No role for quality scores in systematic reviews of diagnostic accuracy studies

Development of quality assessment tool for systematic reviews and meta-analyses of real-world studies: a Delphi consensus survey

The increasing adoption of real-world studies in healthcare for decision making and planning has further necessitated the need for a specific quality assessment tool for evidence synthesis. This study aimed to develop a quality assessment tool for systematic reviews (SR) and meta-analysis (MA) involving real-world studies (QATSM-RWS) using a formal consensus method. Based on scoping review, the authors identified a list of items for possible inclusion in the quality assessment tool. A Delphi survey was formulated based on the identified items. A total of 89 experts, purposively recruited, with research experience in real-world data were invited to participate in the first round of Delphi survey. The participants who responded in the first Delphi round were invited to participate (n = 15) in the phrasing of the items. Strong level of agreement was found on the proposed list of items after the first round of Delphi. A rate of agreement ≥ 0.70 was used to define which items to keep in the tool. A list of 14 items emerged as suitable for QATSM-RWS. The items were structured under five domains: introduction, methods, results, discussions, and others. All participants agreed with the proposed phrasing of the items. This is the first study that has developed a specific tool that can be used to appraise the quality of SR and MA involving real-world studies. QATSM-RWS may be used by policymakers, clinicians, and practitioners when evaluating and generating real-world evidence. This tool is now undergoing validation process.

Cadaveric Biomechanical Laboratory Research Can Be Quantitatively Scored for Quality With the Biomechanics Objective Basic Science Quality Assessment Tool: The BOBQAT Score

PURPOSE

The purpose of this study was to develop a quality appraisal tool for the assessment of cadaveric biomechanical laboratory and other basic science biomechanical studies.

METHODS

For item identification and development, a systematic review of the literature was performed. The content validity index (CVI) was used either to include or exclude items. The content validity ratio (CVR) was used to determine content validity. Weighting was performed by each panel member; the final weight was either up- or downgraded to the closest of 5% or 10%. Face validity was scored on a Likert scale ranked from 1 to 7. Test-retest reliability was determined using the Fleiss kappa coefficient. Internal consistency was assessed with Cronbach's alpha. Concurrent criterion validity was assessed against the Quality Appraisal for Cadaveric Studies scale.

RESULTS

The final Biomechanics Objective Basic science Quality Assessment Tool (BOBQAT) score included 15 items and was shown to be valid, reliable, and consistent. Five items had a CVI of 1.0; 10 items had a CVI of 0.875. For weighting, 5 items received a weight of 10%, and 10 items a weight of 5%. CVR was 1.0 for 6 items and 0.75 for 9 items. For face validity, all items achieved a score above 5. For test-retest reliability, almost-perfect test-retest reliability was observed for 10 items, substantial agreement for 4 items, and moderate agreement for 1 item. For internal consistency, Cronbach's alpha was calculated to be 0.71. For concurrent criterion validity, Pearson's product-moment correlation was 0.56 (95% confidence interval [CI] = 0.38-0.70, P = .0001).

CONCLUSION

Cadaveric biomechanical and laboratory research can be quantitatively scored for quality based on the inclusion of a clear and answerable purpose, demographics, specimen condition, appropriate bone density, reproducible technique, appropriate outcome measures, appropriate loading conditions, appropriate load magnitude, cyclic loading, sample size calculation, proper statistical analysis, results consistent with methods, limitations considered, conclusions based on results, and disclosure of funding and potential conflicts.

CLINICAL RELEVANCE

Study quality assessments are important to evaluate internal and external validity and reliability and to identify methodological flaws and misleading conclusions. The BOBQAT score will help not only in the critical appraisal of cadaveric biomechanical studies but also in guiding the designs of such research endeavors.

Diagnostic Test Accuracy of artificial intelligence-assisted detection of acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

Artificial intelligence (AI) has potential uses in healthcare including the detection of health conditions and prediction of health outcomes. Past systematic reviews had reviewed the accuracy of artificial neural networks (ANN) on Electrocardiogram (ECG) readings but that of other AI models on other Acute Coronary Syndrome (ACS) detection tools remains unclear.

METHODS

Nine electronic databases were searched from 2012 to 31 August 2022 including grey literature search and hand searching of references of included articles. Risk of bias was assessed by two independent reviewers using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Test characteristics namely true positives, false positives, true negatives, and false negatives were extracted from all included articles into a 2x2 table. Study-specific estimates of sensitivity and specificity were pooled using hierarchical summary receiver operating characteristic (HSROC) model and displayed using a forest plot and HSROC curve.

RESULTS

66 studies were included in the review. A total of 518,931 patients were included whose mean ages varied from 32.62 to 70 years old. In 66 studies, the sensitivity and specificity of AI-based detection for ACS screening ranged from 64 % to 100 % and 65 %-100 %, respectively. The overall quality of evidence was low due to the inclusion of case-control studies.

CONCLUSION

Results of the study inform the potential of using AI-assisted ACS detection for accurate diagnosis and prompt treatment for ACS. Adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) guideline and having more cohort studies for future Diagnostic Test Accuracy (DTA) studies are necessary to improve the quality of evidence of AI-based detection of ACS.

Prognostic Accuracy of Antenatal Doppler Ultrasound Measures in Predicting Adverse Perinatal Outcomes for Pregnancies Complicated by Diabetes: A Systematic Review

OBJECTIVE

This study aimed to assess the prognostic accuracies of Doppler ultrasound measures in predicting adverse perinatal outcomes for pregnancies complicated with preexisting or gestational diabetes mellitus.

DATA SOURCES

An online database search of MEDLINE, Cochrane, Embase, CINAHL, Scopus, and Emcare from inception to April 2022 was conducted.

STUDY ELIGIBILITY CRITERIA

Studies reporting singleton, nonanomalous fetuses of women with either preexisting (type 1 or 2 diabetes mellitus) or gestational diabetes mellitus during pregnancy were included. In addition, the included studies assessed cerebroplacental ratio and middle cerebral artery and/or umbilical artery pulsatility index in the prediction of either: preterm birth, cesarean delivery for fetal distress, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score <7 at 5 minutes, neonatal intensive care unit admission (>24 hours), acute respiratory distress syndrome, jaundice, hypoglycemia, hypocalcemia, or neonatal death.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed and 610 articles were identified, of which 15 were included. Two authors independently extracted prognostic data from each article and assessed the study applicability and risk of bias using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) scoring criteria.

RESULTS

A total of 15 studies were included in the review and comprised prospective (n=10; 66%) and retrospective (n=5; 33%) cohorts. Sensitivity and positive predictive values varied widely across each Doppler measurement. Umbilical artery sensitivities were higher than those of cerebroplacental ratio and middle cerebral artery for hypoglycemia, jaundice, neonatal intensive care unit admission, respiratory distress, and preterm birth. Cerebroplacental ratio was the most reported index test; however, prognostic accuracy was worse than that of umbilical artery and middle cerebral artery Doppler across all adverse perinatal outcomes. Significant risk of bias was present in 14 (94%) studies, with substantial heterogeneity observed across studies in terms of study design and outcomes assessed.

CONCLUSION

Abnormal umbilical artery pulsatility index may be of more clinical value in predicting adverse perinatal outcomes compared with cerebroplacental ratio and middle cerebral artery pulsatility index in diabetic pregnancies. Further evaluation of umbilical artery Doppler measurements in diabetic pregnancies using standardized variables across studies is required for broader clinical application. The significant association between abnormal Doppler measurement and hypoglycemia may warrant further investigation.

Monocyte Distribution Width as a Diagnostic Marker for Infection: A Systematic Review and Meta-analysis

BACKGROUND

Monocyte distribution width (MDW) is an emerging biomarker for infection. It is available easily and quickly as part of the CBC count, which is performed routinely on hospital admission. The increasing availability and promising results of MDW as a biomarker in sepsis has prompted an expansion of its use to other infectious diseases.

RESEARCH QUESTION

What is the diagnostic performance of MDW across multiple infectious disease outcomes and care settings?

STUDY DESIGN AND METHODS

A systematic review of the diagnostic performance of MDW across multiple infectious disease outcomes was conducted by searching PubMed, Embase, Scopus, and Web of Science through February 4, 2022. Meta-analysis was performed for outcomes with three or more reports identified (sepsis and COVID-19). Diagnostic performance measures were calculated for individual studies with pooled estimates created by linear mixed-effects models.

RESULTS

We identified 29 studies meeting inclusion criteria. Most examined sepsis (19 studies) and COVID-19 (six studies). Pooled estimates of diagnostic performance for sepsis differed by reference standard (Second vs Third International Consensus Definitions for Sepsis and Septic Shock criteria) and tube anticoagulant used and ranged from an area under the receiver operating characteristic curve (AUC) of 0.74 to 0.94, with mean sensitivity of 0.69 to 0.79 and mean specificity of 0.57 to 0.86. For COVID-19, the pooled AUC of MDW was 0.76, mean sensitivity was 0.79, and mean specificity was 0.59.

