The childhood arthritis radiographic score of the hip: the proposal cut-off value using cluster analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease that affects children. It is crucial to detect and treat hip involvement in JIA early to prevent functional impairment and reduced quality of life. The Childhood Arthritis Radiographic Score of the Hip (CARSH) is a validated radiographic scoring system used to assess hip involvement in JIA. In this study, we aimed to determine cut-off values for CARSH scores using cluster analysis.

METHODS

The study was conducted as a cross-sectional analysis and included JIA patients with hip involvement who underwent a pelvic radiograph. The same pelvic radiograph was interpreted by two experienced pediatric rheumatologists at baseline and after 3 weeks by both readers for reliability. The CARSH scores were calculated for each hip four times (twice by each reader). For the 50 hips, a total of 200 interpretations of the CARSH score were obtained. Model-based clustering was employed to identify distinct groups of CARSH score interpretations and characterize the phenotype of each cluster.

RESULTS

Twenty-five children with hip involvement were included. The mean age was 13.9 ± 4.6 years. JIA subtypes were as follows: ERA in 64%, oligoarthritis in 16%, psoriatic arthritis in 12%, polyarthritis RF + in 4%, and RF - in 4% of patients. For the 200 hip interpretations, three clusters based on the level of the CARSH were identified by model-based clustering. Cluster 1 consisted of 17 CARSH score interpretations with a median score of 7 ± 3 (ranging from 1 to 15). This group primarily comprised patients with enthesitis-related arthritis (ERA) and psoriatic arthritis. Patients in cluster 1 were generally older, experienced longer diagnostic delays, and had a longer disease duration compared to the other clusters. Cluster 2 exhibited a moderate CARSH score, with an average score of 4 ± 3 (1 to 15). Patients in this group had significantly higher body weight compared to the other clusters. Cluster 3 represented the group with the least severe hip involvement, characterized by CARSH scores of 2 ± 1 (ranging from 0 to 9). This cluster had a higher proportion of male patients and higher C-reactive protein (CRP) levels than the other clusters. Regarding the individual items of the CARSH score, cluster 1 showed higher percentages of hip radiograph abnormalities such as joint space narrowing, erosions, growth abnormalities, and subchondral cysts. Cluster 2 was characterized by a high rate of acetabular sclerosis, with little to no abnormalities in other CARSH score items. Cluster 3 was the only group that exhibited hip subluxation, with minimal abnormalities in the other score items. In conclusion, this study identified three distinct groups of CARSH scores, representing varying levels of severity in hip involvement in JIA. These findings provide valuable insights for clinicians in assessing and managing JIA patients with hip involvement, enabling tailored treatment strategies based on the severity of the condition. Key Points • While a Childhood Arthritis Radiographic Score of the Hip (CARSH) is a valid and reliable tool in hip-related juvenile idiopathic arthritis, its use is limited in daily practice due to the lack of available cut-off values. • The cluster analysis defined three clusters based on the CARSH levels. • Cluster 1 exhibited the highest score with more damage and disability. Cluster 2 involved a moderate score and more overweight patients. Cluster 3 included the least level of the score but with an active disease parameter.

Medico-legal indicators and cut-offs in different age classes through quantitative analysis of epiphyseal fusion segments on knee CT scans

Scientists are interested in determining age in subadults for several forensic purposes. High- resolution instrumental techniques are being increasingly used for age estimation, driven by the need to minimize errors; in this context, several studies have focused on the knee joint, recognized as a potential site for age examination in late adolescence. We analyzed 200 CT scans performed on Russian subjects (106 males and 94 females) between 13 and 20 years, without growth diseases, endocrine disorders, or osteodystrophy. Each subject underwent two scans, one for each leg. Two indicators were measured for each bone (femur, tibia and fibula): the entire length of the epiphyseal scar and the length of the part/s that is/are fused with metaphysis. Intra class Correlation Coefficient (ICC) was performed to evaluate the intra-operator reproducibility. The ratio between the two lengths was calculated for each bone (FemurR, TibiaR and FibulaR). The first aim was to evaluate a correlation between the ratios of the three bones and the three bones treated as a single parameter (given by the sum of the ratios) versus age. The results showed good correlations in both cases (τ a = 0.74, 0.64, 0.57 and 0.67). The second aim was to estimate the cut-offs derived from the sum of the three ratios respect to four age classes (14-15 years: cut-off ≤ 0.63, 15-16 years: cut-off ≤ 1.19, 16-17 years: cut-off ≥ 0.68 and 17-18 years: cut-off ≥ 1.49. The results from this research encourage further studies of the knee joint as an indicator of legal adult age.

