How to create PICO questions about diagnostic tests

PRIDASE 2024 guidelines for reporting diagnostic accuracy studies in endodontics: Explanation and elaboration

The Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) 2024 guidelines are based on the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 guidelines and the Clinical and Laboratory Images in Publications (CLIP) principles, with the addition of items specifically related to endodontics. The use of the PRIDASE 2024 guidelines by authors and their application by journals during the peer review process will reduce the possibility of bias and enhance the quality of future diagnostic accuracy studies. The PRIDASE 2024 guidelines consist of a checklist containing 11 domains and 66 individual items. The purpose of the current document is to provide an explanation for each item on the PRIDASE 2024 checklist, along with examples from the literature to help readers understand their importance and offer advice to those developing manuscripts. A link to the PRIDASE 2024 explanation and elaboration document is available on the Preferred Reporting Items for study Designs in Endodontology (PRIDE) website (https://pride-endodonticguidelines.org/pridase/) and on the International Endodontic Journal website (https://onlinelibrary.wiley.com/page/journal/13652591/homepage/pride-guidelines.htm).

MRI and SPECT/CT demonstrate, with low certainty of evidence, the highest diagnostic accuracy for aseptic knee arthroplasty loosening: A systematic comparative diagnostic test review and meta-analysis

PURPOSE

The purpose of this study was to evaluate and compare the diagnostic accuracy of modalities used to aid the diagnosis of aseptic knee arthroplasty loosening.

METHODS

A comparative diagnostic test accuracy systematic review and meta-analysis was conducted following the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE and Cochrane databases were searched for original articles evaluating diagnostic modalities up to March 2024. Included studies compared the modality (index test) to the intraoperative finding as reference test. The QUADAS-C (Quality Assessment of Diagnostic Accuracy Studies-Comparative) tool was used to assess the quality of the included studies. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to evaluate the certainty of evidence. Level of evidence was evaluated using the Oxford Levels of Evidence tool. The primary outcome was the summary of diagnostic accuracy metrics for each modality as demonstrated by a summary receiver-operating characteristic (SROC) curve.

RESULTS

The search yielded 467 articles. Of these, 14 articles were included. These 14 articles evaluated a total of five different diagnostic modalities: bone scintigraphy (three studies, 146 cases), 18-fluorodeoxyglucose positron emission tomography (two studies, 50 cases), single-photon emission computed tomography combined with computed tomography (SPECT/CT) (seven studies, 371 cases), radionuclide arthrogram (three studies, 196 cases) and magnetic resonance imaging (MRI) (one study, 116 cases). Nine studies exhibited a high risk of bias in patient selection, and all studies showed a high risk of bias related to the reference test. The majority of the included studies were classified as Level III evidence, leading to an overall low level of certainty in the evidence. The most accurate tests, as demonstrated by the SROC analysis, were MRI and SPECT/CT, with sensitivities ranging from 0.00 to 1.00 and 0.33 to 1.00 and specificities between 0.31-1.00 and 0.00-1.00, respectively.

CONCLUSIONS

This review and meta-analysis evaluated available diagnostic modalities to aid the diagnosis of knee arthroplasty loosening and based on a low certainty of evidence suggests that MRI and SPECT/CT are currently the most accurate modalities available to aid the diagnosis of aseptic loosening of knee arthroplasty components.

LEVEL OF EVIDENCE

Level III.

Poor evidence for poor R wave progression in coronary disease: A scoping review

BACKGROUND

Poor R wave progression (PRWP) and reversed R wave progression (RRWP) have long been noted in electrocardiograms as potential indicators of anterior wall fibrosis or chronic coronary artery disease; however, the quantity and quality of evidence supporting these associations warrants closer examination.

OBJECTIVE

The aim of this scoping review is to assess the breadth of evidence regarding the diagnostic significance of PRWP and RRWP, explore the extent of research, study populations and methodologies, and the presence of gaps in knowledge regarding these electrocardiographic phenomena and their association with coronary diseases.

DESIGN

We conducted a comprehensive search across PubMed, Web of Science, and Scopus, covering literature on PRWP or RRWP in the context of myocardial infarction, ischemia, or fibrosis from any time period and in any language.

RESULTS

A total of 20 studies were included in this review, highlighting the severe paucity of data. No high-quality accuracy studies have been identified, and existing research suffers from methodological issues, in particular selection bias. Prevalence and prognostic studies showed significant heterogeneity in terms of definitions and outcomes, which contributes to an alarming risk of bias.

