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Hymel KP, Carroll CL, Frazier TN, Weeks K, Herman BE, Marinello M, Chen Y, Wang M, Boos SC. Validation of the PediBIRN-7 clinical prediction rule for pediatric abusive head trauma. Child Abuse Negl 2024; 152:106799. [PMID: 38663048 PMCID: PMC11097240 DOI: 10.1016/j.chiabu.2024.106799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND The PediBIRN-7 clinical prediction rule incorporates the (positive or negative) predictive contributions of completed abuse evaluations to estimate abusive head trauma (AHT) probability after abuse evaluation. Applying definitional criteria as proxies for AHT and non-AHT ground truth, it performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.88 (95 % CI: 0.85-0.92) in its derivation study. OBJECTIVE To validate the PediBIRN-7's AHT prediction performance in a novel, equivalent, patient population. PARTICIPANTS AND SETTINGS Consecutive, acutely head-injured children <3 years hospitalized for intensive care across eight sites between 2017 and 2020 with completed skeletal surveys and retinal exams (N = 342). METHODS Secondary analysis of an existing, cross-sectional, prospective dataset, including assignment of patient-specific estimates of AHT probability, calculation of AHT prediction performance measures (ROC-AUC, sensitivity, specificity, predictive values), and completion of sensitivity analyses to estimate best- and worst-case prediction performances. RESULTS Applying the same definitional criteria, the PediBIRN-7 performed with sensitivity 0.74 (95 % CI: 0.66-0.81), specificity 0.77 (95 % CI: 0.70-0.83), and ROC-AUC 0.83 (95 % CI: 0.78-0.88). The reduction in ROC-AUC was statistically insignificant (p = .07). Applying physicians' final consensus diagnoses as proxies for AHT and non-AHT ground truth, the PediBIRN-7 performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.90 (95 % CI: 0.87-0.94). Sensitivity analyses demonstrated minimal changes in rule performance. CONCLUSION The PediBIRN-7's overall AHT prediction performance has been validated in a novel, equivalent, patient population. Its patient-specific estimates of AHT probability can inform physicians' AHT-related diagnostic reasoning after abuse evaluation.
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Affiliation(s)
- Kent P Hymel
- Adjunct Professor of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | | | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS, USA
| | - Bruce E Herman
- Professor of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Yiming Chen
- Department of Mathematics, Applied Mathematics, and Statistics, Case Western Reserve University, Cleveland, OH, USA
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephen C Boos
- Professor of Pediatrics, UMass Chan Medical School-Baystate, Springfield, MA, USA.
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Wang A, Blackford AL, Behling C, Wilson LA, Newton KP, Xanthakos SA, Fishbein MH, Vos MB, Mouzaki M, Molleston JP, Jain AK, Hertel P, Harlow Adams K, Schwimmer JB. Development of Fibro-PeN, a clinical prediction model for moderate-to-severe fibrosis in children with nonalcoholic fatty liver disease. Hepatology 2024; 79:1381-1392. [PMID: 37870272 PMCID: PMC11035485 DOI: 10.1097/hep.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND AIMS Liver fibrosis is common in children with NAFLD and is an important determinant of outcomes. High-performing noninvasive models to assess fibrosis in children are needed. The objectives of this study were to evaluate the performance of existing pediatric and adult fibrosis prediction models and to develop a clinical prediction rule for identifying moderate-to-severe fibrosis in children with NAFLD. APPROACH AND RESULTS We enrolled children with biopsy-proven NAFLD in the Nonalcoholic Steatohepatitis Clinical Research Network within 90 days of liver biopsy. We staged liver fibrosis in consensus using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. We evaluated existing pediatric and adult models for fibrosis and developed a new pediatric model using the least absolute shrinkage and selection operator with linear and spline terms for discriminating moderate-to-severe fibrosis from none or mild fibrosis. The model was internally validated with 10-fold cross-validation. We evaluated 1055 children with NAFLD, of whom 26% had moderate-to-severe fibrosis. Existing models performed poorly in classifying fibrosis in children, with area under the receiver operator curves (AUC) ranging from 0.57 to 0.64. In contrast, our new model, fibrosis in pediatric NAFLD was derived from fourteen common clinical variables and had an AUC of 0.79 (95% CI: 0.77-0.81) with 72% sensitivity and 76% specificity for identifying moderate-to-severe fibrosis. CONCLUSION Existing fibrosis prediction models have limited clinical utility in children with NAFLD. Fibrosis in pediatric NAFLD offers improved performance characteristics for risk stratification by identifying moderate-to-severe fibrosis in children with NAFLD.