INTERPRETATION

MDW exhibited good diagnostic performance for sepsis and COVID-19. Diagnostic thresholds for sepsis should be chosen with consideration of reference standard and tube type used.

TRIAL REGISTRY

Prospero; No.: CRD42020210074; URL: https://www.crd.york.ac.uk/prospero/.

Reliability and validity of physical examination tests for the assessment of ankle instability

INTRODUCTION

Clinicians rely on certain physical examination tests to diagnose and potentially grade ankle sprains and ankle instability. Diagnostic error and inaccurate prognosis may have important repercussions for clinical decision-making and patient outcomes. Therefore, it is important to recognize the diagnostic value of orthopaedic tests through understanding the reliability and validity of these tests.

OBJECTIVE

To systematically review and report evidence on the reliability and validity of orthopaedic tests for the diagnosis of ankle sprains and instability.

METHODS

PubMed, CINAHL, Scopus, and Cochrane databases were searched from inception to December 2021. In addition, the reference list of included studies, located systematic reviews, and orthopaedic textbooks were searched. All articles reporting reliability or validity of physical examination or orthopaedic tests to diagnose ankle instability or sprains were included. Methodological quality of the reliability and the validity studies was assessed with The Quality Appraisal for Reliability studies checklist and the Quality Assessment of Diagnostic Accuracy Studies-2 respectively. We identified the number of times the orthopaedic test was investigated and the validity and/or reliability of each test.

RESULTS

Overall, sixteen studies were included. Three studies assessed reliability, eight assessed validity, and five evaluated both. Overall, fifteen tests were evaluated, none demonstrated robust reliability and validity scores. The anterolateral talar palpation test reported the highest diagnostic accuracy. Further, the anterior drawer test, the anterolateral talar palpation, the reverse anterior lateral drawer test, and palpation of the anterior talofibular ligament reported the highest sensitivity. The highest specificity was attributed to the anterior drawer test, the anterolateral drawer test, the reverse anterior lateral drawer test, tenderness on palpation of the proximal fibular, and the squeeze test.

CONCLUSION

Overall, the diagnostic accuracy, reliability, and validity of physical examination tests for the assessment of ankle instability were limited. Physical examination tests should not be used in isolation, but rather in combination with the clinical history to diagnose an ankle sprain. Preliminary evidence suggests that the overall validity of physical examination for the ankle may be better if conducted five days after the injury rather than within 48 h of injury.

Accuracy of anthropometric indicators of obesity to identify high blood pressure in adolescents-systematic review

Background

Anthropometric indicators of obesity have been associated with blood pressure in adolescents. However, the accuracy of anthropometric indicators of obesity for screening for high blood pressure (HBP) in adolescents is not known. Thus, the aim of the present study was to summarize the set of evidence regarding the predictive ability of anthropometric indicators of obesity to identify HBP in adolescents.

Methods

Searches were performed in five databases: MEDLINE, Web of Knowledge, Scopus, Scientific Electronic online (SciELO) and SportDiscus. The inclusion criteria for studies were: adolescents aged 10-19 years or mean age included in this range, observational and intervention studies, studies that proposed cutoff points for anthropometric indicators of obesity, and studies in English, Portuguese and Spanish. The methodological quality of studies was assessed using the QUADAS-2 instrument.

Results

Ten studies met the inclusion criteria and had their information summarized. Based on the information described in these studies, the anthropometric indicators body mass index (BMI), waist circumference (WC), waist-to-height-ratio (WHtR), triceps skinfold thickness, body adiposity index, C index, body mass, waist-to-arm span ratio, arm fat area, average arm perimeter, fat percentage and arm span were likely to be used in high blood pressure (HBP) screening among adolescents. However, only one study showed acceptable values (moderate to high precision) in relation to the accuracy measurements of described cutoffs.

Conclusion

Caution is suggested in the use of anthropometric indicators of obesity for HBP screening in adolescents, in which a greater number of studies with accurate diagnostic tools are necessary.

Can Dynamic Assessment Identify Language Disorder in Multilingual Children? Clinical Applications From a Systematic Review

PURPOSE

Multilingual children are disproportionately represented on speech pathology caseloads, in part due to the limited ability of traditional language assessments to accurately capture multilingual children's language abilities. This systematic review evaluates the evidence for identification of language disorder in multilingual children using dynamic assessment and considers clinical applications of the evidence.

METHOD

A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Centre, Education Source, Google Scholar, Linguistics, Medline, and PsycINFO databases produced 10 articles that met the inclusion criteria: between-groups comparison studies that used dynamic assessment to identify language disorder in children under 12 years old that spoke a different language at home to the majority society language. Articles were critically appraised using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) protocol.

RESULTS

Nine of the 10 studies reported that their dynamic assessment identified language disorder in multilingual children. However, small sample sizes, limited language pairs, variability in the reference standard, and design deficiencies resulted in poor ratings for all studies on QUADAS-2.

CONCLUSIONS

The studies in this review reflected an emergent area of research. Preliminary guidelines for clinical application indicate that dynamic assessment may be a suitable and time-efficient complementary method of diagnosis of language disorder in multilingual children. Further recommendations about age of use, language of instruction, and relevant scores are included.

Quality assessment practice in systematic reviews of mediation studies: results from an overview of systematic reviews

OBJECTIVE

To describe the bias assessment practice in recently published systematic reviews of mediation studies and to evaluate the quality of different bias assessment tools for mediation analysis proposed in the literature.

METHOD

We conducted an overview of systematic reviews by searching MEDLINE (OvidSP), PsycINFO (OvidSP), Cochrane Database of Systematic Reviews (OvidSP), and PubMed databases for systematic reviews of mediation studies published from 2007 to 2020. Two reviewers independently screened the title, abstracts, and full texts of the identified reports and extracted the data. The publications of all mediation-specific quality assessment tools used in these reviews were also identified for the evaluation of the tools' development and validation.

RESULT

Among 103 eligible reviews, 24 (23%) reviews did not assess the risk of bias of eligible studies, and 48 (47%) assessed risk of bias using a tool that was not specifically designed to evaluate mediation analysis. 31 (30.1%) reviews assessed the risk of mediation-specific biases, either narratively or by using specific tools for mediation studies. However, none of these tools were consensus-based, rigorously developed or validated.

CONCLUSION

The quality assessment practice in recently published systematic reviews of mediation studies is suboptimal. To improve the quality and consistency of risk of bias assessments for mediation studies, a consensus-based bias assessment tool is needed.

A systematic review of diagnostic tests to detect pelvic floor myofascial pain

INTRODUCTION AND HYPOTHESIS

Myofascial pain arising from pelvic floor muscles occurs in women with vaginismus, interstitial cystitis and endometriosis but is often overlooked. The aim is to examine alternative diagnostic tests to detect pelvic floor myofascial pain compared with standardized vaginal palpation of pelvic floor muscles as the reference test.

METHODS

A systematic review was prospectively conducted (PROSPERO-CRD42020183092) according to PRISMA guidelines. Databases searched included Ovid Medline 1946-, Embase 1957-, Scopus 1960-, Cochrane Combined, Clinical trials, Google Scholar (top 200 articles), Web of Science, TRIP, BIOSIS, DARE, CINHAL, EmCare, PEDro, ProQuest and EBSCOhost up to July 2020. Articles were independently screened by two authors and assessed for bias using QUASDAS-2 tool.

RESULTS

A total of 26,778 articles were screened and 177 were selected for full text review, of which 5 were selected for final analysis. Five studies included 9694 participants of which 1628 had pelvic floor myofascial pain. Only one study reported data to calculate sensitivities and specificities of the index test, which utilized a score of > 40 on the Central Sensitization Inventory to detect women with pelvic floor myofascial pain and revealed a sensitivity of 34.8% and a specificity of 84.9% compared to the reference test.

CONCLUSIONS

This systematic review did not reveal any diagnostic test superior to the pre-defined reference test. There is a lack of consensus on the definition of pelvic floor myofascial pain and a lack of a validated diagnostic criteria which must be addressed to progress with meaningful research in this field.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of uterosacral ligaments/torus uterinus, rectovaginal septum and vaginal deep endometriosis

STUDY QUESTION

Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis?

SUMMARY ANSWER

The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent.

WHAT IS KNOWN ALREADY

The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis.

STUDY DESIGN SIZE DURATION

A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology.

PARTICIPANTS/MATERIALS SETTING METHODS

All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32-82%) and 95% (95% CI 90-98%), respectively, and for all MRI techniques were 81% (95% CI 66-90%) and 83% (95% CI 62-94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30-80%) and 100% (95% CI 92-100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29-74%) and 98% (95% CI 95-99%), respectively, and for all MRI techniques were 64% (95% CI 40-83%) and 98% (96% CI 93-99%). Pooled analyses were not possible for other imaging modalities.