Normative cut-offs for polycystic ovary syndrome (PCOS) diagnostic features in adolescents using cluster analysis

OBJECTIVE

The diagnosis of polycystic ovary syndrome (PCOS) remains challenging with International guidelines prioritising accurate cut-offs for individual diagnostic features. These diagnostic cut-offs are currently based on arbitrary percentiles, often from poorly characterised cohorts, and are dependent on variable laboratory ranges defined by assay manufacturers, limiting diagnostic accuracy. Cluster analysis is the recommended approach for defining normative cut-offs within populations for clinical syndromes. Few PCOS adult studies have applied cluster analysis, with no studies in adolescents. We aimed to define normative cut-offs for individual PCOS diagnostic features in a community-based population of adolescents using cluster analysis.

DESIGN

This analysis utilised data from the Menstruation in Teenagers Study, a sub-group of the Raine Study, which is a population based prospective cohort of 244 adolescents whose mean age at PCOS assessment was 15.2 years.

METHODS

K-means cluster analysis and receiver operating characteristics curves were used to define normative cut-offs for Ferriman Gallwey score (mFG), free testosterone (free T), free androgen index (FAI) and menstrual cycle length.

RESULTS

Normative cut-offs for mFG, free T, FAI and menstrual cycle lengths were 1.0, 23.4 pmol/l, 3.6 and 29 days respectively. These corresponded to the 65th, 71st, 70th and 59th population percentiles respectively.

CONCLUSION

In this novel study we define the normative diagnostic criteria cut-offs in this unselected adolescent population and show that these cut-offs correspond to lower percentiles than conventional cut-offs. These findings highlight the pertinent need to re-define PCOS diagnostic cut-offs in adolescents. Validation is required in larger, multi-ethnic and well characterised adolescent cohorts.

Clinical effect of obesity on N-terminal pro-B-type natriuretic peptide cut-off concentrations for the diagnosis of acute heart failure

AIMS

Obese patients have lower natriuretic peptide concentrations. We hypothesized that adjusting the concentration of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for obesity could further increase its clinical utility in the early diagnosis of acute heart failure (AHF).

METHODS AND RESULTS

This hypothesis was tested in a prospective diagnostic study enrolling unselected patients presenting to the emergency department with acute dyspnoea. Two independent cardiologists/internists centrally adjudicated the final diagnosis using all individual patient information including cardiac imaging. NT-proBNP plasma concentrations were applied: first, using currently recommended cut-offs; second, using cut-offs lowered by 33% with body mass index (BMI) of 30-34.9 kg/m² and by 50% with BMI ≥ 35 kg/m² . Among 2038 patients, 509 (25%) were obese, of which 271 (53%) had AHF. The diagnostic accuracy of NT-proBNP as quantified by the area under the receiver-operating characteristic curve was lower in obese versus non-obese patients (0.890 vs. 0.938). For rapid AHF rule-out in obese patients, the currently recommended cut-off of 300 pg/ml achieved a sensitivity of 96.7% (95% confidence interval [CI] 93.8-98.2%), ruling out 29% of patients and missing 9 AHF patients. For rapid AHF rule-in, the age-dependent cut-off concentrations (age <50 years: 450 pg/ml; age 50-75 years: 900 pg/ml; age >75 years: 1800 pg/ml) achieved a specificity of 84.9% (95% CI 79.8-88.9%). Proportionally lowering the currently recommended cut-offs by BMI increased sensitivity to 98.2% (95% CI 95.8-99.2%), missing 5 AHF patients; reduced the proportion of AHF patients remaining in the 'gray zone' (48% vs. 26%; p = 0.002), achieving a specificity of 76.5% (95% CI 70.7-81.4%).

