarcopenia and examine the potential confounding factors.

DESIGN

This is a meta-analysis.

SETTING AND PARTICIPANTS

PubMed, Embase, and Cochrane Library were searched up to September 18, 2023. Eighteen studies (6184 participants) were included reporting the diagnostic accuracy of PhA for screening sarcopenia.

METHODS

Pooled accuracy [ie, the computed area under the curve value (AUC)] and cutoff value interval for screening sarcopenia were estimated using a random-effects model. Meta-regression analyses were conducted to identify sources of heterogeneity.

RESULTS

The AUC value was 0.81. Pooled sensitivity and specificity were 80% and 70%. The calculated 95% CI of the cutoff value of PhA for screening sarcopenia falls between 4.54° and 5.25°. The results of meta-regression analyses showed that ethnicity, body mass index (BMI), health status, and diagnostic criteria were the main factors affecting the diagnostic accuracy for screening sarcopenia (with all P values < 0.01).

CONCLUSION AND IMPLICATIONS

PhA may serve as a robust screening tool for sarcopenia, and the recommended cutoff interval falls between 4.54° and 5.25°. Ethnicity, BMI, health status, and diagnostic criteria can affect PhA's efficacy in sarcopenia screening.

A discrete time-to-event model for the meta-analysis of full ROC curves

The development of new statistical models for the meta-analysis of diagnostic test accuracy studies is still an ongoing field of research, especially with respect to summary receiver operating characteristic (ROC) curves. In the recently published updated version of the "Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy", the authors point to the challenges of this kind of meta-analysis and propose two approaches. However, both of them come with some disadvantages, such as the nonstraightforward choice of priors in Bayesian models or the requirement of a two-step approach where parameters are estimated for the individual studies, followed by summarizing the results. As an alternative, we propose a novel model by applying methods from time-to-event analysis. To this task we use the discrete proportional hazard approach to treat the different diagnostic thresholds, that provide means to estimate sensitivity and specificity and are reported by the single studies, as categorical variables in a generalized linear mixed model, using both the logit- and the asymmetric cloglog-link. This leads to a model specification with threshold-specific discrete hazards, avoiding a linear dependency between thresholds, discrete hazard, and sensitivity/specificity and thus increasing model flexibility. We compare the resulting models to approaches from the literature in a simulation study. While the estimated area under the summary ROC curve is estimated comparably well in most approaches, the results depict substantial differences in the estimated sensitivities and specificities. We also show the practical applicability of the models to data from a meta-analysis for the screening of type 2 diabetes.

Non-invasive prediction of human embryonic ploidy using artificial intelligence: a systematic review and meta-analysis

Background

Embryonic ploidy is critical for the success of embryo transfer. Currently, preimplantation genetic testing for aneuploidy (PGT-A) is the gold standard for detecting ploidy abnormalities. However, PGT-A has several inherent limitations, including invasive biopsy, high economic burden, and ethical constraints. This paper provides the first comprehensive systematic review and meta-analysis of the performance of artificial intelligence (AI) algorithms using embryonic images for non-invasive prediction of embryonic ploidy.

Methods

Comprehensive searches of studies that developed or utilized AI algorithms to predict embryonic ploidy from embryonic imaging, published up until August 10, 2024, across PubMed, MEDLINE, Embase, IEEE, SCOPUS, Web of Science, and the Cochrane Central Register of Controlled Trials were performed. Studies with prospective or retrospective designs were included without language restrictions. The summary receiver operating characteristic curve, along with pooled sensitivity and specificity, was estimated using a bivariate random-effects model. The risk of bias and study quality were evaluated using the QUADAS-AI tool. Heterogeneity was quantified using the inconsistency index (I 2 ), derived from Cochran's Q test. Predefined subgroup analyses and bivariate meta-regression were conducted to explore potential sources of heterogeneity. This study was registered with PROSPERO (CRD42024500409).

Findings

Twenty eligible studies were identified, with twelve studies included in the meta-analysis. The pooled sensitivity, specificity, and area under the curve of AI for predicting embryonic euploidy were 0.71 (95% CI: 0.59-0.81), 0.75 (95% CI: 0.69-0.80), and 0.80 (95% CI: 0.76-0.83), respectively, based on a total of 6879 embryos (3110 euploid and 3769 aneuploid). Meta-regression and subgroup analyses identified the type of AI-driven decision support system, external validation, risk of bias, and year of publication as the primary contributors to the observed heterogeneity. There was no evidence of publication bias.

Interpretation

Our findings indicate that AI algorithms exhibit promising performance in predicting embryonic euploidy based on embryonic imaging. Although the current AI models developed cannot entirely replace invasive methods for determining embryo ploidy, AI demonstrates promise as an auxiliary decision-making tool for embryo selection, particularly for individuals who are unable to undergo PGT-A. To enhance the quality of future research, it is essential to overcome the specific challenges and limitations associated with AI studies in reproductive medicine.

Funding

This work was supported by the National Key R&D Program of China (2022YFC2702905), the Shengjing Freelance Researcher Plan of Shengjing Hospital and the 345 talent project of Shengjing Hospital.

Toe-brachial index and toe systolic blood pressure for the diagnosis of peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) of the lower limbs is caused by atherosclerotic occlusive disease in which narrowing of arteries reduces blood flow to the lower limbs. PAD is common; it is estimated to affect 236 million individuals worldwide. Advanced age, smoking, hypertension, diabetes and concomitant cardiovascular disease are common factors associated with increased risk of PAD. Complications of PAD can include claudication pain, rest pain, wounds, gangrene, amputation and increased cardiovascular morbidity and mortality. It is therefore clinically important to use diagnostic tests that accurately identify PAD. Accurate and timely detection of PAD allows clinicians to implement appropriate risk management strategies to prevent complications, slow progression or intervene when indicated. Toe-brachial index (TBI) and toe systolic blood pressure (TSBP) are amongst a suite of non-invasive bedside tests used to detect PAD. Both TBI and TSBP are commonly utilised by a variety of clinicians in different settings, therefore a systematic review and meta-analysis of their diagnostic accuracy is warranted and highly relevant to inform clinical practice.