CONCLUSIONS

The lack of solid evidence for PRWP and RRWP as diagnostic markers for acute and chronic coronary artery disease necessitates caution in clinical interpretation. Future research should focus on well-designed case-control studies to clarify the diagnostic accuracy of these markers. Until robust evidence is available, the reliance on PRWP/RRWP for diagnosing anterior infarction should be discouraged, reflecting a gap between clinical practice and evidence-based medicine.

Utilization of Radiomics Features Extracted From Preoperative Medical Images to Detect Metastatic Lymph Nodes in Cholangiocarcinoma and Gallbladder Cancer Patients: A Systemic Review and Meta-analysis

OBJECTIVES

This study aimed to determine the methodological quality and evaluate the diagnostic performance of radiomics features in detecting lymph node metastasis on preoperative images in patients with cholangiocarcinoma and gallbladder cancer.

METHODS

Publications between January 2005 and October 2022 were considered for inclusion. Databases such as Pubmed/Medline, Scopus, Embase, and Google Scholar were searched for relevant studies. The quality of the methodology of the manuscripts was determined using the Radiomics Quality Score and Quality Assessment of Diagnostic Accuracy Studies 2. Pooled results with corresponding 95% confidence intervals (CIs) were calculated using the DerSimonian-Liard method (random-effect model). Forest plots were used to visually represent the diagnostic profile of radiomics signature in each of the data sets pertaining to each study. Fagan plot was used to determine clinical applicability.

RESULTS

Overall sensitivity was 0.748 (95% CI, 0.703-0.789). Overall specificity was 0.795 (95% CI, 0.742-0.839). The combined negative likelihood ratio was 0.299 (95% CI, 0.266-0.350), and the positive likelihood ratio was 3.545 (95% CI, 2.850-4.409). The combined odds ratio of the studies was 12.184 (95% CI, 8.477-17.514). The overall summary receiver operating characteristics area under the curve was 0.83 (95% CI, 0.80-0.86). Three studies applied nomograms to 8 data sets and achieved a higher pooled sensitivity and specificity (0.85 [0.80-0.89] and 0.85 [0.71-0.93], respectively).

CONCLUSIONS

The pooled analysis showed that predictive models fed with radiomics features achieve good sensitivity and specificity in detecting lymph node metastasis in computed tomography and magnetic resonance imaging images. Supplementation of the models with biological correlates increased sensitivity and specificity in all data sets.

Mediterranean diet for cancer prevention and survivorship

Cancer is one of the main noncommunicable diseases in terms of health impact. Factors such as a progressively aging population point to future increases in the incidence of cancer on a global level. The elevated number of affected individuals, together with continuous improvements in cancer prevention and therapy, is creating a growing population of cancer survivors, with often inadequately met needs. Lifestyle is a key modulator of cancer risk and of associated morbidity and mortality, and is included in all approaches to the long-term management of cancer. Diet is a principal component of lifestyle, and most of the available evidence is centered on the Mediterranean diet. Our objective was to provide a narrative review of the evidence on the effect of the Mediterranean diet on cancer risk and health threats related to cancer survivorship. For this purpose, we searched the PubMed database for articles published between January 1, 2000, and June 12, 2023. Current data show that the Mediterranean diet is inversely associated with risk, or is risk neutral, for most types of cancer. Tumors of the digestive system have received preferential interest, but studies have also been published on tumors in other organs. The evidence, however, is meager due to the observational nature of most studies, although it is reassuring that benefit is reproduced in studies performed in different populations and environments. Evidence related to cancer survivors is limited by the paucity of studies, yet several findings regarding survival, recurrence, and short- and long-term morbidity suggest a potential role for the Mediterranean diet that warrants further research.

Respiratory Syncytial Virus: A Systematic Review and Meta-Analysis of Tomographic Findings (2000-2022)