CONCLUSIONS

Adjusting NT-proBNP concentrations for obesity seems to further increase its clinical utility in the early diagnosis of AHF.

Should we be more aware of gender aspects in hyperuricemia? Analysis of the population-based German health interview and examination survey for adults (DEGS1)

OBJECTIVES

While gout is a well-known entity, little research has been conducted on its pathophysiology. There is growing evidence that women with hyperuricemia are at higher cardiovascular risk than men with hyperuricemia. We aim to evaluate whether gender-specific cut-offs should be considered.

STUDY DESIGN

Cross-sectional study (the German Health Interview and Examination Survey for Adults; DEGS1).

MAIN OUTCOME MEASURES

Self-reported gout or hyperuricemia and uric acid level.

RESULTS

Of 6,918 participants (mean age 47.2 years; 50.5% females), 9.7% had had a diagnosis of hyperuricemia or gout at least once in their lifetime. Men were nearly twice as often affected as women (12.9 vs. 6.5%). In women, the prevalence of cardiovascular and renal diseases increased with higher uric acid level to a much greater extent than in men. This association remained in multivariate analyses.

CONCLUSIONS

No commonly accepted cut-off value for uric acid has been established. Overall, women were at lower risk of hyperuricemia. However, women were at higher risk of having cardiovascular and renal comorbidities, even at lower uric acid levels. Our results are in line with the accumulating evidence that we should consider gender in gout and hyperuricemia.

Assessment of hormonal levels as prognostic markers and of their optimal cut-offs in small intestinal neuroendocrine tumours grade 2

PURPOSE

Small intestinal neuroendocrine tumours (siNETs) with a Ki-67 proliferation index between 3 and 20% belong to WHO grade 2. Response to treatment may be monitored by blood chromogranin A (CgA) and urine 5-hydroxyindoleacetic acid (5HIAA). The aim of this retrospective study was to investigate the prognostic value of baseline CgA and 5HIAA and of the early biochemical response to treatment, and to compare different cut-off values used in the literature.

METHODS

A retrospective cohort study of 184 patients with siNET Grade 2 treated with somatostatin analogues (SSA), interferon-alpha (IFN) or peptide receptor radionuclide therapy (PRRT).

RESULTS

Baseline CgA was a statistically significant prognostic marker for both cancer-specific survival (CSS) and progression-free survival (PFS). A cut-off of 5 × ULN (upper limit of normal) was best discriminative in most cases, but 2 × ULN discriminated better for SSA. Baseline 5HIAA was a prognostic marker for CSS in treatment with IFN and PRRT, but not for single SSA. Early changes of CgA and 5HIAA correlated well with CSS (HR 3.18, 95% CI 1.82-5.56 and HR 1.47, 95% CI 1.16-1.86) and PFS (HR 3.08, 95% CI 1.86-5.10 and HR 1.37, 95% CI 1.11-1.68) for SSA, but not for PRRT.

CONCLUSIONS

Baseline CgA and to a lesser extent 5HIAA are associated with CSS irrespective of treatment used, and with PFS after PRRT, and 5 × ULN provides best discrimination in many, but not all, cases. Early reductions of CgA and 5HIAA are prognostic for treatment with SSA, but not PRRT.

Assessing toxicity of hydrophobic aliphatic and monoaromatic hydrocarbons at the solubility limit using novel dosing methods

Reliable delineation of aquatic toxicity cut-offs for poorly soluble hydrocarbons is lacking. In this study, vapor and passive dosing methods were applied in limit tests with algae and daphnids to evaluate the presence or absence of chronic effects at exposures corresponding to the water solubility for representative hydrocarbons from five structural classes: branched alkanes, mono, di, and polynaphthenic (cyclic) alkanes and monoaromatic naphthenic hydrocarbons (MANHs). Algal growth rate and daphnid immobilization, growth and reproduction served as the chronic endpoints investigated. Results indicated that the dosing methods applied were effective for maintaining mean measured exposure concentrations within a factor of two or higher of the measured water solubility of the substances investigated. Chronic effects were not observed for hydrocarbons with an aqueous solubility below approximately 5 μg/L. This solubility cut-off corresponds to structures consisting of 13-14 carbons for branched and cyclic alkanes and 16-18 carbons for MANHs. These data support reliable hazard and risk evaluation of hydrocarbon classes that comprise petroleum substances and the methods described have broad applicability for establishing empirical solubility cut-offs for other classes of hydrophobic substances. Future work is needed to understand the role of biotransformation on the observed presence or absence of toxicity in chronic tests.