LIMITATIONS REASONS FOR CAUTION

There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease.

WIDER IMPLICATIONS OF THE FINDINGS

MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women's and Children's Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics.

REGISTRATION NUMBER

Prospective registration with PROSPERO (CRD42017059872) was obtained.

Subjective Cognitive Decline: Level of Risk for Future Dementia and Mild Cognitive Impairment, a Meta-Analysis of Longitudinal Studies

Subjective Cognitive Decline (SCD) in older adults has been identified as a risk factor for dementia, although the literature is inconsistent, and it is unclear which factors moderate progression from SCD to dementia. Through separate meta-analyses, we aimed to determine if SCD increased the risk of developing dementia or mild cognitive impairment (MCI). Furthermore, we examined several possible moderators. Longitudinal studies of participants with SCD at baseline, with data regarding incident dementia or MCI, were extracted from MEDLINE and PsycINFO. Articles were excluded if SCD occurred solely in the context of dementia, MCI, or as part of a specific disease. Pooled estimates were calculated using a random-effects model, with moderator analyses examining whether risk varied according to SCD definition, demographics, genetics, recruitment source, and follow-up duration. Risk of study bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. 46 studies with more than 74,000 unique participants were included. SCD was associated with increased risk of developing dementia (HR = 1.90, 95% CI 1.52-2.36; OR = 2.48, 95% CI 1.97-3.14) and MCI (HR = 1.73, 95% CI 1.18-2.52; OR = 1.83, 95% CI 1.56-2.16). None of the potential moderating factors examined influenced the HR or OR of developing dementia. In contrast, including worry in the definition of SCD, younger age, and recruitment source impacted the OR of developing MCI, with clinic samples demonstrating highest risk. SCD thus represents an at-risk phase, ideal for early intervention, with further research required to identify effective interventions for risk reduction, and cognitive-behavioural interventions for cognitive management. PROSPERO, protocol number: CRD42016037993.

Does ozone inhalation cause adverse metabolic effects in humans? A systematic review

We utilized a practical, transparent approach for systematically reviewing a chemical-specific evidence base. This approach was used for a case study of ozone inhalation exposure and adverse metabolic effects (overweight/obesity, Type 1 diabetes [T1D], Type 2 diabetes [T2D], and metabolic syndrome). We followed the basic principles of systematic review. Studies were defined as "Suitable" or "Supplemental." The evidence for Suitable studies was characterized as strong or weak. An overall causality judgment for each outcome was then determined as either causal, suggestive, insufficient, or not likely. Fifteen epidemiologic and 33 toxicologic studies were Suitable for evidence synthesis. The strength of the human evidence was weak for all outcomes. The toxicologic evidence was weak for all outcomes except two: body weight, and impaired glucose tolerance/homeostasis and fasting/baseline hyperglycemia. The combined epidemiologic and toxicologic evidence was categorized as weak for overweight/obesity, T1D, and metabolic syndrome,. The association between ozone exposure and T2D was determined to be insufficient or suggestive. The streamlined approach described in this paper is transparent and focuses on key elements. As systematic review guidelines are becoming increasingly complex, it is worth exploring the extent to which related health outcomes should be combined or kept distinct, and the merits of focusing on critical elements to select studies suitable for causal inference. We recommend that systematic review results be used to target discussions around specific research needs for advancing causal determinations.

Optimal imaging modality for detection of rectosigmoid deep endometriosis: systematic review and meta-analysis

OBJECTIVES

To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality.

METHODS

A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS-2 tool was used to assess the quality of the included studies. Mixed-effects diagnostic meta-analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR-) test and diagnostic odds ratio (DOR).

RESULTS

Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR- and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83-92%), 97% (95% CI, 95-98%), 30.8 (95% CI, 17.6-54.1), 0.12 (95% CI, 0.08-0.17) and 264 (95% CI, 113-614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79-91%), 96% (95% CI, 94-97%), 21.0 (95% CI, 13.4-33.1), 0.15 (95% CI, 0.09-0.23) and 144 (95% CI, 70-297). For computed tomography, the respective values were 93% (95% CI, 84-97%), 95% (95% CI, 81-99%), 20.3 (95% CI, 4.3-94.9), 0.07 (95% CI, 0.03-0.19) and 280 (95% CI, 28-2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87-95%), 98% (95% CI, 96-99%), 37.1 (95% CI, 21.1-65.4), 0.08 (95% CI, 0.05-0.14) and 455 (95% CI, 196-1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS-2 tool.

CONCLUSIONS

The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first-line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

A systematic review of small sided games within rugby: Acute and chronic effects of constraints manipulation

Small-sided games is a commonly used training method to develop technical, tactical and physical qualities concurrently. However, a review of small-sided games in rugby football codes (e.g. rugby union, rugby league) is not available. This systematic review aims to investigate the acute responses and chronic adaptations of small-sided games within rugby football codes considering the constraints applied. Four electronical databases were systematically searched until August 2020. Acute and chronic studies investigating rugby football codes small-sided games, with healthy amateur and professional athletes were included. Twenty studies were eventually included: 4 acute and 1 chronic in rugby union, 13 acute and 2 chronic in rugby league. Acute studies investigated task and individual constraints. Chronic studies showed that small-sided games would be an effective training method to improve physical performance. Current research in rugby football codes is heavily biased towards investigating how manipulating constraints can affect the physical characteristics of small-sided games, with limited literature investigating the effect on technical skills, and no studies investigating tactical behaviour. Future research is needed to evidence the effects of constraint manipulation on technical and tactical behaviour of rugby football players in small-sided games, in addition to physical characteristics.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis

OBJECTIVE

To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis.

METHODS

A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872).

RESULTS

Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28-79%), 99 % (95 % CI 98-100%), 54.5 (95 % CI 18.9-157.4), 0.46 (95 % CI 0.25 - 0.85) and 119 (95 % CI 24-577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23-82%), 99 % (96 % CI 97-100%), 48.8 (95 % CI 13.1-181.4), 0.47 (95 % CI 0.23 - 0.98), and 104 (95 % CI 15-711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool.

CONCLUSIONS

Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.

Microbiome changes associated with acute and chronic pancreatitis: A systematic review

BACKGROUND

Altered intestinal microbiota has been reported in pancreatic disorders, however, it remains unclear whether these changes alter the course of disease in patients with acute (AP) and chronic pancreatitis (CP), or whether these disease states alter the environment to enable pathogenic microbial composition changes to occur. We undertook a systematic review to characterize the gut microbiome in pancreatitis patients.

METHODS

MEDLINE and EMBASE were searched for studies on microbiota in pancreatitis published from January 1, 2000 to June 5, 2020. Animal studies, reviews, case reports, and non-English articles were excluded. A frequency analysis was performed for outcomes reported in ≥2 studies and studies were analyzed for risk of bias and quality of evidence.

RESULTS

22 papers met inclusion criteria; 15 included AP, 7 included CP. No studies were appropriately designed to assess whether alterations in the gut microbiome exacerbate pancreatitis or develop as a result of pancreatitis. We did identify several patterns of microbiome changes that are associated with pancreatitis. The gut microbiome demonstrated decreased alpha diversity in 3/3 A P studies and 3/3 C P studies. Beta diversity analysis revealed differences in bacterial community composition in the gut microbiome in 2/2 A P studies and 3/3 C P studies. Functionally, gut microbiome changes were associated with infectious pathways in AP and CP. Several studies suffered from high risk of bias and inadequate quality.

CONCLUSIONS

Detecting differences in microbial composition associated with AP and CP may represent a diagnostic tool. Appropriately controlled longitudinal studies are needed to determine whether microbiome changes are causative or reactive in pancreatitis.

A tool for assessment of risk of bias in studies of adverse effects of orthodontic treatment applied in a systematic review on external root resorption

BACKGROUND AND AIMS

Systematic reviews (SRs) are considered to provide reliable estimates, but flaws in designs, methods of monitoring effects, and outcomes have the potential to bias results. There are several tools for assessing risk of bias (RoB), most of them designed for SRs of beneficial effects. To our knowledge, there is no tool that is adapted specifically to assess RoB in studies of adverse effects associated with orthodontic treatment. To address this, the aim of this study was first to introduce a tool for assessment of RoB in studies of adverse effects associated with orthodontic treatment and, second, to apply it in an SR of external root resorption (ERR) associated with orthodontic treatment with fixed appliance.

MATERIALS AND METHODS

The approach with domains supported by signalling questions was used for the tool. Domains and signalling questions were tailored to the review questions of the SR of studies of ERR after orthodontic treatment using periapical radiography or cone beam computed tomography. Duplicate study selection, data extraction, and RoB assessment using the tool, followed by meta-analyses, were performed.