OBJECTIVES

To (1) estimate the accuracy of TSBP and TBI for the diagnosis of PAD in the lower extremities at different cut-off values for test positivity in populations at risk of PAD, and (2) compare the accuracy of TBI and TSBP for the diagnosis of PAD in the lower extremities. Secondary objectives were to investigate several possible sources of heterogeneity in test accuracy, including the following: patient group tested (people with type 1 or type 2 diabetes, people with renal disease and general population), type of equipment used, positivity threshold and type of reference standard.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the MEDLINE, Embase, CINAHL, Web of Science, LILACS, Zetoc and DARE databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 27 February 2024.

SELECTION CRITERIA

We included diagnostic case-control, cross-sectional, prospective and retrospective studies in which all participants had either a TSBP or TBI measurement plus a validated method of vascular diagnostic imaging for PAD. We needed to be able to cross-tabulate (2 x 2 table) results of the index test and the reference standard to include a study. To be included, study populations had to be adults aged 18 years and over. We included studies of symptomatic and asymptomatic participants. Studies had to use TSBP and TBI (also called toe-brachial pressure index (TBPI)), either individually, or in addition to other non-invasive tests as index tests to diagnose PAD in individuals with suspected disease. We included data collected by photoplethysmography, laser Doppler, continuous wave Doppler, sphygmomanometers (both manual and aneroid) and manual or automated digital equipment.

DATA COLLECTION AND ANALYSIS

Two review authors independently completed data extraction using a standardised form. We extracted data to populate 2 x 2 contingency tables when available (true positives, true negatives, false positives, false negatives). Where data were not available to enable statistical analysis, we contacted study authors directly. Two review authors working independently undertook quality assessment using QUADAS-2, with disagreements resolved by a third review author. We incorporated two additional questions into the quality appraisal to aid our understanding of the conduct of studies and make appropriate judgements about risk of bias and applicability.

MAIN RESULTS

Eighteen studies met the inclusion criteria; 13 evaluated TBI only, one evaluated TSBP only and four evaluated both TBI and TSBP. Thirteen of the studies used colour duplex ultrasound (CDU) as a reference standard, two used computed tomography angiography (CTA), one used multi-detector row tomography (MDCT), one used angiography and one used a combination of CDU, CTA and angiography. TBI was investigated in 1927 participants and 2550 limbs. TSBP was investigated in 701 participants, of which 701 limbs had TSBP measured. Studies were generally of low methodological quality, with poor reporting of participant recruitment in regard to consecutive or random sampling, and poor reporting of blinding between index test and reference standard, as well as timing between index test and reference standard. The certainty of evidence according to GRADE for most studies was very low.

AUTHORS' CONCLUSIONS

Whilst a small number of diagnostic test accuracy studies have been completed for TBI and TSBP to identify PAD, the overall methodological quality was low, with most studies providing a very low certainty of evidence. The evidence base to support the use of TBI and TSBP to identify PAD is therefore limited. Whilst both TBI and TSBP are used extensively clinically, the overall diagnostic performance of these tests remains uncertain. Future research using robust methods and clear reporting is warranted to comprehensively determine the diagnostic test accuracy of the TBI and TSBP for identification of PAD with greater certainty. However, conducting such research where some of the reference tests are invasive and only clinically indicated in populations with known PAD is challenging.

A systematic review and meta-analysis of diagnostic test accuracy of chest ultrasound in diagnosing pediatric pulmonary tuberculosis

INTRODUCTION

Despite medical advancement, pediatric pulmonary tuberculosis (PTB) still has high morbidity and mortality, due to challenging detection in clinical practice. Ultrasound has been touted as the next best diagnostic tool but currently, this claim is unfounded. Therefore, this study aims to systematically review the diagnostic parameters of chest ultrasound in diagnosing pediatric PTB.

METHODS

The literature search started and ended on December 23, 2023. We searched MEDLINE, Cochrane Library, Pubmed, Science Direct, and Google Scholar. Our research question could be formulated as "In pediatric patients who present with signs and symptoms of PTB such as fever, cough, and poor weight gain, how accurate is chest ultrasound in ruling in and ruling out pediatric PTB when the diagnosis is compared to culture, PCR or CXR?" This systematic review adhered to the PRISMA-DTA guidelines while the meta-analysis was conducted with STATA program using the "midas" and "metandi" commands.

RESULTS

There are five studies included with 137 positive PTB children. The combined sensitivity is 84% (95% confidence interval [CI]: 76-89), specificity of 38% (95% CI: 24-54), and summary receiver operating curve yields an area under the curve of 0.83 (95% CI: 0.80-0.86). The I2 value is 24% (95% CI: 0-100) with a p-value of 0.13. The combined negative predictive value is 0.68 (95% CI: 0.58-0.79), and the positive predictive value is 0.57 (95% CI: 0.51-0.63). The positive likelihood ratio is 1 with a 6% increase from the baseline while the negative likelihood ratio is 0.43 with a 12% decrease from the baseline.

CONCLUSION

Chest ultrasound is sensitive but currently could neither exclude nor confirm pediatric PTB.