Associations of low handgrip strength with cancer mortality: a multicentre observational study

BACKGROUND

Handgrip strength (HGS) is associated with poor clinical outcomes, including all-cause, non-cardiovascular, and cardiovascular mortalities. The published cut-off points for HGS are mostly based on community populations from Western countries, lacking information on cancer patients from China. The objective of this study was to establish sex-specific cut-off points for Chinese cancer patients and investigate the effect of low HGS on cancer mortality.

METHODS

We did a retrospective cohort study of patients who were diagnosed with malignant cancer from June 2012 to December 2018. HGS was measured using a hand dynamometer in 8257 cancer patients. Optimal stratification was used to solve threshold points. The hazard ratio (HR) of all cancer mortality and cancer-specific mortality was calculated using Cox proportional hazard regression models.

RESULTS

Among all participants, there were 3902 (47.3%) women and 4355 (52.7%) men. The median age was 58 years old. The cut-off points of HGS to best classify patients with respect to time to mortality were <16.1 kg for women and <22 kg for men. Low HGS was associated with overall cancer mortality in both women and men [HR = 1.339, 95% confidence interval (CI) = 1.170-1.531, P < 0.001; HR = 1.346, 95% CI = 1.176-1.540, P < 0.001, respectively]. For specific cancer types, low HGS was associated with breast cancer (HR = 1.593, 95% CI = 1.230-2.063, P < 0.001) in women, and lung cancer (HR = 1.369, 95% CI = 1.005-1.866, P = 0.047) and colorectal cancer (HR = 1.399, 95% CI = 1.007-1.944, P = 0.045) in men.

CONCLUSIONS

On the basis of our sex-specific cut-off points, low HGS was strongly associated with cancer mortalities. These results indicate the usefulness of HGS measurement in routine clinical practice for improving patient assessments, cancer prognosis, and intervention.

Assessing agreement between the three common clinical measurement methods of HbA1c

Reliable measurement of hemoglobin A1c (HbA1c) has great importance in the diagnosis and monitoring of diabetes mellitus. The aim of the present study was to compare the performance parameters of the three common methods of HbA1c assay, including the Roche, Sebia and TOSOH G8 systems. We studied 120 patients referred to a clinical laboratory for HbA1c assay. The blood samples were analyzed with the Roche, Sebia and TOSOH G8 systems based on immunoassay, capillary electrophoresis, and ion-exchange chromatography techniques, respectively. The Spearman and the Passing-Bablok regression,as well as the Bland-Altman plots, were used to compare these methods. For each assay, the patients' classification was evaluated at the three cut-points of 6.5, 7, and 8% and the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the methods were estimated. Our results showed that there were good correlations and agreement between the methods. We found a mean difference of 0.07% for the TOSOH G8 vs. Roche, 0.06% for the TOSOH G8 vs. Sebia and - 0.01% for the Roche vs. Sebia. The methods represented very low bias, indicating the good accuracy of the results. The sensitivity and specificity of the methods were comparable as well. The three methods also performed similarly in the classification of patients at the proposed cut-off points. Based on our results, the Roche, Sebia and TOSOH G8 systems showed a very high level of agreement with comparable performance parameters and yielded similar and accurate classification of diabetic patients. Therefore, these methods can be used interchangeably.