RESULTS

Using the tool for the assessment of RoB identified shortcomings and report deficiencies of primary studies concerning the presentation of orthodontic treatment, identification of ERR, and analysis of outcomes. RoB assessment resulted in 12 of 32 studies read in full text being included. Reported severe ERR varied across studies between 2 and 14 per cent for all incisors and 10 and 29 per cent for maxillary incisors. Results of ERR related to patients' age and sex, orthodontic diagnosis, and treatment were contradictory. Quality of evidence evaluated by GRADE was low due to study limitations, imprecision, and inconsistency of study results.

CONCLUSIONS

As the tool and its application highlight important issues to consider when planning, conducting, and reporting research, the tool may have a valuable role for quality enhancement of future studies of outcomes of orthodontic treatment. The tool may also serve for authors when planning SRs. Our SR identified a need for studies that use rigorous methodology and transparent reporting.

REGISTRATION

PROSPERO (ID = CRD42018084725).

A unified framework for bias assessment in clinical research

Methodological flaws, limitations, and inadequate practices in research are well known and pose threats to the internal validity of any research study. However, there are ways of safeguarding research conduct to reduce the chance of research producing distorted results. Numerous tools now exist to assess the incorporation of such safeguards into primary research studies (also known as quality and/or risk-of-bias assessment). These tools typically include a variety of items that are then checked against those implemented in the study. Despite a lot of research in this area, no comprehensive generic classification of safeguards across study designs exist, although attempts have been made to clarify aspects of this. We review the developments in this area as well as use preliminary data from 100 methodological studies to illustrate our proposed approach. We conclude by proposing a new framework for identifying research studies at risk of being biased and the information in this article will promote a unification of the diverse approaches to facilitating bias assessment in clinical research.

Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome: A Systematic Review

Ultrasound (US) assists in the determination of the pathology underlying greater trochanteric pain syndrome (GTPS); however, there exists no consensus regarding the US criteria used to define these pathologies. We aim to explore these US definitions and their associated prevalence. "Trochanteric bursitis" was defined in 10 studies (13 included studies) and was heterogeneously described. "Tendinopathy" was defined in 4 studies, while 7 studies defined "tendinosis." "Tendon tears" were defined in 8 studies, 6 of which distinguished between "partial- and full-thickness tears." Tendon pathology was most frequent in 5 studies (prevalence: 7%-93%), and bursitis in 2 studies (prevalence: 10%-75%); 3 studies had equal distribution. Methodological quality was limited in the descriptions of GTPS and US approaches. Together, we document the lack of standardized US definitions of the pathologies underlying GTPS. This may explain the heterogenous prevalence of US findings. Standardized definitions are needed to improve the reliability of future GTPS studies.

Will urinary biomarkers provide a breakthrough in diagnosing cardiac surgery-associated AKI? - A systematic review

Introduction: Acute kidney injury following cardiac surgery is a dreaded complication contributing to early mortality. Diagnosing AKI using serum creatinine usually results in a delay. To combat this, certain kidney damage specific biomarkers were investigated to identify if they can serve as early predictors of cardiac surgery-associated AKI (CSA-AKI). This study systematically reviews three such biomarkers; NGAL, tissue inhibitor of matrix metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP7) to identify if they can serve as early predictors of CSA-AKI.Methods: Systematic search was carried out on literature reporting the diagnostic ability of the three biomarkers from databases in accordance with PRISMA guidelines.Results: We found 43 articles reporting urinary-NGAL levels (n = 34 in adults, n = 9 in children) and 10 studies reporting TIMP-2 and IGFBP7 levels among adults. Interestingly, NGAL showed high diagnostic value in predicting AKI in children (seven among nine studies with AUROC > 0.8). The cell cycle arrest biomarkers, namely TIMP-2 and IGFBP7, showed high diagnostic value in predicting AKI in adults (five among ten studies with AUROC > 0.8).Conclusion: In predicting CSA-AKI; the diagnostic value of NGAL is high in the paediatric population while the diagnostic value of TIMP-2 and IGFBP7 is high in adults.

Postmortem evidence of brain inflammatory markers in bipolar disorder: a systematic review

Bipolar disorder (BD) is a chronic affective disorder with extreme mood swings that include mania or hypomania and depression. Though the exact mechanism of BD is unknown, neuroinflammation is one of the numerous investigated etiopathophysiological causes of BD. This article presents a systematic review of the data regarding brain inflammation evaluating microglia, astrocytes, cytokines, chemokines, adhesion molecules, and other inflammatory markers in postmortem BD brain samples. This systematic review was performed according to PRISMA recommendations, and relevant studies were identified by searching the PubMed/MEDLINE, PsycINFO, EMBASE, LILACS, IBECS, and Web of Science databases for peer-reviewed journal articles published by March 2019. Quality of included studies appraised using the QUADAS-2 tool. Among the 1814 articles included in the primary screening, 51 articles measured inflammatory markers in postmortem BD brain samples. A number of studies have shown evidence of inflammation in BD postmortem brain samples. However, an absolute statement cannot be concluded whether neuroinflammation is present in BD due to the large number of studies did not evaluate the presence of infiltrating peripheral immune cells in the central nervous system (CNS) parenchyma, cytokines levels, and microglia activation in the same postmortem brain sample. For example, out of 15 studies that evaluated microglia cells markers, 8 studies found no effect of BD on these cells. Similarly, 17 out of 51 studies evaluating astrocytes markers, 9 studies did not find any effect of BD on astrocyte cells, whereas 8 studies found a decrease and 2 studies presented both increase and decrease in different brain regions. In addition, multiple factors account for the variability across the studies, including postmortem interval, brain area studied, age at diagnosis, undergoing treatment, and others. Future analyses should rectify these potential sources of heterogeneity and reach a consensus regarding the inflammatory markers in postmortem BD brain samples.

The diagnostic performance of magnetic resonance imaging for differentiating the nature of cardiac masses: A systematic review protocol

BACKGROUND

Cardiac masses are rare, but lead to high risk of stroke and death. Because of the different treatment methods, it is significant for clinicians to differentiate the nature of masses. Cardiac magnetic resonance (CMR) imaging has high intrinsic soft-tissue contrast and high spatial and temporal resolution and can provide evidence for differential diagnosis of cardiac masses. However, there is no evidence-based conclusion as to its accuracy. Therefore, the purpose of our study is to perform a systematic review on this issue and provide useful information for clinical diagnosis and treatment.

METHODS

We will perform a systematic search in EMBASE, Cochrane Library, PubMed and Web of Science for diagnostic studies using CMR to detect cardiac masses from inception to October, 2019. Two authors will independently screen titles and abstracts for relevance, review full texts for inclusion and conduct detail data extraction. The methodological quality will be assessed using the QUADAS-2 tool. If pooling is possible, we will use bivariate model for diagnostic meta-analysis to estimate summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of CMR, as well as different sequences of CMR. Estimates of sensitivity and specificity from each study will be plotted in summary receive operating curve space and forest plots will be constructed for visual examination of variation in test accuracy. If enough studies are available, we will conduct sensitivity analysis and subgroup analysis.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

To our knowledge, this will be the first systematic review on the accuracy of CMR in the differential diagnosis of cardiac masses. This study will provide evidence and data to form a comprehensive understanding of the clinical value of CMR for cardiac masses patients.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required, as this study is a systematic review.

PROSPERO REGISTRATION NUMBER

CRD42019137800.

Diagnostic accuracy of midkine on hepatocellular carcinoma: A meta-analysis

OBJECTIVE

To evaluate the dependability and accuracy of midkine (MK) in the diagnosis of hepatocellular carcinoma (HCC).

METHODS

PubMed, EMBASE, Web of Science, China Biology Medicine disc and grey literature sources were searched from the date of database inception to January 2019. Two authors (B-H.Z. and B.L.) independently extracted the data and evaluated the study quality using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were estimated using a bivariate model. Moreover, hierarchical summary receiver operating characteristic curves were generated. The diagnostic odds ratio (DOR) and area under the curve (AUC) were pooled using a univariate model.

RESULTS

Nine articles (11 studies) were included (1941 participants). The bivariate analysis revealed that the sensitivity and specificity of MK for HCC diagnosis were 0.85 (95% CI 0.78-0.91) and 0.83 (95% CI 0.76-0.88), respectively. We also found a LR+ of 5.05 (95% CI 3.33-7.40), a LR- of 0.18 (95% CI 0.11-0.28), a DOR of 31.74 (95% CI 13.98-72.09) and an AUC of 0.91 (95% CI 0.84-0.99). Subgroup analyses showed that MK provided the best efficiency for HCC diagnosis when the cutoff value was greater than 0.5 ng/mL.