Joint meta-analysis of two diagnostic tests accounting for within and between studies dependence

There is an extensive literature on methods for meta-analysis of diagnostic test accuracy, but it mainly focuses on a single test. A multinomial generalised linear mixed model was recently proposed for the joint meta-analysis of studies comparing two tests on the same participants in a paired tests design with a gold standard. In this setting, we propose a novel model for joint meta-analysis of studies comparing two diagnostic tests which assumes independent multinomial distributions for the counts of each combination of test results in diseased and non-diseased patients, conditional on the latent vector of probabilities of each combination of test results in diseased and non-diseased patients. For the random effects distribution of the latent proportions, we employ a one-truncated D-vine copula that can provide tail dependence or asymmetry. The proposed model includes the multinomial generalised linear mixed model as a special case, accounts for the within-study dependence induced because the tests are applied to the same participants, allows for between-studies dependence, and can also operate on the original scale of the latent proportions. The latter enables the derivation of summary receiver operating characteristic curves. Our methodology is demonstrated with simulation studies and a meta-analysis of screening for Down's syndrome with two tests: shortened humerus and shortened femur.

Meta-Analysis of Diagnostic Accuracy Studies With Multiple Thresholds: Comparison of Approaches in a Simulation Study

The development of methods for the meta-analysis of diagnostic test accuracy (DTA) studies is still an active area of research. While methods for the standard case where each study reports a single pair of sensitivity and specificity are nearly routinely applied nowadays, methods to meta-analyze receiver operating characteristic (ROC) curves are not widely used. This situation is more complex, as each primary DTA study may report on several pairs of sensitivity and specificity, each corresponding to a different threshold. In a case study published earlier, we applied a number of methods for meta-analyzing DTA studies with multiple thresholds to a real-world data example (Zapf et al., Biometrical Journal. 2021; 63(4): 699-711). To date, no simulation study exists that systematically compares different approaches with respect to their performance in various scenarios when the truth is known. In this article, we aim to fill this gap and present the results of a simulation study that compares three frequentist approaches for the meta-analysis of ROC curves. We performed a systematic simulation study, motivated by an example from medical research. In the simulations, all three approaches worked partially well. The approach by Hoyer and colleagues was slightly superior in most scenarios and is recommended in practice.

Diagnostic accuracy of carotid plaque instability by noninvasive imaging: a systematic review and meta-analysis

AIMS

There is increasing evidence that plaque instability in the extracranial carotid artery may lead to an increased stroke risk independently of the degree of stenosis. We aimed to determine diagnostic accuracy of vulnerable and stable plaque using noninvasive imaging modalities when compared to histology in patients with symptomatic and asymptomatic carotid atherosclerosis.

METHODS AND RESULTS

Medline Ovid, Embase, Cochrane Library, and Web of Science were searched for diagnostic accuracy of noninvasive imaging modalities (CT, MRI, US) in the detection of 1) vulnerable/stable plaque, and 2) vulnerable/stable plaque characteristics, compared to histology. The quality of included studies was assessed by QUADAS-2 and univariate and bivariate random-effect meta-analyses were performed. We included 36 vulnerable and 5 stable plaque studies in the meta-analysis, and out of 211 plaque characteristics from remaining studies, we classified 169 as vulnerable and 42 as stable characteristics (28 CT, 120 MRI, 104 US characteristics). We found that MRI had high accuracy [90% (95% CI: 82-95%)] in the detection of vulnerable plaque, similar to CT [86% (95% CI: 76-92%); P > 0.05], whereas US showed less accuracy [80% (95% CI: 75-84%); P = 0.013]. CT showed high diagnostic accuracy in visualizing characteristics of vulnerable or stable plaques (89% and 90%) similar to MRI (86% and 89%; P > 0.05); however, US had lower accuracy (77%, P < 0.001 and 82%, P > 0.05).

CONCLUSION

CT and MRI have a similar, high performance in detecting vulnerable carotid plaques, whereas US showed significantly less diagnostic accuracy. Moreover, MRI visualized all vulnerable plaque characteristics allowing for a better stroke risk assessment.

REGISTRATION

PROSPERO ID CRD42022329690.

Discriminant diagnostic validity of paediatric bipolar disorder screening tests: A systematic review and meta-analysis

INTRODUCTION

Bipolar disorders (BD) are among the most significantly impairing of childhood and adolescent psychiatric disorders. Although BD symptoms may begin in adolescence, they are frequently not diagnosed until adulthood, and accordingly BD scales could aid diagnostic assessment in paediatric populations. This review aims to synthesis the evidence for the accuracy of BD symptom index tests for discriminating BD from non-BD (other diagnoses or healthy controls) in paediatric population. Additionally, several theoretically relevant moderators of diagnostic accuracy were evaluated.

METHODS

A systematic search across three databases were conducted from 1980 to 2022, augmented by grey literature database searches, citation chaining and contacting authors. Data from eligible studies were synthesized using meta-analysis. A multilevel model was fitted to account for nested effect sizes, with 31 potential moderators examined in univariate and multivariate models.

RESULTS

Twenty-Eight studies were eligible, yielding 115 effect sizes for analysis. Meta-analytic modelling indicated BD symptom index tests have a high diagnostic accuracy (g = 1.300; 95% CI: 0.982 - 1.619; p < .001) in paediatric population. Accuracy was relative to the type of comparison group, index test content, index test informant and index test's scale or subscale.

CONCLUSIONS

Screening tests based on mania content, caregiver report and non-healthy comparison groups have clinical utility in identifying paediatric BD. Other informant-and-content combination may not accurately identify paediatric BD. Unlike healthy controls, tests derived from studies using non-healthy comparison groups, represent BD symptom non-specificity and BD symptom overlap with other disorders, providing external validity and clinical utility.