Optimization of cloned enzyme donor immunoassay cut-offs for drugs of abuse in post-mortem whole blood

INTRODUCTION

Immunoassay (IA) tests are not widely applied in post-mortem samples, since they are based on technologies requiring relatively non-viscous specimens, and compounds originating from the degradation of proteins and lipids during the post-mortem interval can alter the efficiency of the test. However, since the extraction techniques for IA tests are normally rapid and low-cost, IA could be used as near-body drug-screening for the classes of drugs most commonly found in Italy and Europe. In this study, semi-quantitative results on post-mortem whole blood samples obtained through CEDIA analysis (cannabinoids, cocaine, amphetamine compounds, opiates and methadone), were compared with results of confirmatory analysis obtained using GC-MS. Screening cut-offs for all drugs were retrospectively optimized.

METHODS

Post-mortem whole blood samples from autopsy cases of suspected fatal intoxication were collected over 3 years. Samples were initially analyzed through CEDIA (CEDIA, ILab 650, Werfen). Confirmatory analyses were then performed by GC-MS (QP 2010 Plus, Shimadzu). Screening cut-offs were retrospectively optimized using Receiver Operating Characteristic (ROC) analysis.

RESULTS

CEDIA results were available for 125 samples. Two-hundred-eighty-nine (289) positive screening results were found. Among these, 162 positive confirmation results were obtained. Optimized screening cut-offs were as follows: 6.5ng/ml for THC; 4.2ng/ml for THC-COOH; 12.0ng/ml for cocaine; 6.6ng/ml for benzoylecgonine; 6.4ng/ml for opiates; 2.0ng/ml for methadone. Analysis of ROC-curves showed a satisfying degree of separation in all tests except for amphetamine compounds, with areas under the curve (AUC) between 0.915 (THC) and 0.999 (for benzoylecgonine and methadone).

DISCUSSION

The results of the study showed that CEDIA screening at the optimized cut-offs exhibits a very high sensitivity and good specificity and positive predictive value (PPV) for cannabinoids, cocaine and metabolites, opiates and methadone. A high number of false positives (n=19) for amphetamine compounds was observed at the optimized cut-off, resulting in a very low PPV, which is also influenced by the very low number of TP (n=4).

CONCLUSION

The results of the study show that the CEDIA is a valuable screening test on post-mortem whole blood for cannabinoids, cocaine and metabolites, opiates and methadone, but it is not recommended for amphetamine compounds, due to the high number of false positives. The strengths of the study are the large sample size, the inclusion of post-mortem cases only and the high level of sensitivity and specificity obtained at the optimized cut-offs.

Evaluation of an online training tool for scoring programmed cell death ligand-1 (PD-L1) diagnostic tests for lung cancer

BACKGROUND

Numerous studies indicate that higher tumour programmed cell death ligand-1 (PD-L1) expression is associated with greater response to anti-programmed cell death-1 (PD-1)/PD-L1 immunotherapy in non-small cell lung cancer (NSCLC). In the era of precision medicine, there is a need to provide reliable, standardised training for pathologists to improve their accuracy of interpretation and scoring, as the results are used directly to inform clinical decisions. Here we present findings regarding reader reproducibility of PD-L1 tumour cell (TC) staining scoring for NSCLC using a PD-L1 e-trainer tool as part of a PD-L1 immunohistochemistry reader training course.

METHODS

The PD-L1 training course was developed based on the use of VENTANA PD-L1 (SP263) and Dako PD-L1 IHC PharmDx 22C3 stained NSCLC samples in combination with a PD-L1 e-trainer tool. Five-hundred formalin-fixed, paraffin-embedded archival samples were obtained from commercial sources and stained for PD-L1. Slides were scored by two expert pathologists, then scanned to produce digital images and re-scored. Thirty-three cases were selected and sorted into three sets: a training set and two self-assessment tests (pre-test and 'competence' test). Participants (all selected board-certified pathologists) received face-to-face training including use of an e-trainer tool. Statistical analyses were performed using the competence test set. Overall percentage agreement (OPA) was assessed between the participant pathologists' registered scores and the reference scores assigned by expert pathologists at clinically relevant PD-L1 cut-offs (≥1%, ≥25% and ≥ 50%).

RESULTS

Seven sessions were held and 69 participant pathologists completed the training. Inter-reader concordance indicated high OPA (85-95%) for PD-L1 TC scoring at clinically relevant cut-offs, with Fleiss' Kappa > 0.5.