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Affiliation(s)
- Andrew Wang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Amanda L Blackford
- Department of Oncology, Division of Quantitative Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Laura A Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark H Fishbein
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Miriam B Vos
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jean P Molleston
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ajay K Jain
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | - Paula Hertel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kathryn Harlow Adams
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
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Kharel P, Zadro JR, Wong G, Rojanabenjawong K, Traeger A, Linklater J, Maher CG. Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review. BMC Emerg Med 2024; 24:84. [PMID: 38760697 PMCID: PMC11100091 DOI: 10.1186/s12873-024-00996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. OBJECTIVE To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). DESIGN Systematic review. METHODS The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. RESULTS We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. CONCLUSION Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
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Affiliation(s)
- Priti Kharel
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050.
| | - Joshua R Zadro
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | - Grace Wong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Adrian Traeger
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | | | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
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Velasco R, Gomez B, Labiano I, Mier A, Ugedo A, Benito J, Mintegi S. Performance of Febrile Infant Algorithms by Duration of Fever. Pediatrics 2024; 153:e2023064342. [PMID: 38563061 DOI: 10.1542/peds.2023-064342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.
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Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Tauli, Institut d'Investigació i Innovació I3PT, Sabadell, Spain
- Department of Paediatrics & Child Health, University College Cork (UCC), Cork, Ireland
| | - Borja Gomez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Ismael Labiano
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Ana Mier
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Alberto Ugedo
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
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Bahta NNA, Gram-Hanssen A, Jonsson I, Petersen SM, Rosenberg J, Fonnes S. Clinical decision rules for appendicitis are not used by surgeons in training: A survey. World J Surg 2024; 48:1086-1093. [PMID: 38411218 DOI: 10.1002/wjs.12108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/09/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUNDS We aimed to investigate surgeons in training knowledge of clinical decision rules (CDR) for diagnosing appendicitis and their attitudes toward implementing them. METHODS We included surgeons in training practicing in East Denmark who independently could decide to perform a diagnostic laparoscopy for suspected appendicitis. The survey was developed in Research Electronic Data Capture and face-validated before use. It consisted of three parts: (1) the characteristics of the surgeons, (2) their diagnostic approach, and (3) their knowledge and attitude toward introducing CDR in the clinic. Data were collected in January 2023. RESULTS We achieved 83 (90%) responses, and 52% of surgeons in training believed that appendicitis was difficult to diagnose. Their diagnostic approach mostly included symptoms and physical examinations for abdominal pain, and C-reactive protein. A total of 48% knew of at least one clinical decision rule, and 72% had never used a clinical decision rule. Regarding the necessity of CDR in clinical practice, surgeons in training options were divided into thirds: not needed, neither needed nor not needed, and needed. Surgeons in training indicated that CDR needed to be validated and easily applied before they would implement them. CONCLUSION Approximately 3/4 of surgeons in training had never utilized a clinical decision rule to diagnose appendicitis, and only half knew of their existence. The symptoms and findings incorporated in most CDR aligned with their diagnostic approach. They were conflicted if CDR needed to be implemented in clinical practice.
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Affiliation(s)
- Nadir Noureldin Abdella Bahta
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Anders Gram-Hanssen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Surgery, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Isabella Jonsson
- Department of Surgery, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark
| | - Stine Mette Petersen
- Department of Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Siv Fonnes
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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Davis DP. A Clinical Decision Rule for Isolated Subdural Hematomas: Divine Inspiration, Slippery Slope, or Meaningless Machinations? Ann Emerg Med 2024; 83:432-434. [PMID: 38180399 DOI: 10.1016/j.annemergmed.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/12/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Daniel P Davis
- Emergency Medical Services, Logan Health, Kalispell, MT.