Meta-Analysis of the Efficacy of Raman Spectroscopy and Machine-Learning-Based Identification of Glioma Tissue

Intraoperative Raman spectroscopy (RS) has been identified as a potential tool for surgeons to rapidly and noninvasively differentiate between diseased and normal tissue. Since the previous meta-analysis on the subject was published in 2016, improvements in both spectroscopy equipment and machine learning models used to process spectra may have led to an increase in RS efficacy. Therefore, we decided to conduct a meta-analysis to determine the efficacy of RS when differentiating between glioma tissue and normal brain tissue. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed while conducting this meta-analysis. A search was conducted on PubMed and Web of Science for prospective and retrospective studies published between 2016 and 2022 using intraoperative RS and standard histology methods to differentiate between glioma and normal brain tissue. Meta-analyses of log odds ratios, sensitivity, and specificity were conducted in JASP using the random-effects model with restricted maximum likelihood estimation. A total of 9 studies met our inclusion criteria, comprising 673 patients and 8319 Raman spectra. Meta-analysis of log diagnostic odds ratios revealed high heterogeneity (I2 = 79.83%) and yielded a back-transformed diagnostic odds ratio of 76.71 (95% confidence interval: 39.57-148.71). Finally, meta-analysis for sensitivity and specificity of RS for glioma tissue showed high heterogeneity (I2 = 99.37% and 98.21%, respectively) and yielded an overall sensitivity of 95.3% (95% confidence interval: 91.0%-99.6%) and an overall specificity of 71.2% (95% confidence interval: 54.8%-87.6%). Calculation of a summary receiver operating curve yielded an overall area under the curve of 0.9265. Raman spectroscopy represents a promising tool for surgeons to quickly and accurately differentiate between healthy brain tissue and glioma tissue.

Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis

IMPORTANCE

Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes.

OBJECTIVE

To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients.

REGISTRATION

The protocol was registered at PROSPERO: CRD42019146781.

INFORMATION SOURCES AND SEARCH

PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023.

STUDY SELECTION AND DATA COLLECTION

Prospective and intervention studies were selected.

STATISTICAL ANALYSIS

Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed.

RESULTS

A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89).

CONCLUSIONS

Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.

FDG PET-CT for the Detection of Occult Nodal Metastases in Head and Neck Cancer: A Systematic Review and Meta-Analysis

Because of an estimated 20-30% prevalence of occult lymph node (LN) metastases in patients with head and neck squamous cell carcinoma (HNSCC), neck dissection is often proposed, despite its potential morbidity. In this systematic review and meta-analysis, the diagnostic performance of FDG PET-CT in detecting occult LN metastases was evaluated in patients with clinically negative necks (cN0) and in whom histopathology of a neck dissection specimen served as gold standard. Overall, 16 studies out of 2062 screened on PubMed and EMBASE fulfilled the inclusion criteria (n = 1148 patients). Seven of these sixteen studies were split into two or three studies because they contained data that could be processed distinctly in our meta-analysis. For this reason, a total of 25 studies were identified and included in the analysis (n total = 1918 patients). The overall prevalence of metastatic nodes per patient was 22.67%. The pooled sensitivity, specificity, diagnostic odds ratios, and negative predictive value (NPV) were 0.71 (95%CI: 0.66-0.75), 0.90 (95%CI: 0.84-0.93), 20.03 (95%CI: 13.51-29.70), and 0.92 (95%CI: 0.89-0.95), respectively. The main causes of inter-study heterogeneity included different reference standards (evaluation per patient, per neck side, or per neck level). The current meta-analysis showed that FDG PET-CT has a high specificity and NPV for ruling out nodal involvement in cN0 necks, but a limited sensitivity.

Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis

PURPOSE

This meta-analysis aimed to evaluate the performance of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and the Geriatric Trauma Outcome Score (GTOS) in predicting mortality in geriatric trauma patients.

METHODS

The MEDLINE, Web of Science, and EMBASE databases were searched for studies published from January 2008 to October 2023. Studies assessing the performance of the ISS, TRISS, or GTOS in predicting mortality in geriatric trauma patients (over 60 years old) and reporting data for the analysis of the pooled area under the receiver operating characteristic curve (AUROC) and the hierarchical summary receiver operating characteristic curve (HSROC) were included. Studies that were not conducted in a group of geriatric patients, did not consider mortality as the outcome variable, or had incomplete data were excluded. The Critical Appraisal Skills Programme (CASP) Clinical Prediction Rule Checklist was utilized to assess the risk of bias in included studies. STATA 16.0. was used for the AUROC analysis and HSROC analysis.

RESULTS

Nineteen studies involving 118,761 geriatric trauma patients were included. The pooled AUROC of the TRISS (AUC = 0.82, 95% CI: 0.77-0.87) was higher than ISS (AUC = 0.74, 95% CI: 0.71-0.79) and GTOS (AUC = 0.80, 95%CI: 0.77-0.83). The diagnostic odds ratio (DOR) calculated from HSROC curves also suggested that the TRISS (DOR = 21.5) had a better performance in predicting mortality in geriatric trauma patients than the ISS (DOR = 6.27) and GTOS (DOR = 4.76).

CONCLUSION

This meta-analysis suggested that the TRISS showed better accuracy and performance in predicting mortality in geriatric trauma patients than the ISS and GTOS.

Inferior vena cava ultrasound to predict hypotension after general anesthesia induction: a systematic review and meta-analysis of observational studies

PURPOSE

Hypotension after induction of general anesthesia is common and is associated with significant adverse events. Identification of patients at high risk can inform the use of preoperative mitigation strategies. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CI) and maximal diameter (dIVCmax) in predicting postinduction hypotension and to identify their predictive performance across different threshold ranges.

