92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

Systematic Review and Meta-Analysis of Diagnostic Accuracy of Serum Refractometry and Brix Refractometry for the Diagnosis of Inadequate Transfer of Passive Immunity in Calves

BACKGROUND

Transfer of passive immunity in calves can be assessed by direct measurement of immunoglobulin G (IgG) by methods such as radial immunodiffusion (RID) or turbidimetric immunoassay (TIA). IgG can also be measured indirectly by methods such as serum refractometry (REF) or Brix refractometry (BRIX).

OBJECTIVES

To determine the accuracy of REF and BRIX for assessment of inadequate transfer of passive immunity (ITPI) in calves.

DESIGN

Systematic review and meta-analysis of diagnostic accuracy studies.

METHODS

Databases (PubMed and CAB Abstract, Searchable Proceedings of Animal Science) and Google Scholar were searched for relevant studies. Studies were eligible if the accuracy (sensitivity and specificity) of REF or BRIX was determined using direct measurement of IgG by RID or turbidimetry as the reference standard. The study population included calves <14 days old that were fed with natural colostrum (colostrum replacement products were excluded). Quality assessment was performed by the QUADAS-2 tool. Hierarchical models were used for meta-analysis.

RESULTS

From 1,291 references identified, 13 studies of 3,788 calves were included. Of these, 11 studies evaluated REF and 5 studies evaluated BRIX. The median (range) prevalence of ITPI (defined as calves with IgG <10 g/L by RID or TIA) was 21% (1.3-56%). Risk of bias and applicability concerns were generally low or unclear. For REF, summary estimates were obtained for 2 different cutoffs: 5.2 g/dL (6 studies) and 5.5 g/dL (5 studies). For the 5.2 g/dL cutoff, the summary sensitivity (95% CI) and specificity (95% CI) were 76.1% (63.8-85.2%) and 89.3% (82.3-93.7%), and 88.2% (80.2-93.3%) and 77.9% (74.5-81.0%) for the 5.5 g/dL cutoff. Due to the low number of studies using the same cutoffs, summary estimates could not be obtained for BRIX.

CONCLUSIONS AND CLINICAL IMPORTANCE

Despite their widespread use on dairy farms, evidence about the optimal strategy for using refractometry, including the optimal cutoff, are sparse (especially for BRIX). When using REF to rule out ITPI in herds, the 5.5 g/dL cutoff may be used whereas for ruling in ITPI, the 5.2 g/dL cutoff may be used.

The diagnosis of food allergy: a systematic review and meta-analysis

BACKGROUND

We investigated the accuracy of tests used to diagnose food allergy.

METHODS

Skin prick tests (SPT), specific-IgE (sIgE), component-resolved diagnosis and the atopy patch test (APT) were compared with the reference standard of double-blind placebo-controlled food challenge. Seven databases were searched and international experts were contacted. Two reviewers independently identified studies, extracted data, and used QUADAS-2 to assess risk of bias. Where possible, meta-analysis was undertaken.

RESULTS

Twenty-four (2831 participants) studies were included. For cows' milk allergy, the pooled sensitivities were 53% (95% CI 33-72), 88% (95 % CI 76-94), and 87% (95% CI 75-94), and specificities were 88% (95% CI 76-95), 68% (95% CI 56-77), and 48% (95% CI 36-59) for APT, SPT, and sIgE, respectively. For egg, pooled sensitivities were 92% (95% CI 80-97) and 93% (95% CI 82-98), and specificities were 58% (95% CI 49-67) and 49% (40-58%) for skin prick tests and specific-IgE. For wheat, pooled sensitivities were 73% (95% CI 56-85) and 83% (95% CI 69-92), and specificities were 73% (95% CI 48-89) and 43% (95% CI 20-69%) for SPT and sIgE. For soy, pooled sensitivities were 55% (95% CI 33-75) and 83% (95% CI 64-93), and specificities were 68% (95% CI 52-80) and 38% (95% CI 24-54) for SPT and sIgE. For peanut, pooled sensitivities were 95% (95% CI 88-98) and 96% (95% CI 92-98), and specificities were 61% (95% CI 47-74), and 59% (95% CI 45-72) for SPT and sIgE.

CONCLUSIONS

The evidence base is limited and weak and is therefore difficult to interpret. Overall, SPT and sIgE appear sensitive although not specific for diagnosing IgE-mediated food allergy.

Surveillance for ocular hypertension: an evidence synthesis and economic evaluation

OBJECTIVES

To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN

A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING

Primary and secondary care.

PARTICIPANTS

Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS

We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES

Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS

The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS

Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS

For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment Programme.