CONCLUSIONS

Use of this web-based training tool incorporated into classroom-style training was associated with an overall moderately good level of inter-reader reproducibility at key cut-offs for TC PD-L1 expression testing in NSCLC. Overall, the online training tool offers a means of standardised training for practising pathologists in a clinical setting.

Thresholds for clinical importance were established to improve interpretation of the EORTC QLQ-C30 in clinical practice and research

OBJECTIVE

The objective of this study was to establish thresholds for clinical importance (TCIs) for the five functioning and nine symptom scales of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).

STUDY DESIGN AND SETTING

In this diagnostic study, cancer patients with mixed diagnoses and treatments completed the EORTC QLQ-C30 and anchored the questions in each domain in terms of their clinical importance. The anchor questions, concerned limitations in daily life, need for help/care, and the worries of the patient and his/her partner/family. These questions allowed categorizing patients into whether they exhibited a clinically important symptom/functional impairment for each scale and performing a receiver operating characteristic curve analysis to establish TCIs.

RESULTS

Data from 498 patients from six European countries (mean age 60.4 years, 55.2% women) were analyzed. For the TCIs generated using the patient questionnaire data, the EORTC QLQ-C30 scales showed sensitivity values between 0.71 and 0.97 and specificity values between 0.62 and 0.92 (area under the curve above 0.80 for all scales).

CONCLUSION

This EORTC Quality of Life Group study provides TCIs for the functioning and symptom scales of the EORTC QLQ-C30. These TCIs can increase the interpretability of the questionnaire results and foster its use in daily clinical practice and in clinical research.

[Development and validation of a simplified height-specific blood pressure cutoffs table for screening hypertension in Chinese children and adolescents]

Objective: To develop and validate a simplified height-specific blood pressure cutoffs table for screening hypertension in Chinese children and adolescents. Methods: We developed a simplified height-specific blood pressure cut offs table according to Chinese Blood Pressure Reference for Children and Adolescents aged 7-18 years (WS/T 610-2018) (hereafter referred to as "complex definition"). Populations from Early Warning, Diagnosis and Treatment of Children Cardiovascular Disease Project ("Ji'nan sample") and Shandong Children Cardiovascular Cohort Study Project ("Zibo sample") were used as validation populations for evaluating the screening effect of the simplified table for elevated blood pressure and hypertension in children and adolescents. Results: We developed simplified height-specific blood pressure cutoffs table including 7 height groups and 28 cutoffs. Both Ji'nan and Zibo samples were selected by convenient sampling method, and the former included 7 233 participants aged 7 to 17 years, among whom 3 790 (52.4%) were boys. Latter population included 1 277 participants aged 7 to 11 years, among whom 681 (53.3%) were boys. The simplified table performed well for identifying elevated blood pressure in Ji'nan sample, with values of area under the receiver operating curve (AUC) (95%CI), sensitivity, specificity, and Kappa statistic as 0.96 (0.95-0.97), 93.0%, 98.5% and 0.91, respectively, which were similar with results in Zibo sample [the values were 0.92 (0.90-0.95), 87.0%, 98.0% and 0.85, respectively]. The simplified table also performed well for identifying hypertension in Ji'nan sample with values of AUC (95%CI), sensitivity, specificity, and Kappa statistic as 0.92 (0.91-0.94), 86.9%, 98.1% and 0.85, respectively, which were similar with results in Zibo sample [the values were 0.94 (0.91-0.96), 88.2%, 98.9% and 0.88, respectively]. Conclusion: Screening for elevated and high blood pressure based on simplified height-specific blood pressure cutoffs table is easy to use and it shows satisfying effect.

Vitamin D status in healthy black African adults at a tertiary hospital in Nairobi, Kenya: a cross sectional study

BACKGROUND

Vitamin D has been known since the twentieth Century for its benefits in bone health. Recent observational studies have demonstrated its benefits in infectious diseases such as tuberculosis and non-communicable diseases such as diabetes mellitus, cardiovascular diseases and cancer. This has led to a dramatic increase in testing among adults. The cut-offs for vitamin D deficiency have been debated for decades and the current cut off is derived from a Caucasian population. Studies done among black African adults in Africa are few with vitamin D deficiency ranging from 5 to 91%. A few cut- offs have correlated vitamin D deficiency to physiological markers such as parathyroid hormone (PTH), calcium and phosphate with varying results.