METHODS

We searched MEDLINE, PubMed®, and Embase from inception to March 2023 for prospective observational studies exploring the performance of IVC-CI and dIVCmax in predicting postinduction hypotension in adults presenting for elective surgery under general anesthesia. We excluded studies reporting on IVC parameters predicting postinduction hypotension in the obstetric patient population or exclusively in patients with obesity. Trials screening and data extraction were conducted independently. We performed meta-analyses to identify the performance of IVC parameters in predicting postinduction hypotension, followed by subgroup analyses that sought the IVC-CI range with the highest hierarchical summary receiver-operating characteristic area under the curve (HSROC-AUC). We used a bivariate random effects model to calculate summary estimates. We evaluated study quality using Newcastle-Ottawa scores and certainty of evidence using the GRADE framework.

RESULTS

We included 14 studies involving 1,166 patients. Pooled sensitivity and specificity of the IVC-CI to predict postinduction hypotension was 0.68 (95% confidence interval [CI], 0.55 to 0.79; coverage probability, 0.91) and 0.78 (95% CI, 0.69 to 0.85; coverage probability, 0.9), respectively, with an HSROC-AUC of 0.80 (95% CI, 0.68 to 0.85, high quality of evidence). An IVC-CI threshold range of 40-45% had an HSROC-AUC of 0.86 (95% CI, 0.69 to 0.93, high quality of evidence).

CONCLUSIONS

Preoperative IVC-CI is a strong predictor of postinduction hypotension. We recommend that future studies use an IVC-CI threshold of 40-45% (low certainty of evidence). Future studies are needed to establish whether ultrasound-guided preoperative optimization improves outcomes in high-risk patients.

STUDY REGISTRATION

PROSPERO ( CRD42022316140 ); first submitted 10 March 2022.

Ultrasound prediction of fetal macrosomia in pregnancies complicated by diabetes mellitus: a systematic review and meta-analysis

OBJECTIVES

To report the diagnostic accuracy of ultrasound in identifying fetuses with macrosomia in pregnancies complicated by gestational or pregestational diabetes.

METHODS

Medline, Embase and Cochrane databases were searched. Inclusion criteria were singleton pregnancies complicated by diabetes undergoing third-trimester ultrasound evaluation. The index test was represented by ultrasound estimation of fetal macrosomia (estimated fetal weight EFW or abdominal circumference AC >90th or 95th percentile). Subgroup analyses were also performed. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were computed using the hierarchical summary receiver-operating characteristics model.

RESULTS

Twenty studies were included in the systematic review including 8,530 pregnancies complicated by diabetes. Ultrasound showed an overall moderate accuracy in identifying fetuses with macrosomia with a sensitivity of 71.2 % (95 % CI 63.1-78.2), a specificity of 88.6 % (95 % CI 83.9-92.0). The interval between ultrasound and birth of two weeks showed the highest sensitivity and specificity (71.6 %, 95 % CI 47.9-87.3 and 91.7, 95 % CI 86.2-95.5). EFW sensitivity and specificity were 76.6 % (95 % CI 70.1-82.3) and 82.9 % (95 % CI 80.9-84.8), while AC 84.8 % (95 % CI 78.2-90.0) and 73.7 % (95 % CI 71.0-76.4).

CONCLUSIONS

Ultrasound demonstrates an overall good diagnostic accuracy in detecting fetal macrosomia in pregnancies with diabetes.

Predictive value of dynamic arterial elastance for vasopressor withdrawal: a systematic review and meta-analysis

BACKGROUND

Dynamic arterial elastance (Eadyn) has been investigated for its ability to predict hypotension during the weaning of vasopressors. Our study focused on assessing Eadyn's performance in the context of critically ill adult patients admitted to the intensive care unit, regardless of diagnosis.

MAIN BODY

Our study was conducted in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. The protocol was registered in PROSPERO (CRD42023421462) on May 26, 2023. We included prospective observational studies from the MEDLINE and Embase databases through May 2023. Five studies involving 183 patients were included in the quantitative analysis. We extracted data related to patient clinical characteristics, and information about Eadyn measurement methods, results, and norepinephrine dose. Most patients (76%) were diagnosed with septic shock, while the remaining patients required norepinephrine for other reasons. The average pressure responsiveness rate was 36.20%. The synthesized results yielded an area under the curve of 0.85, with a sensitivity of 0.87 (95% CI 0.74-0.93), specificity of 0.76 (95% CI 0.68-0.83), and diagnostic odds ratio of 19.07 (95% CI 8.47-42.92). Subgroup analyses indicated no variations in the Eadyn based on norepinephrine dosage, the Eadyn measurement device, or the Eadyn diagnostic cutoff to predict cessation of vasopressor support.

CONCLUSIONS

Eadyn, evaluated through subgroup analyses, demonstrated good predictive ability for the discontinuation of vasopressor support in critically ill patients.

Diagnostic Accuracy of Artificial Intelligence-Based Automated Diabetic Retinopathy Screening in Real-World Settings: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the diagnostic accuracy of artificial intelligence (AI)-based automated diabetic retinopathy (DR) screening in real-world settings.

DESIGN

Systematic review and meta-analysis METHODS: We conducted a systematic review of relevant literature from January 2012 to August 2022 using databases including PubMed, Scopus and Web of Science. The quality of studies was evaluated using Quality Assessment for Diagnostic Accuracy Studies 2 (QUADAS-2) checklist. We calculated pooled accuracy, sensitivity, specificity, and diagnostic odds ratio (DOR) as summary measures. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO - CRD42022367034).

RESULTS

We included 34 studies which utilized AI algorithms for diagnosing DR based on real-world fundus images. Quality assessment of these studies indicated a low risk of bias and low applicability concern. Among gradable images, the overall pooled accuracy, sensitivity, specificity, and DOR were 81%, 94% (95% CI: 92.0-96.0), 89% (95% CI: 85.0-92.0) and 128 (95% CI: 80-204) respectively. Sub-group analysis showed that, when acceptable quality imaging could be obtained, non-mydriatic fundus images had a better DOR of 143 (95% CI: 82-251) and studies using 2 field images had a better DOR of 161 (95% CI 74-347). Our meta-regression analysis revealed a statistically significant association between DOR and variables such as the income status, and the type of fundus camera.