CONCLUSIONS

MK has an excellent diagnostic value for hepatocellular carcinoma.

Polymerase chain reaction blood tests for the diagnosis of invasive aspergillosis in immunocompromised people

BACKGROUND

This is an update of the original review published in the Cochrane Database of Systematic Reviews Issue 10, 2015.Invasive aspergillosis (IA) is the most common life-threatening opportunistic invasive mould infection in immunocompromised people. Early diagnosis of IA and prompt administration of appropriate antifungal treatment are critical to the survival of people with IA. Antifungal drugs can be given as prophylaxis or empirical therapy, instigated on the basis of a diagnostic strategy (the pre-emptive approach) or for treating established disease. Consequently, there is an urgent need for research into both new diagnostic tools and drug treatment strategies. Increasingly, newer methods such as polymerase chain reaction (PCR) to detect fungal nucleic acids are being investigated.

OBJECTIVES

To provide an overall summary of the diagnostic accuracy of PCR-based tests on blood specimens for the diagnosis of IA in immunocompromised people.

SEARCH METHODS

We searched MEDLINE (1946 to June 2015) and Embase (1980 to June 2015). We also searched LILACS, DARE, Health Technology Assessment, Web of Science and Scopus to June 2015. We checked the reference lists of all the studies identified by the above methods and contacted relevant authors and researchers in the field. For this review update we updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 3) in the Cochrane Library; MEDLINE via Ovid (June 2015 to March week 2 2018); and Embase via Ovid (June 2015 to 2018 week 12).

SELECTION CRITERIA

We included studies that: i) compared the results of blood PCR tests with the reference standard published by the European Organisation for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG); ii) reported data on false-positive, true-positive, false-negative and true-negative results of the diagnostic tests under investigation separately; and iii) evaluated the test(s) prospectively in cohorts of people from a relevant clinical population, defined as a group of individuals at high risk for invasive aspergillosis. Case-control and retrospective studies were excluded from the analysis.

DATA COLLECTION AND ANALYSIS

Authors independently assessed quality and extracted data. For PCR assays, we evaluated the requirement for either one or two consecutive samples to be positive for diagnostic accuracy. We investigated heterogeneity by subgroup analyses. We plotted estimates of sensitivity and specificity from each study in receiver operating characteristics (ROC) space and constructed forest plots for visual examination of variation in test accuracy. We performed meta-analyses using the bivariate model to produce summary estimates of sensitivity and specificity.

MAIN RESULTS

We included 29 primary studies (18 from the original review and 11 from this update), corresponding to 34 data sets, published between 2000 and 2018 in the meta-analyses, with a mean prevalence of proven or probable IA of 16.3 (median prevalence 11.1% , range 2.5% to 57.1%). Most patients had received chemotherapy for haematological malignancy or had undergone hematopoietic stem cell transplantation. Several PCR techniques were used among the included studies. The sensitivity and specificity of PCR for the diagnosis of IA varied according to the interpretative criteria used to define a test as positive. The summary estimates of sensitivity and specificity were 79.2% (95% confidence interval (CI) 71.0 to 85.5) and 79.6% (95% CI 69.9 to 86.6) for a single positive test result, and 59.6% (95% CI 40.7 to 76.0) and 95.1% (95% CI 87.0 to 98.2) for two consecutive positive test results.

AUTHORS' CONCLUSIONS

PCR shows moderate diagnostic accuracy when used as screening tests for IA in high-risk patient groups. Importantly the sensitivity of the test confers a high negative predictive value (NPV) such that a negative test allows the diagnosis to be excluded. Consecutive positives show good specificity in diagnosis of IA and could be used to trigger radiological and other investigations or for pre-emptive therapy in the absence of specific radiological signs when the clinical suspicion of infection is high. When a single PCR positive test is used as the diagnostic criterion for IA in a population of 100 people with a disease prevalence of 16.3% (overall mean prevalence), three people with IA would be missed (sensitivity 79.2%, 20.8% false negatives), and 17 people would be unnecessarily treated or referred for further tests (specificity of 79.6%, 21.4% false positives). If we use the two positive test requirement in a population with the same disease prevalence, it would mean that nine IA people would be missed (sensitivity 59.6%, 40.4% false negatives) and four people would be unnecessarily treated or referred for further tests (specificity of 95.1%, 4.9% false positives). Like galactomannan, PCR has good NPV for excluding disease, but the low prevalence of disease limits the ability to rule in a diagnosis. As these biomarkers detect different markers of disease, combining them is likely to prove more useful.

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

Inflammatory proteins are altered in chronic fatigue syndrome-A systematic review and meta-analysis

Immune dysfunction has been posited as a key element in the aetiology of chronic fatigue syndrome (CFS) since the illness was first conceived. However, systematic reviews have yet to quantitatively synthesise inflammatory biomarkers across the literature. We undertook a systematic review and meta-analysis to quantify available data on circulating inflammatory proteins, examining studies recruiting patients with a CFS diagnosis and a non-affected control group. Results were meta-analysed from 42 studies. Patients with CFS had significantly elevated tumour necrosis factor (ES = 0.274, p < 0.001), interleukin-2 (ES = 0.203, p = 0.006), interleukin-4 (ES = 0.373, p = 0.004), transforming growth factor-β (ES = 0.967, p < 0.001) and c-reactive protein (ES = 0.622, p = 0.019). 12 proteins did not differ between groups. These data provide some support for an inflammatory component in CFS, although inconsistency of results indicates that inflammation is unlikely to be a primary feature in all those suffering from this disorder. It is hoped that further work will elucidate whether there are subgroups of patients with clinically-relevant inflammatory dysfunction, and whether inflammatory cytokines may provide a prognostic biomarker or moderate treatment effects.

¹³C-Urea Breath Test Accuracy for <i>Helicobacter pylori</i> Infection in the Asian Population: A Meta-Analysis

Background:

Helicobacter pylori (H. pylori) infection is known to be associated with peptic ulcer and gastric cancer. Detection of H. pylori infection is a significant part of peptic ulcer and gastric cancer prevention and management. ¹³C-urea breath test (UBT) provides a good option for the pathogen detection due to its accuracy and safety.

Objective:

This review aims to evaluate the ¹³C-UBT diagnostic accuracy studies conducted among Asian population and validate its use for the Asian population.

Methods:

Original articles were systematically searched in PubMed, Scopus, and Google Scholar using the PICOS strategy by applying relevant keywords. Only studies published in English and conducted in Asia were included. Our search returned 276 articles. After assessment, 11 articles which answered our research question and met the criteria set for systematic review and meta-analysis were accepted. A total of 15 study protocols were extracted from the 11 accepted articles.

Findings:

Majority of the studies were conducted in Hong Kong (six), followed by Taiwan (five), Japan (two), and one each in Singapore and Israel. All studies had used histology as part of its gold standard of reference. All but one study was performed on adult populations. The summary estimate for sensitivity was 97% (95% CI: 96, 98%), and specificity was 96% (95% CI: 95, 97%), with significant heterogeneity between studies. Adjusting for the dose (50 mg) and breath sample collection time (20 minutes) had improved both accuracy estimates and significantly reduced heterogeneity.

Conclusion:

This review supports the test-and-treat strategy for H. pylori infection management. Prevalence and cost-effectiveness studies are mandatory for health authorities to adopt this strategy into national policy.

Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy

BACKGROUND

Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disorder, possibly associated with an increased risk of severe fetal adverse events. Total serum bile acids (TSBA) concentration, alone or in combination with serum aminotransferases, have been the most often used biomarkers for the diagnosis of intrahepatic cholestasis of pregnancy in clinical practice. Serum bile acid profile, composed of primary or secondary, conjugated or non-conjugated bile acids, may provide more specific disease information.

OBJECTIVES

To assess and compare, independently or in combination, the diagnostic accuracy of total serum bile acids or serum bile acids profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women, presenting with pruritus. To define the optimal cut-off values for components of serum bile acid profile; to investigate possible sources of heterogeneity.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, BIOSIS, CINAHL, two Chinese databases (CKNI, VIP), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Evidence Search: Health and Social Care by the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO) Reproductive Health Library (RHL), and the Turning Research into Practice database (TRIP). The most recent date of search was 6 May 2019. We identified additional references by handsearching the references of articles, meta-analyses, and evidence-based guidelines retrieved from the computerised databases, on-line trial registries, and grey literature through OpenSIGLE, National Technical Information Service (NTIS), ProQuest Dissertations & Thesis Database, and Index to Theses in Great Britain and Ireland.

SELECTION CRITERIA

Prospective or retrospective diagnostic case-control or cross-sectional studies, irrespective of publication date, format, and language, which evaluated the diagnostic accuracy of total serum bile acids (TSBA) or components of serum bile acid profile for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women of any age or ethnicity, in any clinical setting, symptomatic for pruritus.