Human respiratory syncytial virus (RSV) is a main cause of medical referrals and hospitalizations in all infants, particularly among newborns. Nevertheless, relatively limited evidence on chest tomography (CT) findings has been collected. According to the PRISMA statement, Pubmed, Embase, and medRxiv were searched for eligible observational studies published up to 31 December 2022. Cases were categorized in children and adolescents (age < 18 years), adults and elderly (age ≥ 18 years), and immunocompromised patients, and then pooled in a random-effects model. Heterogeneity was assessed using the I2 statistics, while reporting bias was assessed by means of funnel plots and regression analysis. A total of 10 studies (217 RSV cases) were retrieved (children, 37.3%; immunocompromised, 41.0%; adults, 21.7%). The most common features were signs of organizing pneumonia (33.65%, 95% confidence interval [95% CI] 22.39-47.27), followed by septal thickening (33.19%, 95% CI 21.76-47.03), ground glass opacities (GGOs; 28.03%, 95% CI 14.69-46.82), and tree-in-bud (TIB, 27.44%, 95% CI 15.04-44.68). Interestingly, up to 16.23% (95% CI 8.17-29.69) showed normal findings, while the large majority (76.06%, 95% CI 64.81-84.56) were characterized by bilateral involvement. Studies were highly heterogeneous without substantial reporting bias. Assuming children and adolescents as reference groups, healthy adults were characterized by a higher risk ratio [RR] for septal thickening (RR 3.878, 95% CI 1.253-12.000), nodular lesions (RR 20.197, 95% CI 1.286-317.082), and GGOs (RR 2.121, 95% CI 1.121-4.013). RSV cases are rarely assessed in terms of CT characteristics. Our study identified some specificities, suggesting that RSV infections evolve heterogeneous CT features in children/adolescents and adults, but the paucity of studies recommends a cautious appraisal.

Prediction of medical sciences students' performance on high-stakes examinations using machine learning models: a protocol for a systematic review

INTRODUCTION

Predicting medical science students' performance on high-stakes examinations has received considerable attention. Machine learning (ML) models are well-known approaches to enhance the accuracy of determining the students' performance. Accordingly, we aim to provide a comprehensive framework and systematic review protocol for applying ML in predicting medical science students' performance on high-stakes examinations. Improving the current understanding of the input and output features, preprocessing methods, setting of ML models and required evaluation metrics seems essential.

METHODS AND ANALYSIS

A systematic review will be conducted by searching the electronic bibliographic databases of MEDLINE/PubMed, EMBASE, SCOPUS and Web of Science. The search will be limited to studies published from January 2013 to June 2023. Studies explicitly predicting student performance in high-stakes examinations and referencing their learning outcomes and use of ML models will be included. Two team members will first screen literature meeting the inclusion criteria at the title, abstract and full-text levels. Second, the Best Evidence Medical Education quality framework rates the included literature. Later, two team members will extract data, including the studies' general data and the ML approach's details. Finally, the information consensus will be reached and submitted for analysis. The synthesised evidence from this review provides helpful information for medical education policy-makers, stakeholders and other researchers in adopting the ML models to evaluate medical science students' performance in high-stakes exams.

ETHICS AND DISSEMINATION

This systematic review protocol summarises findings of existing publications rather than primary data and does not require an ethics review. The results will be disseminated in publications of peer-reviewed journals.

The role of SPECT/CT in painful, noninfected knees after knee arthroplasty: a systematic review and meta-analysis-a diagnostic test accuracy review

PURPOSE

The aim of this systematic review was to present the current evidence on the clinical use of single-photon emission computed tomography/computed tomography (SPECT/CT) in the evaluation of noninfected painful knees after knee arthroplasty.

METHODS

Embase, PubMed, Google Scholar, Ovid, Scopus, Science Direct and the Cochrane Database of Systematic Reviews were searched from database inception to May 2022 following the PRISMA guidelines. As a primary outcome, we defined the role of SPECT/CT in the diagnostic approach to noninfected painful knee arthroplasty; as a secondary objective, we described the noninfection-related factors linked to painful knee arthroplasty. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio values and other indicators were calculated; receiver operating characteristic (ROC) curve analysis results and a summary of the areas under the curve (AUCs) from the included studies were reported. A Fagan plot, likelihood ratio plot and Deeks' funnel plot were generated and analysed. Methodological quality was assessed using the QUADAS-2 tool, and the certainty of evidence was assessed by the GRADE approach.

RESULTS

A total of 493 publications were identified, of which eight met the inclusion criteria, with a final pooled sample size of 308 patients. The pooled sensitivity and specificity of SPECT/CT in diagnosing the source of pain in painful knee prostheses were 0.86 (95% CI: 0.75-0.93) and 0.90 (95% CI: 0.79-0.96), respectively, with pooled +LR and -LR values of 8.9 (95% CI: 4.11-19.19) and 0.15 (95% CI: 0.09-0.28). The pooled diagnostic odds ratio was 57.35, and the area under the curve was 0.94. SPECT/CT highly accurately identified different sources of pain, such as loosening of the prosthetic components, patellofemoral overloading, instability, malalignment of the components and degeneration of the patellofemoral compartment. The confidence of the estimates was moderate according to the GRADE approach.