METHODS

This was a cross sectional study carried out among blood donors at Aga Khan University hospital, Nairobi (AKUHN) from March to May 2015. Vitamin D (25(OH)D) levels were assayed and correlated with PTH, calcium and phosphate.

RESULTS

A total of 253 individuals were included in the final analysis. The proportion of study participants who had a 25(OH) D level of < 20 ng/ml thus classified as vitamin D deficient was 17.4% (95% C.I 12.73-22.07). The 25(OH) D level that coincided with a significant increase in PTH was 30 ng/ml. Males were less likely to be vitamin D deficient (O.R 0.48 (C.I 0.233-0.993) p 0.04). Sunshine exposure for ≥3 h per day reduced the odds of being Vitamin D deficient though this was not statistically significant after multivariate regression analysis.

CONCLUSIONS

We found a much lower prevalence of Vitamin D deficiency compared to many similar studies carried out in sub-Saharan Africa possibly due to the recruitment of healthy individuals and the proximity of Nairobi to the equator which allows for considerable exposure to sunshine. Vitamin D levels below 30 ng/mL was associated with a significant rise in PTH levels, suggesting that this cut off could be appropriate for defining Vitamin D deficiency in the population served by our laboratory.

Specific IgE and skin prick tests to diagnose allergy to fresh and baked cow's milk according to age: a systematic review

BACKGROUND

The diagnosis of IgE-mediated cow's milk allergy is often based on anamnesis, and on specific IgE (sIgE) levels and/or Skin Prick Tests (SPT), which have both a good sensitivity but a low specificity, often causing positive results in non-allergic subjects. Thus, oral food challenge is still the gold standard test for diagnosis, though being expensive, time-consuming and possibly at risk for severe allergic reactions.

AIM

The aim of the present study was to perform a systematic review of the studies that have so far analyzed the positive predictive values for sIgE and SPT in the diagnosis of allergy to fresh and baked cow's milk according to age, and to identify possible cut-offs that may be useful in clinical practice.

METHODS

A comprehensive search on Medline via PubMed and Scopus was performed August 2017. Studies were included if they investigated possible sIgE and/or SPT cut-off values for cow's milk allergy diagnosis in pediatric patients. The quality of the studies was evaluated according to QUADAS-2 criteria.

RESULTS

The search produced 471 results on Scopus, and 2233 on PubMed. Thirty-one papers were included in the review and grouped according to patients' age, allergen type and cooking degree of the milk used for the oral food challenge. In children < 2 years, CMA diagnosis seems to be highly likely when sIgE to CM extract are ≥ 5 KU_A/L or when SPT with commercial extract are above 6 mm or Prick by Prick (PbP) with fresh cow's milk are above 8 mm. Any cut-offs are proposed for single cow's milk proteins and for baked milk allergy in children younger than 2 years. In Children ≥ 2 years of age it is hard to define practical cut-offs for allergy to fresh and baked cow's milk. Cut-offs identified are heterogeneous.

CONCLUSIONS

None of the cut-offs proposed in the literature can be used to definitely confirm cow's milk allergy diagnosis, either to fresh pasteurized or to baked milk. However, in children < 2 years, cut-offs for specific IgE or SPT seem to be more homogeneous and may be proposed.

Childhood obesity classification systems and cardiometabolic risk factors: a comparison of the Italian, World Health Organization and International Obesity Task Force references

Background

Body Mass Index Italian reference data are available for clinical and/or epidemiological use, but no study compared the ability of this system to classify overweight and obesity and detect subjects with clustered cardiometabolic risk factors with international standards. Therefore our aim was to assess 1) the agreement among the Italian Society for Pediatric Endocrinology and Diabetology (ISPED), the World Health Organisation (WHO) and the International Obesity Task Force (IOTF) Body Mass Index cut-offs in estimating overweight or obesity in children and adolescents; 2) the ability of each above-mentioned set of cut-points to detect subjects with cardiometabolic risk factors.