DATA COLLECTION AND ANALYSIS

We selected studies by reading titles, abstracts, or full texts, and assessing their fulfilment of our inclusion criteria. We emailed primary authors to request missing data or individual participant data. Having extracted data from each included study, we built the two-by-two tables for each primary study and for all the index tests considered. We estimated sensitivity and specificity with their 95% confidence intervals (CI). We presented data in coupled forest plots, showing sensitivities and specificities of each study, and we plotted the studies in the Receiver Operating Characteristic (ROC) space. We performed meta-analyses adopting the hierarchical summary ROC model (HSROC) or the bivariate model to meta-analyse the data. We made indirect comparisons of the considered index tests by adding the index tests as covariates to the bivariate or HSROC models. We performed heterogeneity analysis and sensitivity analysis on studies assessing TSBA accuracy. We used Review Manager 5 (RevMan 5) and SAS statistical software, release 9.4 (SAS Institute Inc., Cary, NC, USA), to perform all statistical analyses. We used QUADAS-2 domains to assess the risk of bias of the included studies.

MAIN RESULTS

Our search yielded 5073 references, but at the end of our selection process, only 16 studies fulfilled the review inclusion criteria. Nine of these provided individual participant data. We analysed only data concerning TSBA, cholic acid (CA), glycocholic acid (GCA), chenodeoxycholic acid (CDCA), and CA/CDCA because the remaining planned index tests were assessed in few studies. Only one study had low risk of bias in all four QUADAS-2 domains. The most biased domains were the patient sampling and the reference standard domains. When considering all studies with a cut-off of 10 μmol/L, TSBA overall sensitivity ranged from 0.72 to 0.98 and specificity ranged from 0.81 to 0.97. After a sensitivity analysis excluding case-control studies, TSBA sensitivity ranged from 0.48 to 0.66 and specificity from 0.52 to 0.99. After a sensitivity analysis excluding studies in which TSBA was part of the reference standard, TSBA sensitivity ranged from 0.49 to 0.65 and specificity from 0.53 to 0.99. We found the estimates of the overall accuracy for some serum bile acid components (CA, GCA, CDCA, and CA/CDCA) to be imprecise, with the CI for sensitivity and specificity very wide or impossible to calculate. Indirect comparisons between serum bile acid profile components and TSBA were not statistically significant. None of the heterogeneity analysis performed was statistically significant, except for the timing of assessment of TSBA (onset of symptoms, peak value among multiple assessments, delivery) but without clinically relevant results. We could not analyse the diagnostic accuracy of combinations of index tests because none of the included studies carried them out, and because of the small number of included studies.

AUTHORS' CONCLUSIONS

The overall high risk of bias, the existing concern regarding applicability of the results in clinical practice, and the great heterogeneity of the results in the included studies prevents us from making recommendations and reaching definitive conclusions at the present time. Thus, we do not find any compelling evidence to recommend or refute the routine use of any of these tests in clinical practice. So far, the diagnostic accuracy of TSBA for intrahepatic cholestasis of pregnancy might have been overestimated. There were too few studies to permit a precise estimate of the accuracy of serum bile acid profile components. Further primary clinical research is mandatory. We need both further phase II and phase III diagnostic studies.

Galactomannan detection in broncho-alveolar lavage fluid for invasive aspergillosis in immunocompromised patients

BACKGROUND

Invasive aspergillosis (IA) is a life-threatening opportunistic mycosis that occurs in some people with a compromised immune system. The serum galactomannan enzyme-linked immunosorbent assay (ELISA) rapidly gained widespread acceptance as part of the diagnostic work-up of a patient suspected of IA. Due to its non-invasive nature, it can be used as a routine screening test. The ELISA can also be performed on bronchoalveolar lavage (BAL), allowing sampling of the immediate vicinity of the infection. The invasive nature of acquiring BAL, however, changes the role of the galactomannan test significantly, for example by precluding its use as a routine screening test.

OBJECTIVES

To assess the diagnostic accuracy of galactomannan detection in BAL for the diagnosis of IA in people who are immunocompromised, at different cut-off values for test positivity, in accordance with the Cochrane Diagnostic Test Accuracy Handbook.

SEARCH METHODS

We searched three bibliographic databases including MEDLINE on 9 September 2016 for aspergillosis and galactomannan as text words and subject headings where appropriate. We checked reference lists of included studies for additional studies.

SELECTION CRITERIA

We included cohort studies that examined the accuracy of BAL galactomannan for the diagnosis of IA in immunocompromised patients if they used the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) classification as reference standard.

DATA COLLECTION AND ANALYSIS

Two review authors assessed study quality and extracted data. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used for quality assessment.

MAIN RESULTS

We included 17 studies in our review. All studies except one had a high risk of bias in two or more domains. The diagnostic performance of an optical density index (ODI) of 0.5 as cut-off value was reported in 12 studies (with 1123 patients). The estimated sensitivity was 0.88 (95% confidence interval (CI) 0.75 to 1.00) and specificity 0.81 (95% CI 0.71 to 0.91). The performance of an ODI of 1.0 as cut-off value could be determined in 11 studies (with 648 patients). The sensitivity was 0.78 (95% CI 0.61 to 0.95) and specificity 0.93 (95% CI 0.87 to 0.98). At a cut-off ODI of 1.5 or higher, the heterogeneity in specificity decreased significantly and was invariably >90%.

AUTHORS' CONCLUSIONS

The optimal cut-off value depends on the local incidence and clinical pathway. At a prevalence of 12% a hypothetical population of 1000 patients will consist of 120 patients with IA. At a cut-off value of 0.5 14 patients with IA will be missed and there will be 167 patients incorrectly diagnosed with IA. If we use the test at a cut-off value of 1.0, we will miss 26 patients with IA. And there will be 62 patients incorrectly diagnosed with invasive aspergillosis. The populations and results were very heterogeneous. Therefore, interpretation and extrapolation of these results has to be performed with caution. A test result of 1.5 ODI or higher appears a strong indicator of IA.

Seven Hormonal Biomarkers for Diagnosing Endometriosis: Meta-Analysis and Adjusted Indirect Comparison of Diagnostic Test Accuracy

OBJECTIVE

To compare the diagnostic accuracy of different hormonal biomarkers and to find the most effective hormonal biomarker for the diagnosis of endometriosis.

DATA SOURCES

We conducted a systematic search using PubMed, EMBASE, Cochrane Library, and China Biomedical Literature to identify relevant studies from the first day of databases to August 2018.

METHODS OF STUDY SELECTION

Two independent reviewers screened for study eligibility and extracted data. Random controlled trials, cross-sectional studies, case-control studies, and cohort studies evaluating the diagnostic accuracy of hormonal markers for endometriosis were included.

TABULATION, INTEGRATION, AND RESULTS

We included 17 studies that involved 1279 participants and evaluated 7 hormonal biomarkers. The pooled sensitivity and specificity in endometriosis were .79 (.71, .86) and .89 (.82, .94) for aromatase, .30 (.18, .46) and .80 (.65, .90) for human chorionic gonadotropin/luteinizing hormone receptor, .75 (.66, .83) and .47 (.34, .60) for estrogen receptor (ER)-α, .65 (.56, .74) and .68 (.55, .80) for ER-β, .45 (.38-.52) and .92 (.85-.97) for serum prolactin, .69 (.51, .83) and .30 (.16, .49) for estrogen sulfotransferase, and .73 (.60-.84) and .48 (.33-.63) for 17β-hydroxysteroid dehydrogenase type 2 (17βHSD2). Compared with human chorionic gonadotropin/luteinizing hormone receptor, ER-α, ER-β, estrogen sulfotransferase, and 17βHSD2, aromatase had a higher sensitivity, specificity, positive likelihood ratio, and diagnostic odds ratio. The specificities of aromatase and serum prolactin were comparable, but the sensitivity, positive likelihood ratio, and positive likelihood ratio of serum prolactin were much lower than that of aromatase.

CONCLUSION

Aromatase may be an excellent diagnostic test for endometriosis. However, because of the moderate quality of the included studies and the limited sample size, this result requires more research to validate. (PROSPERO registration number: PROSPERO 2018 CRD42018105126.).

Measurement properties of quality assessment tools for studies of diagnostic accuracy

OBJECTIVES

To determine the reliability, internal consistency, measurement error, convergent validity, and floor and ceiling effects of three quality assessment tools commonly used to evaluate the quality of diagnostic test accuracy studies in physical therapy. A secondary aim was to describe the quality of a sample of diagnostic accuracy studies.

STUDY DESIGN AND SETTING

50 studies were randomly selected from a comprehensive database of physical therapy-relevant diagnostic accuracy studies. Two reviewers independently rated each study with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Diagnostic Accuracy Quality Scale (DAQS) tools in random sequence.