CONCLUSION

With demonstrated high sensitivity and specificity, as a diagnostic tool, SPECT/CT can identify the source of pain in painful knees after knee arthroplasty, particularly in cases of loosening, patellofemoral disorders and component malalignment (level of evidence III). These findings have significant clinical repercussions, such as in changing the initial diagnosis, identifying or excluding different causes of painful knee arthroplasties, guiding subsequent treatment and positively impacting the final clinical outcome. We moderately recommend the use of SPECT/CT for identifying the source of pain after knee arthroplasty according to the GRADE assessment. This review was preregistered in Prospero under code CRD42022320457.

Clinical Sensor-Based Fall Risk Assessment at an Orthopedic Clinic: A Case Study of the Staff's Views on Utility and Effectiveness

In-hospital falls are a serious threat to patient security and fall risk assessment (FRA) is important to identify high-risk patients. Although sensor-based FRA (SFRA) can provide objective FRA, its clinical use is very limited and research to identify meaningful SFRA methods is required. This study aimed to investigate whether examples of SFRA methods might be relevant for FRA at an orthopedic clinic. Situations where SFRA might assist FRA were identified in a focus group interview with clinical staff. Thereafter, SFRA methods were identified in a literature review of SFRA methods developed for older adults. These were screened for potential relevance in the previously identified situations. Ten SFRA methods were considered potentially relevant in the identified FRA situations. The ten SFRA methods were presented to staff at the orthopedic clinic, and they provided their views on the SFRA methods by filling out a questionnaire. Clinical staff saw that several SFRA tasks could be clinically relevant and feasible, but also identified time constraints as a major barrier for clinical use of SFRA. The study indicates that SFRA methods developed for community-dwelling older adults may be relevant also for hospital inpatients and that effectiveness and efficiency are important for clinical use of SFRA.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Potential Use of Exhaled Breath Condensate for Diagnosis of SARS-CoV-2 Infections: A Systematic Review and Meta-Analysis

Background. Reverse-transcriptase polymerase chain reaction (RT-qPCR) assays performed on respiratory samples collected through nasal swabs still represent the gold standard for COVID-19 diagnosis. Alternative methods to this invasive and time-consuming options are still being inquired, including the collection of airways lining fluids through exhaled breath condensate (EBC). Materials and Methods. We performed a systematic review and meta-analysis in order to explore the reliability of EBC as a way to collect respiratory specimens for RT-qPCR for diagnosis of COVID-19. Results. A total of 4 studies (205 specimens), were ultimately collected, with a pooled sensitivity of 69.5% (95%CI 26.8–93.4), and a pooled specificity of 98.3% (95%CI 87.8–99.8), associated with high heterogeneity and scarce diagnostic agreement with the gold standard represented by nasal swabs (Cohen’s kappa = 0.585). Discussion. Even though non-invasive options for diagnosis of COVID-19 are still necessary, EBC-based RT-qPCR showed scarce diagnostic performances, ultimately impairing its implementation in real-world settings. However, as few studies have been carried out to date, and the studies included in the present review are characterized by low numbers and low sample power, further research are requested to fully characterize the actual reliability of EBC-based RT-qPCR in the diagnosis of COVID-19.

Research Questions with PICO: A Universal Mnemonic

A well-formulated research question should incorporate the components of a ‘problem’, an ‘intervention’, a ‘control’, and an ‘outcome’—at least according to the PICO mnemonic. The utility of this format, however, has been said to be limited to clinical studies that pose ‘which’ questions demanding correlational study designs. In contrast, its suitability for descriptive approaches outside of clinical investigations has been doubted. This paper disagrees with the alleged limitations of PICO. Instead, it argues that the scheme can be used universally for every scientific endeavour in any discipline with all study designs. This argument draws from four abstract components common to every research, namely, a research object, a theory/method, a (null) hypothesis, and the goal of knowledge generation. Various examples of how highly heterogenous studies from different disciplines can be grounded in the single scheme of PICO are offered. The finding implies that PICO is indeed a universal technique that can be used for teaching academic writing in any discipline, beyond clinical settings, regardless of a preferred study design.

Metabolomic Biomarkers to Predict and Diagnose Cystic Fibrosis Pulmonary Exacerbations: A Systematic Review

INTRODUCTION

Metabolomics is an emerging area of research and has the potential to identify clinical biomarkers for predicting or diagnosing cystic fibrosis (CF) pulmonary exacerbations (PEx).

OBJECTIVE

To identify clinically promising metabolites across different sample sources that can be used to predict or diagnose PEx in CF.