CONCLUSION

Our findings indicate that AI algorithms have acceptable performance in screening for DR using fundus images compared to human graders. Implementing a fundus camera with AI-based software has the potential to assist ophthalmologists in reducing their workload and improving the accuracy of DR diagnosis.

Ultrasound Surveillance in Melanoma Management: Bridging Diagnostic Promise with Real-World Adherence: A Systematic Review and Meta-Analysis

BACKGROUND

Ultrasound surveillance has become the new standard of care in stage III melanoma after the 2017 Multicenter Selective Lymphadenectomy Trial II (MSLT-II) demonstrated non-inferior 3-year survival compared with complete lymph node dissection.

OBJECTIVE

We aimed to quantify diagnostic performance and adherence rates of ultrasound surveillance for melanoma locoregional metastasis, offering insights into real-world applicability.

METHODS

Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases from inception until 11 October 2023. All primary studies that reported data on the diagnostic performance or adherence rates to ultrasound surveillance in melanoma were included. R statistical software was used for data synthesis and analysis. Sensitivity and specificity were aggregated across studies using the meta-analytic method for diagnostic tests outlined by Rutter and Gatsonis. Adherence rates were calculated as the ratio of patients fully compliant to planned follow-up to those who were not.

RESULTS

A total of 36 studies including 18,273 patients were analysed, with a mean age of 56.6 years and a male-to-female ratio of 1:1.11. The median follow-up duration and frequency was 36 and 4 months, respectively. The pooled sensitivity of ultrasound examination was 0.879 (95% confidence interval [CI] 0.878-0.879) and specificity was 0.969 (95% CI 0.968-0.970), representing a diagnostic odds ratio of 224.5 (95% CI 223.1-225.9). Ultrasound examination demonstrated a substantial improvement in absolute sensitivity over clinical examination alone, with a number needed to screen (NNS) of 2.95. The overall adherence rate was 77.0% (95% CI 76.0-78.1%), with significantly lower rates in the United States [US] (p <  0.001) and retrospective studies (p <  0.001).

CONCLUSION

Ultrasound is a powerful diagnostic tool for locoregional melanoma metastasis. However, the real applicability to surveillance programmes is limited by low adherence rates, especially in the US. Further studies should seek to address this adherence gap.

Nonparametric worst-case bounds for publication bias on the summary receiver operating characteristic curve

The summary receiver operating characteristic (SROC) curve has been recommended as one important meta-analytical summary to represent the accuracy of a diagnostic test in the presence of heterogeneous cutoff values. However, selective publication of diagnostic studies for meta-analysis can induce publication bias (PB) on the estimate of the SROC curve. Several sensitivity analysis methods have been developed to quantify PB on the SROC curve, and all these methods utilize parametric selection functions to model the selective publication mechanism. The main contribution of this article is to propose a new sensitivity analysis approach that derives the worst-case bounds for the SROC curve by adopting nonparametric selection functions under minimal assumptions. The estimation procedures of the worst-case bounds use the Monte Carlo method to approximate the bias on the SROC curves along with the corresponding area under the curves, and then the maximum and minimum values of PB under a range of marginal selection probabilities are optimized by nonlinear programming. We apply the proposed method to real-world meta-analyses to show that the worst-case bounds of the SROC curves can provide useful insights for discussing the robustness of meta-analytical findings on diagnostic test accuracy.

An Umbrella Review and Updated Meta-Analysis of Imaging Modalities in Occult Scaphoid and Hip and Femoral Fractures

Background: Occult fractures may cause multiple morbidities. If occult fractures were detected earlier, complications may be preventable. This umbrella review and updated meta-analysis will aim to evaluate the use of imaging modalities in detecting occult scaphoid and hip fractures. Methods: The protocol for this study is available in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42024525388). The literature search started and ended on 17 March 2024. We searched seven academic databases: MEDLINE, Cochrane Library, Pubmed, Science Direct, Google Scholar, WHO International Clinical Trials Registry Platform, and The Joanna Briggs Institute (JBI) database. The meta-analysis was conducted with the STATA program using the "midas" command. Results: There are four systematic reviews evaluating occult hip and femoral fractures with 6174 patients and two reviews evaluating occult scaphoid fractures with 1355 patients. The prevalence of occult scaphoid fracture and occult hip and femoral fractures is 23.87% (95% CI 18.25-29.49) and 44.8% (95% CI 39.38-51.4), respectively. Magnetic resonance imaging (MRI) had the best posterior probability of positive likelihood ratio (LR+) with 95% and 96% and negative likelihood ratio (LR-) with 0.15% and 1% for both occult scaphoid and hip fractures, respectively, assuming a 25% baseline. MRI could both confirm and exclude occult hip fractures while it can only confirm occult scaphoid fractures. Bone scans are inappropriate for either type of occult fractures The level of evidence for occult scaphoid fracture is weak while it is suggestive for occult hip fractures. Conclusion: The findings strengthen the use of MRI after an initially negative radiograph fracture for occult hip and femoral fractures, with a CT scan as a viable second option.

Application of CT and MRI images based on artificial intelligence to predict lymph node metastases in patients with oral squamous cell carcinoma: a subgroup meta-analysis

Background

The performance of artificial intelligence (AI) in the prediction of lymph node (LN) metastasis in patients with oral squamous cell carcinoma (OSCC) has not been quantitatively evaluated. The purpose of this study was to conduct a systematic review and meta-analysis of published data on the diagnostic performance of CT and MRI based on AI algorithms for predicting LN metastases in patients with OSCC.