RESULTS

Only 7% of QUADAS items, 14% of QUADAS-2 items, and 33% of DAQS items had at least moderate inter-rater reliability (kappa>0.40). Internal consistency and convergent validity measures were acceptable (>0.70) in 33% and 50% of cases respectively. Floor or ceiling effects were not present in any tool. The quality of studies was mixed: most avoided case-control sampling strategies and used the same reference standard on all subjects, but many failed to enroll a consecutive or random sample of subjects or provide confidence intervals about estimates of diagnostic accuracy.

CONCLUSION

The QUADAS, QUADAS-2 and DAQS tools provide unreliable estimates of the quality of studies of diagnostic accuracy in physical therapy.

Meta-analysis of the diagnostic value of Wisteria floribunda agglutinin-sialylated mucin1 and the prognostic role of mucin1 in human cholangiocarcinoma

OBJECTIVE

Serum carbohydrate antigen 19-9 (CA19-9) is a widely used tumour marker for cholangiocarcinoma (CCA). However, it is not a necessarily good CCA marker in terms of diagnostic accuracy. The purpose of this study is to evaluate the diagnostic value of Wisteria floribundaagglutinin-sialylated Mucin1 (WFA-MUC1) and the prognostic role of Mucin1 (MUC1) in human CCA.

DESIGN

Meta-analysis.

DATA SOURCES

Studies published in PubMed, Web of Science, The Cochrane Library and the China National Knowledge Infrastructure up to 11 October 2017.

ELIGIBILITY CRITERIA

We included reports assessing the diagnostic capacity of WFA-MUC1 and the prognostic role of MUC1 in CCA. The receiver operating characteristic curve (ROC) of WFA-MUC1 and/or CA19-9 was described, and the HRs including 95% CI and the corresponding p value for MUC1 can be extracted.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted data and assessed risk of bias. The diagnostic sensitivity and specificity data of WFA-MUC1 were extracted and analysed as bivariate data. Pooled HRs and its 95% CI for MUC1 were calculated with a random-effects meta-analysis model on overall survival of resectable CCA.

RESULTS

Sixteen reports were included in this study. The pooled sensitivity and specificity of WFA-MUC1 were 0.76 (95% CI 0.71 to 0.81) and 0.72 (95% CI 0.59 to 0.83) in serum, 0.85 (95% CI 0.81 to 0.89) and 0.72 (95% CI 0.64 to 0.80) in bile and 0.72 (95% CI 0.50 to 0.87) and 0.85 (95% CI 0.70 to 0.93) in tissue, respectively. The summary ROC (SROC) were 0.77 (95% CI 0.73 to 0.81) in serum, 0.88 (95% CI 0.85 to 0.90) in bile and 0.86 (95% CI 0.83 to 0.89) in tissue, respectively. Furthermore, the pooled sensitivity and specificity and the SROC of CA19-9 in serum were 0.67 (95% CI 0.61 to 0.72), 0.86 (95% CI 0.75 to 0.93) and 0.75 (95% CI 0.71 to 0.79), respectively. The pooled HRs for MUC1 was 2.20 (95% CI 1.57 to 3.01) in CCA and 4.17 (95% CI 1.71 to 10.17) in mass-forming intrahepatic CCA.

CONCLUSIONS

Compared with CA19-9, WFA-MUC1 was shown to possess stronger diagnostic capability. MUC1 could serve as a prognosis factor for poor outcomes of CCA, particularly, mass-forming intrahepatic CCA.

PROBAST: A Tool to Assess Risk of Bias and Applicability of Prediction Model Studies: Explanation and Elaboration

Prediction models in health care use predictors to estimate for an individual the probability that a condition or disease is already present (diagnostic model) or will occur in the future (prognostic model). Publications on prediction models have become more common in recent years, and competing prediction models frequently exist for the same outcome or target population. Health care providers, guideline developers, and policymakers are often unsure which model to use or recommend, and in which persons or settings. Hence, systematic reviews of these studies are increasingly demanded, required, and performed. A key part of a systematic review of prediction models is examination of risk of bias and applicability to the intended population and setting. To help reviewers with this process, the authors developed PROBAST (Prediction model Risk Of Bias ASsessment Tool) for studies developing, validating, or updating (for example, extending) prediction models, both diagnostic and prognostic. PROBAST was developed through a consensus process involving a group of experts in the field. It includes 20 signaling questions across 4 domains (participants, predictors, outcome, and analysis). This explanation and elaboration document describes the rationale for including each domain and signaling question and guides researchers, reviewers, readers, and guideline developers in how to use them to assess risk of bias and applicability concerns. All concepts are illustrated with published examples across different topics. The latest version of the PROBAST checklist, accompanying documents, and filled-in examples can be downloaded from www.probast.org.

Comparison of the diagnostic efficiency for local recurrence of rectal cancer using CT, MRI, PET and PET-CT: A systematic review protocol

BACKGROUND

The risk of local recurrence (LR) continues to threat patients with rectal cancer after surgery or chemoradiotherapy. The main reason is that there is frequently extensive scarring and reactive changes after radiotherapy and resection. Thus, the diagnosis of LR can be challenging. There are different imaging modalities that have been used in the follow-up of rectal cancer, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and positron emission tomography-computed tomography (PET-CT) in clinical practice.

METHODS

We will systematically search PubMed, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Database for diagnostic trials using CT, MRI, PET, and PET-CT to detect LR of rectal cancer in April, 2018. Two review authors will independently screen titles and abstracts for relevance, assess full texts for inclusion, and carry out data extraction and methodological quality assessment using the QUADAS-2 tool. We will use bivariate meta-analysis to estimate summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of CT, MRI, PET, and PET-CT, as well as different sequences of MRI. For each index test, estimates of sensitivity and specificity from each study will be plotted in summary receive operating curve space and forest plots will be constructed for visual examination of variation in test accuracy. We will perform meta-analyses using the hierarchical summary receiver-operating characteristic model to produce summary estimates of sensitivity and specificity. Then, head-to-head and indirect comparison meta-analyses will be carried out.

DISCUSSION

This review will help determine the diagnostic accuracy of CT, MRI, PET, and PET-CT for the diagnosis of patients with LR of rectal cancer.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required, as this study is a systematic review.

PROSPERO REGISTRATION NUMBER

CRD42018104918.

Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis

OBJECTIVE

The cerebroplacental ratio (CPR) has been proposed for the routine surveillance of pregnancies with suspected fetal growth restriction (FGR), but the predictive performance of this test is unclear. The aim of this study was to determine the accuracy of CPR for predicting adverse perinatal and neurodevelopmental outcomes in suspected FGR.

METHODS

PubMed, EMBASE, CINAHL and Lilacs were searched from inception to 31 July 2017 for cohort or cross-sectional studies reporting on the accuracy of CPR for predicting adverse perinatal and/or neurodevelopmental outcomes in singleton pregnancies with FGR suspected antenatally based on sonographic parameters. Summary receiver-operating characteristics (ROC) curves, pooled sensitivities and specificities, and summary likelihood ratios (LRs) were generated.

RESULTS

Twenty-two studies (including 4301 women) met the inclusion criteria. Summary ROC curves showed that the best predictive accuracy of CPR was for perinatal death and the worst was for neonatal acidosis, with areas under the summary ROC curves of 0.83 and 0.57, respectively. The predictive accuracy of CPR was moderate to high for perinatal death (pooled sensitivity and specificity of 93% and 76%, respectively, and summary positive and negative LRs of 3.9 and 0.09, respectively) and low for composite of adverse perinatal outcomes, Cesarean section for non-reassuring fetal status, 5-min Apgar score < 7, admission to the neonatal intensive care unit, neonatal acidosis and neonatal morbidity, with summary positive and negative LRs ranging from 1.1 to 2.5 and 0.3 to 0.9, respectively. An abnormal CPR result had moderate accuracy for predicting small-for-gestational age at birth (summary positive LR of 7.4). CPR had a higher predictive accuracy in pregnancies with suspected early-onset FGR. No study provided data for assessing the predictive accuracy of CPR for adverse neurodevelopmental outcome.

CONCLUSION

CPR appears to be useful in predicting perinatal death in pregnancies with suspected FGR. Nevertheless, before incorporating CPR into the routine clinical management of suspected FGR, randomized controlled trials should assess whether the use of CPR reduces perinatal death or other adverse perinatal outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Prediction of preterm delivery in symptomatic women using PAMG-1, fetal fibronectin and phIGFBP-1 tests: systematic review and meta-analysis

OBJECTIVE

To assess the accuracy of placental alpha microglobulin-1 (PAMG-1), fetal fibronectin (fFN) and phosphorylated insulin-like growth factor-binding protein-1 (phIGFBP-1) tests in predicting spontaneous preterm birth (sPTB) within 7 days of testing in women with symptoms of preterm labor, through a systematic review and meta-analysis of the literature. The test performance of each biomarker was also assessed according to pretest probability of sPTB ≤ 7 days.