Methods

Data of 6070 Italian subjects aged 5–17 years were collected. Prevalence of normal-weight, overweight and obesity was determined using three classification systems: ISPED, WHO and IOTF. High blood pressure, hypertriglyceridemia, low high density lipoprotein-cholesterol and impaired fasting glucose were considered as cardiometabolic risk factors.

Results

ISPED and IOTF classified more subjects as normal-weight or overweight and less subjects as obese as compared to WHO (p <0.0001) in the whole sample and in groups divided by gender and age. The strength of agreement between the three methods compared to each other was excellent for overweight (including obesity) definition (k > 0.900), while it differed for obesity definition, ranging from the highest agreement between ISPED and IOTF (k 0.875) to the lowest between ISPED and WHO (k 0.664). WHO had the highest sensitivity, while ISPED and IOTF systems had the highest specificity, in identifying obese subjects with clustered cardiometabolic risk factors. Analogous results were found in subjects stratified by gender or age.

Conclusions

ISPED and IOTF systems performed similarly in assessing overweight and obesity, and were more specific in identifying obese children/adolescents with clustered cardiometabolic risk factors; on the contrary, the WHO system was more sensitive. Given the seriousness of the obesity epidemic, we wonder whether the WHO system should be preferable to the national standards for clinical practice and/or obesity screening.

Hypovitaminosis D in a sunny country: time trends, predictors, and implications for practice guidelines

The aim of the current study is to investigate the prevalence of hypovitaminosis D in Lebanese subjects, its robust predictors, evaluate the relationship between 25 hydroxy vitamin D [25(OH)D] and parathyroid hormone levels, and derive desirable vitamin D levels, based on a large hospital laboratory database spanning all age groups. Data from a large representative digitized database of 9147 subjects, mostly outpatients, evaluated between 2000-2004 and 2007-2008, in whom information on age, gender, service, and time of the year, was analyzed. The PTH-25(OH)D relationship was studied in a subset of 657 adult subjects, in whom such data were available. At a 25(OH)D cut-off of<20 ng/ml, the prevalence of hypovitaminosis D ranged between 58% and 62% in pediatric subjects, 44% and 60% in adults, and 41% and 62% in elderly, in the 2 study periods. At a cut-off <30 ng/ml, the prevalence was above 78%, in most sub-groups. Regardless of cut-off used, the only significant predictors of high mean 25(OH)D levels were the male gender in the pediatric group, and female gender in adults and elderly, summer/fall seasons, out-patient status, as well as study period. Curve fitting of the PTH-25(OH)D relationship, in adults and elderly, revealed a plateau at 25(OH)D levels of 17-21 ng/ml, depending on sub-study group. Hypovitaminosis D is prevalent in our sunny country, even using a conservative population-derived cut-off of 20 ng/ml, and thus the need for a public health strategy for supplementation.

Stimulated calcitonin cut-offs by different tests

Medullary thyroid cancer can be highly aggressive, especially if the diagnosis is done in advanced stages. Early diagnosis is based on RET genetic testing, for familial forms, and on the routine measurement of calcitonin (Ct). Nevertheless, since false-positive results can be obtained with the basal measurement of Ct, a provocative test to evaluate stimulated Ct is often needed. Pentagastrin which has been widely used to stimulate basal Ct, especially in European countries, is now hardly available. Thus, the stimulation with calcium (Ca), used in the 1970s-1980s and then abandoned for around 30 years, has recently elicited more interest. In the past 3 years, studies in patients and normal controls have demonstrated that the stimulation with Ca (2.3-2.5 mg/kg of elemental Ca, corresponding to 25 mg/kg of Ca gluconate) is highly potent and accurate. Novel gender-related cut-offs have been proposed for the Ca test, though the analysis of additional large series is predicted to modify these preliminary data. Finally, Ca seems to be the test of choice to stimulate Ct for the diagnosis and follow-up of medullary thyroid cancer, also because it is widely available, has a low cost and it is associated with a low number and intensity of side effects. In the present review the different methods to stimulate Ct and the cut-offs for the identification of the hyperplastic/neoplastic transformation of the C cells will be reported and discussed.