Methods

We searched the Embase, PubMed (Medline), Web of Science, and Cochrane databases for studies on the use of AI in predicting LN metastasis in OSCC. Binary diagnostic accuracy data were extracted to obtain the outcomes of interest, namely, the area under the curve (AUC), sensitivity, and specificity, and compared the diagnostic performance of AI with that of radiologists. Subgroup analyses were performed with regard to different types of AI algorithms and imaging modalities.

Results

Fourteen eligible studies were included in the meta-analysis. The AUC, sensitivity, and specificity of the AI models for the diagnosis of LN metastases were 0.92 (95% CI 0.89-0.94), 0.79 (95% CI 0.72-0.85), and 0.90 (95% CI 0.86-0.93), respectively. Promising diagnostic performance was observed in the subgroup analyses based on algorithm types [machine learning (ML) or deep learning (DL)] and imaging modalities (CT vs. MRI). The pooled diagnostic performance of AI was significantly better than that of experienced radiologists.

Discussion

In conclusion, AI based on CT and MRI imaging has good diagnostic accuracy in predicting LN metastasis in patients with OSCC and thus has the potential for clinical application.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, PROSPERO (No. CRD42024506159).

Diagnostic performance of MRI in detecting prostate cancer in patients with prostate-specific antigen levels of 4-10 ng/mL: a systematic review and meta-analysis

OBJECTIVE

To investigate the diagnostic performance of MRI in detecting clinically significant prostate cancer (csPCa) and prostate cancer (PCa) in patients with prostate-specific antigen (PSA) levels of 4-10 ng/mL.

METHODS

A computerized search of PubMed, Embase, Cochrane Library, Medline, and Web of Science was conducted from inception until October 31, 2023. We included articles on the use of MRI to detect csPCa or PCa at 4-10 ng/mL PSA. The primary and secondary outcomes were MRI performance in csPCa and PCa detection, respectively; the estimates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were pooled in a bivariate random-effects model.

RESULTS

Among the 19 studies (3879 patients), there were 10 (2205 patients) and 13 studies (2965 patients) that reported MRI for detecting csPCa or PCa, respectively. The pooled sensitivity and specificity for csPCa detection were 0.84 (95% confidence interval [CI], 0.79-0.88) and 0.76 (95%CI, 0.65-0.84), respectively, for PCa detection were 0.82 (95%CI, 0.75-0.87) and 0.74 (95%CI, 0.65-0.82), respectively. The pooled NPV for csPCa detection was 0.91 (0.87-0.93). Biparametric magnetic resonance imaging also showed a significantly higher sensitivity and specificity relative to multiparametric magnetic resonance imaging (both p < 0.01).

CONCLUSION

Prostate MRI enables the detection of csPCa and PCa with satisfactory performance in the PSA gray zone. The excellent NPV for csPCa detection indicates the possibility of biopsy decision-making in patients in the PSA gray zone, but substantial heterogeneity among the included studies should be taken into account.

CLINICAL RELEVANCE STATEMENT

Prostate MRI can be considered a reliable and satisfactory tool for detecting csPCa and PCa in patients with PSA in the "gray zone", allowing for reducing unnecessary biopsy and optimizing the overall examination process.

KEY POINTS

Prostate-specific antigen (PSA) is a common screening tool for prostate cancer but risks overdiagnosis. MRI demonstrated excellent negative predictive value for prostate cancer in the PSA gray zone. MRI can influence decision-making for these patients, and biparametric MRI should be further evaluated.

Palliative prognostic scores for survival prediction of cancer patients: a systematic review and meta-analysis

BACKGROUND

The palliative prognostic score is the most widely validated prognostic tool for cancer survival prediction, with modified versions available. A systematic evaluation of palliative prognostic score tools is lacking. This systematic review and meta-analysis aimed to evaluate the performance and prognostic utility of palliative prognostic score, delirium-palliative prognostic score, and palliative prognostic score without clinician prediction in predicting 30-day survival of cancer patients and to compare their performance.

METHODS

Six databases were searched for peer-reviewed studies and grey literature published from inception to June 2, 2023. English studies must assess palliative prognostic score, delirium-palliative prognostic score, or palliative prognostic score without clinician-predicted survival for 30-day survival in adults aged 18 years and older with any stage or type of cancer. Outcomes were pooled using the random effects model or summarized narratively when meta-analysis was not possible.

RESULTS

A total of 39 studies (n = 10 617 patients) were included. Palliative prognostic score is an accurate prognostic tool (pooled area under the curve [AUC] = 0.82, 95% confidence interval [CI] = 0.79 to 0.84) and outperforms palliative prognostic score without clinician-predicted survival (pooled AUC = 0.74, 95% CI = 0.71 to 0.78), suggesting that the original palliative prognostic score should be preferred. The meta-analysis found palliative prognostic score and delirium-palliative prognostic score performance to be comparable. Most studies reported survival probabilities corresponding to the palliative prognostic score risk groups, and higher risk groups were statistically significantly associated with shorter survival.

CONCLUSIONS

Palliative prognostic score is a validated prognostic tool for cancer patients that can enhance clinicians' confidence and accuracy in predicting survival. Future studies should investigate if accuracy differs depending on clinician characteristics. Reporting of validation studies must be improved, as most studies were at high risk of bias, primarily because calibration was not assessed.

Early warning scores for sepsis identification and prediction of in-hospital mortality in adults with sepsis: A systematic review and meta-analysis

AIM

The early warning scores (EWS), quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) criteria have been proposed as sepsis screening tools. This review aims to summarise and compare the performance of EWS with the qSOFA and SIRS criteria for predicting sepsis diagnosis and in-hospital mortality in patients with sepsis.