METHODS

The Cochrane, MEDLINE, PubMed and ResearchGate bibliographic databases were searched from inception until October 2017. Cohort studies that reported on the predictive accuracy of PAMG-1, fFN and phIGFBP-1 for the prediction of sPTB within 7 days of testing in women with symptoms of preterm labor were included. Summary receiver-operating characteristics (ROC) curves and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive (LR+) and negative (LR-) likelihood ratios were generated using indirect methods for the calculation of pooled effect sizes with a bivariate linear mixed model for the logit of sensitivity and specificity, with each diagnostic test as a covariate, as described by the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy.

RESULTS

Bivariate mixed model pooled sensitivity of PAMG-1, fFN and phIGFBP-1 for the prediction of sPTB ≤ 7 days was 76% (95% CI, 57-89%), 58% (95% CI, 47-68%) and 93% (95% CI, 88-96%), respectively; pooled specificity was 97% (95% CI, 95-98%), 84% (95% CI, 81-87%) and 76% (95% CI, 70-80%) respectively; pooled PPV was 76.3% (95% CI, 69-84%) (P < 0.05), 34.1% (95% CI, 29-39%) and 35.2% (95% CI, 31-40%), respectively; pooled NPV was 96.6% (95% CI, 94-99%), 93.3% (95% CI, 92-95%) and 98.7% (95% CI, 98-99%), respectively; pooled LR+ was 22.51 (95% CI, 15.09-33.60) (P < 0.05), 3.63 (95% CI, 2.93-4.50) and 3.80 (95% CI, 3.11-4.66), respectively; and pooled LR- was 0.24 (95% CI, 0.12-0.48) (P < 0.05), 0.50 (95% CI, 0.39-0.64) and 0.09 (95% CI, 0.05-0.16), respectively. The areas under the ROC curves for PAMG-1, fFN and phIGFBP-1 for sPTB ≤ 7 days were 0.961, 0.874 and 0.801, respectively.

CONCLUSIONS

In the prediction of sPTB within 7 days of testing in women with signs and symptoms of preterm labor, the PPV of PAMG-1 was significantly higher than that of phIGFBP-1 or fFN. Other diagnostic accuracy measures did not differ between the three biomarker tests. As prevalence affects the predictive performance of a diagnostic test, use of a highly specific assay for a lower-prevalence syndrome such as sPTB may optimize management. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A Systematic Review and Meta-Analysis on the Strength and Consistency of the Associations between Dupuytren Disease and Diabetes Mellitus, Liver Disease, and Epilepsy

Supplemental Digital Content is available in the text.

Background:

The role of diabetes mellitus, liver disease, and epilepsy as risk factors for Dupuytren disease remains unclear. In this systematic review and meta-analysis, the strength and consistency of these associations were examined.

Methods:

The MEDLINE, EMBASE, and Web of Science databases were searched for articles reporting an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy published before September 26, 2016. The frequencies of Dupuytren disease and diabetes mellitus, liver disease, and epilepsy were extracted, as was information on potential confounders. Generalized linear mixed models were applied to estimate pooled odds ratios, adjusted for confounders. Heterogeneity between studies was quantified using an intraclass correlation coefficient and was accounted for by a random effect for study.

Results:

One thousand two hundred sixty unique studies were identified, of which 32 were used in the meta-analyses. An association between Dupuytren disease and diabetes mellitus was observed (OR, 3.06; 95 percent CI, 2.69 to 3.48, adjusted for age), which was stronger for type 1 diabetes mellitus than for type 2 diabetes mellitus but was not statistically significant (p = 0.24). An association between Dupuytren disease and liver disease was observed (OR, 2.92; 95 percent CI, 2.08 to 4.12, adjusted for sex). Dupuytren disease and epilepsy were associated, yielding an OR of 2.80 (95 percent CI, 2.49 to 3.15). Heterogeneity between studies was moderate to low.

Conclusions:

These findings demonstrate an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy. Prospective, longitudinal studies are needed to elucidate the pathways causing these associations.

Urinary biomarkers reporting weakness and validation failure in Type 2 diabetic nephropathy: systematic review

For better identification of novel diagnostic urinary biomarker in Type 2 diabetic nephropathy (T2DN), methodological and reporting quality is as important as validity of biomarkers. The aim of this systematic review is to find out the best-reported diagnostic urinary biomarkers study in T2DN based on STARD criteria. We also analyzed the validity of urinary markers in the selected articles those followed STARD criteria. The diagnostic accuracy of urinary biomarkers on T2DN is not conclusive because of the poor reporting quality and differences in adjustment for conventional risk factors. For a proper validation of urinary biomarkers on T2DN, in future large well-designed longitudinal studies, with specific prediction analysis and validation of the biomarkers by adjusting with possible conventional risk factors.

Metabolomics for biomarker discovery in the diagnosis, prognosis, survival and recurrence of colorectal cancer: a systematic review

Colorectal cancer (CRC) remains an incurable disease. There are no effective noninvasive techniques that have achieved colorectal cancer (CRC) diagnosis, prognosis, survival and recurrence in clinic. To investigate colorectal cancer metabolism, we perform an electronic literature search, from 1998 to January 2016, for studies evaluating the metabolomic profile of patients with CRC regarding the diagnosis, recurrence, prognosis/survival, and systematically review the twenty-three literatures included. QUADOMICS tool was used to assess the quality of them. We highlighted the metabolism perturbations based on metabolites and pathway. Metabolites related to cellular respiration, carbohydrate, lipid, protein and nucleotide metabolism were significantly altered in CRC. Altered metabolites were also related to prognosis, survival and recurrence of CRC. This review could represent the most comprehensive information and summary about CRC metabolism to date. It certificates that metabolomics had great potential on both discovering clinical biomarkers and elucidating previously unknown mechanisms of CRC pathogenesis.

A Systematic Review and Aggregated Analysis on the Impact of Amyloid PET Brain Imaging on the Diagnosis, Diagnostic Confidence, and Management of Patients being Evaluated for Alzheimer's Disease

BACKGROUND

Amyloid PET (aPET) imaging could improve patient outcomes in clinical practice, but the extent of impact needs quantification.

OBJECTIVE

To provide an aggregated quantitative analysis of the value added by aPET in cognitively impaired subjects.

METHODS

Systematic literature searches were performed in Embase and Medline until January 2017. 1,531 cases over 12 studies were included (1,142 cases over seven studies in the primary analysis where aPET was the key biomarker; the remaining cases included as defined groups in the secondary analysis). Data was abstracted by consensus among two observers and assessed for bias. Clinical utility was measured by diagnostic change, diagnostic confidence, and patient management before and after aPET. Three groups were further analyzed: control patients for whom feedback of aPET scan results was delayed; aPET Appropriate Use Criteria (AUC+) cases; and patients undergoing additional FDG/CSF testing.

RESULTS

For 1,142 cases with only aPET, 31.3% of diagnoses were revised, whereas 3.2% of diagnoses changed in the delayed aPET control group (p < 0.0001). Increased diagnostic confidence following aPET was found for 62.1% of 870 patients. Management changes with aPET were found in 72.2% of 740 cases and in 55.5% of 299 cases in the control group (p < 0.0001). The diagnostic value of aPET in AUC+ patients or when FDG/CSF were additionally available did not substantially differ from the value of aPET alone in the wider population.

CONCLUSIONS

Amyloid PET contributed to diagnostic revision in almost a third of cases and demonstrated value in increasing diagnostic confidence and refining management plans.

Intra- and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review

Neck pain is common and often becomes chronic. Various clinical tests of the cervical spine are used to direct and evaluate treatment. This systematic review aimed to identify studies examining the intra- and/or interrater reliability of tests used in clinical examination of patients with neck pain. A database search up to April 2016 was conducted in PubMed, CINAHL, and AMED. The Quality Appraisal of Reliability Studies Checklist (QAREL) was used to assess risk of bias. Eleven studies were included, comprising tests of active and passive movement and pain evaluating participants with ongoing neck pain. One study was assessed with a low risk of bias, three with medium risk, while the rest were assessed with high risk of bias. The results showed differing reliabilities for the included tests ranging from poor to almost perfect. In conclusion, active movement and pain for pain or mobility overall presented acceptable to very good reliability (Kappa >0.40); while passive intervertebral tests had lower Kappa values, suggesting poor reliability. It may be a coincidence that the studies indicating very good reliability tended to be of higher quality (low to moderate risk of bias), while studies finding poor reliability tended to be of lower quality (high risk of bias). Regardless, the current recommendation from this review would suggest the clinical use of tests with acceptable reliability and avoiding the use of tests that have been shown to not be reliable. Finally, it is critical that all future reliability studies are of higher quality with low risk of bias.