EVIDENCE REVIEW

Searches for original literature were completed through EMBASE, MEDLINE, and all databases on the Web of Science with no restrictions on language or publication date. Gray literature was collected through Google Scholar. Additional studies were obtained by contacting authors and searching reference lists of candidate papers. The patient population included individuals with CF. Studies involving patients who underwent lung transplantation were excluded. The outcome was the prediction or diagnosis of pulmonary exacerbations from metabolites directly measured from biological samples. Search results were downloaded and imported into Covidence and duplicates were removed automatically. Any remaining duplicates were manually tagged and excluded. Two independent reviewers screened each abstract for eligibility and repeated this process for full texts. Risk of bias was conducted using QUADAS-2 by two independent reviewers. A third author resolved any remaining conflicts.

RESULTS

A combined 3974 relevant abstracts were identified and 115 full texts were assessed for eligibility. The final 25 studies underwent data extraction for study design, patient demographics, studied metabolites, concentration values, and diagnostic accuracy values. Included studies differed considerably in methodologies, sample specimen types (exhaled breath condensate [EBC], sputum, saliva, plasma, urine), and disease states. We identified 19 unique metabolites that were measured by two or more studies of which 2 have the potential to predict PEx (EBC 4-hydroxycyclohexylcarboxylic acid [4-HCHC] and lactic acid) and 6 to diagnose PEx (EBC 4-HCHC and lactic acid, sputum lactic acid and nitrate, and plasma arginine and methionine).

CONCLUSION AND RELEVANCE

This systematic review has identified promising metabolites for further study in CF. Certain metabolites may provide clinical potential in predicting or diagnosing PEx, but further validation studies are required. With better tools to aid in the earlier identification of PEx, clinicians can implement preventative measures to mitigate airway damage.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Evaluation of the Suitability of RNAscope as a Technique to Measure Gene Expression in Clinical Diagnostics: A Systematic Review

Objective

To evaluate the application of RNAscope in the clinical diagnostic field compared to the current ‘gold standard’ methods employed for testing gene expression levels, including immunohistochemistry (IHC), quantitative real time PCR (qPCR), and quantitative reverse transcriptase PCR (qRT-PCR), and to detect genes, including DNA in situ hybridisation (DNA ISH).

Methods

This systematic review searched CINAHL, Medline, Embase and Web of Science databases for studies that were conducted after 2012 and that compared RNAscope with one or more of the ‘gold standard’ techniques in human samples. QUADAS-2 test was used for the evaluation of the articles’ risk of bias. The results were reviewed narratively and analysed qualitatively.

Results

A total of 27 articles (all retrospective studies) were obtained and reviewed. The 27 articles showed a range of low to middle risk of bias scores, as assessed by QUADAS-2 test. 26 articles studied RNAscope within cancer samples. RNAscope was compared to different techniques throughout the included studies (IHC, qPCR, qRT-PCR and DNA ISH). The results confirmed that RNAscope is a highly sensitive and specific method that has a high concordance rate (CR) with qPCR, qRT-PCR, and DNA ISH (81.8–100%). However, the CR with IHC was lower than expected (58.7–95.3%), which is mostly due to the different products that each technique measures (RNA vs. protein).

Discussion

This is the first systematic review to be conducted on the use of RNAscope in the clinical diagnostic field. RNAscope was found to be a reliable and robust method that could complement gold standard techniques currently used in clinical diagnostics to measure gene expression levels or for gene detection. However, there were not enough data to suggest that RNAscope could stand alone in the clinical diagnostic setting, indicating further prospective studies to validate diagnostic accuracy values, in keeping with relevant regulations, followed by cost evaluation are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40291-021-00570-2.

Performance and Characteristics of Wearable Sensor Systems Discriminating and Classifying Older Adults According to Fall Risk: A Systematic Review

Sensor-based fall risk assessment (SFRA) utilizes wearable sensors for monitoring individuals’ motions in fall risk assessment tasks. Previous SFRA reviews recommend methodological improvements to better support the use of SFRA in clinical practice. This systematic review aimed to investigate the existing evidence of SFRA (discriminative capability, classification performance) and methodological factors (study design, samples, sensor features, and model validation) contributing to the risk of bias. The review was conducted according to recommended guidelines and 33 of 389 screened records were eligible for inclusion. Evidence of SFRA was identified: several sensor features and three classification models differed significantly between groups with different fall risk (mostly fallers/non-fallers). Moreover, classification performance corresponding the AUCs of at least 0.74 and/or accuracies of at least 84% were obtained from sensor features in six studies and from classification models in seven studies. Specificity was at least as high as sensitivity among studies reporting both values. Insufficient use of prospective design, small sample size, low in-sample inclusion of participants with elevated fall risk, high amounts and low degree of consensus in used features, and limited use of recommended model validation methods were identified in the included studies. Hence, future SFRA research should further reduce risk of bias by continuously improving methodology.