DESIGN

A systematic review with meta-analysis.

REVIEW METHODS

Seven databases were searched from January 1, 2016 until March 10, 2022. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Sensitivity, specificity, likelihood ratios and diagnostic odd ratios were pooled by using the bivariate random effects model. Overall performance was summarised by using the hierarchical summary receiver-operating characteristics curve. This paper adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines.

RESULTS

Ten studies involving 52,474 subjects were included in the review. For predicting sepsis diagnosis, the pooled sensitivity of EWS (65%, 95% CI: 55, 75) was similar to SIRS ≥2 (70%, 95% CI: 49, 85) and higher than qSOFA ≥2 (37%, 95% CI: 20, 59). The pooled specificity of EWS (77%, 95% CI: 64, 86) was higher than SIRS ≥2 (62%, 95% CI: 41, 80) but lower than qSOFA ≥2 (94%, 95% CI: 86, 98). Results were similar for the secondary outcome of in-hospital mortality.

CONCLUSIONS

Although no one scoring system had both high sensitivity and specificity, the EWS had at least equivalent values in most measures of diagnostic accuracy compared with SIRS or qSOFA.

IMPLICATIONS FOR THE PROFESSION

Healthcare systems in which EWS is already in place should consider whether there is any clinical benefit in adopting qSOFA or SIRS.

NO PATIENT OR PUBLIC CONTRIBUTION

This systematic review did not directly involve patient or public contribution to the manuscript.

Predicting Fluid Responsiveness Using Carotid Ultrasound in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies

BACKGROUND

A noninvasive and accurate method of determining fluid responsiveness in ventilated patients would help to mitigate unnecessary fluid administration. Although carotid ultrasound has been previously studied for this purpose, several studies have recently been published. We performed an updated systematic review and meta-analysis to evaluate the accuracy of carotid ultrasound as a tool to predict fluid responsiveness in ventilated patients.

METHODS

Studies eligible for review investigated the accuracy of carotid ultrasound parameters in predicting fluid responsiveness in ventilated patients, using sensitivity and specificity as markers of diagnostic accuracy (International Prospective Register of Systematic Reviews [PROSPERO] CRD42022380284). All included studies had to use an independent method of determining cardiac output and exclude spontaneously ventilated patients. Six bibliographic databases and 2 trial registries were searched. Medline, Embase, Emcare, APA PsycInfo, CINAHL, and the Cochrane Library were searched on November 4, 2022. Clinicaltrials.gov and Australian New Zealand Clinical Trials Registry were searched on February 24, 2023. Results were pooled, meta-analysis was conducted where possible, and hierarchical summary receiver operating characteristic models were used to compare carotid ultrasound parameters. Bias and evidence quality were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines.

RESULTS

Thirteen prospective clinical studies were included (n = 648 patients), representing 677 deliveries of volume expansion, with 378 episodes of fluid responsiveness (58.3%). A meta-analysis of change in carotid Doppler peak velocity (∆CDPV) yielded a sensitivity of 0.79 (95% confidence interval [CI], 0.74-0.84) and a specificity of 0.85 (95% CI, 0.76-0.90). Risk of bias relating to recruitment methodology, the independence of index testing to reference standards and exclusionary clinical criteria were evaluated. Overall quality of evidence was low. Study design heterogeneity, including a lack of clear parameter cutoffs, limited the generalizability of our results.

CONCLUSIONS

In this meta-analysis, we found that existing literature supports the ability of carotid ultrasound to predict fluid responsiveness in mechanically ventilated adults. ∆CDPV may be an accurate carotid parameter in certain contexts. Further high-quality studies with more homogenous designs are needed to further validate this technology.

Diagnostic accuracy of serological and imaging tests used in surveillance for hepatocellular carcinoma in adults with cirrhosis: a systematic review protocol

Background

Liver cirrhosis is the largest risk factor for developing hepatocellular carcinoma (HCC), and surveillance is therefore recommended among this population. Current guidance recommends surveillance with ultrasound, with or without alpha-fetoprotein (AFP). This review is part of a larger project looking at benefits, harms and costs of surveillance for HCC in people with cirrhosis. It aims to synthesise the evidence on the diagnostic accuracy of imaging or biomarker tests, alone or in combination, to identify HCC in adults with liver cirrhosis in a surveillance programme.

Methods

We will identify studies through a 2021 Cochrane review with similar eligibility criteria, and a database search of MEDLINE, Embase and the Cochrane Database of Systematic Reviews. We will include diagnostic test accuracy studies with adult cirrhosis patients of any aetiology. Studies must assess at least one of the following index tests: ultrasound (US), magnetic resonance imaging (MRI), computerised tomography (CT), alpha-fetoprotein (AFP), des-gamma-carboxyprothrombin (DCP), lens culinaris agglutinin-reactive fraction of AFP (AFP-L3), a genomic biomarker, or a diagnostic prediction model incorporating at least one of the above-mentioned tests. We will assess studies for risk of bias using QUADAS-2 and QUADAS-C. We will combine data using bivariate random effects meta-analyses. For tests evaluated across varying diagnostic thresholds, we will produce pooled estimates of sensitivity and specificity across the full range of numerical thresholds, where possible. Where sufficient studies compare two or more index tests, we will perform additional analyses to compare the accuracy of different tests. Where feasible, we will stratify all meta-analyses by tumour size and patient characteristics, including cirrhosis aetiology and liver disease severity.

Discussion

This review will synthesise evidence across the full range of possible surveillance tests, using advanced statistical methods to summarise accuracy across all thresholds and to compare the accuracy of different tests.

PROSPERO registration

CRD42022357163.