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Andersson RE. Invited commentary to " Clinical decision rules for appendicitis are not used by surgeons in training: A survey". World J Surg 2024; 48:1094-1095. [PMID: 38517355 DOI: 10.1002/wjs.12152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Roland E Andersson
- Department of Surgery, Linköping University, Linkoping, Östergötland, Sweden
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Martin NG, Defres S, Willis L, Beckley R, Hardwick H, Coxon A, Kadambari S, Yu LM, Liu X, Galal U, Conlin K, Griffiths MJ, Kneen R, Nadel S, Heath PT, Kelly DE, Solomon T, Sadarangani M, Pollard AJ. Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology. J Infect 2024; 88:106145. [PMID: 38552719 DOI: 10.1016/j.jinf.2024.106145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.
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Affiliation(s)
- N G Martin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK; Department of Paediatrics, University of Otago Christchurch, 2 Riccarton Avenue, Christchurch Central City, Christchurch 8011, New Zealand
| | - S Defres
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - L Willis
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - R Beckley
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - H Hardwick
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - A Coxon
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - S Kadambari
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; Infection, Immunity & Inflammation Department, University College London, Great Ormond Street Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK
| | - L-M Yu
- Nuffield Department of Primary Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - X Liu
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - U Galal
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - K Conlin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - M J Griffiths
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - R Kneen
- Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - S Nadel
- Department of Paediatrics, St. Mary's Hospital, Praed St, London W2 1NY, UK
| | - P T Heath
- Centre for Neonatal and Paediatric Infection & Vaccine Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - D E Kelly
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - T Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Lower Ln, Fazakerley, Liverpool L9 7LJ, UK
| | - M Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, 950 West 28th Ave, Vancouver, BC V5Z 4H4, Canada; Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC V5Z 4H4, Canada.
| | - A J Pollard
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
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Asha SE, Prageshan J, Seidman Z. Derivation of a clinical decision rule to exclude cerebral venous sinus thrombosis in emergency department patients: A retrospective cohort study. Emerg Med Australas 2024; 36:288-294. [PMID: 38030393 DOI: 10.1111/1742-6723.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To derive a clinical decision rule to exclude cerebral venous sinus thrombosis (CVST) in the ED. A secondary aim was to derive a rule that incorporated clinical parameters and the non-contrast CT brain. METHODS Single-centre, retrospective cohort study. Patients suspected of CVST were identified from the radiology database for CT/MR venograms. Clinical features included in the rule were determined by literature review. The presence of these features in participants was determined by chart review. Variables were tested for univariate association with CVST using logistic regression. Variable selection was accomplished using a forward-stepwise process, calculating the sensitivity/specificity of a rule containing the variable of most significance, then repeating the process after adding the next most significant variable. RESULTS Forty-five out of 912 participants had confirmed CVST. The primary clinical rule was answering 'no' to all the following: any prothrombotic risk factor, age ≥54 years, confusion: sensitivity 95.6% (95% confidence interval [CI] 84.9-99.5%), specificity 40.9% (95% CI 37.6-44.2%), negative predictive value 99.4% (95% CI 97.9-99.9%) and positive predictive value 7.7% (95% CI 7.1-8.3%). The rule classified 39.5% of participants as CVST ruled out. The rule incorporating the non-contrast CT brain was answering 'no' to all the following: abnormal non-contrast CT brain, any prothrombotic risk-factor, age ≥54 years, confusion: sensitivity 100.0% (95% CI 91.6-100.0%), specificity 42.0% (95% CI 38.7-45.4%), negative predictive value 100.0% (95% CI not calculated) and positive predictive value 7.8% (95% CI 7.4-8.2%). The rule classified 40.0% of participants as CVST ruled out. CONCLUSIONS A clinical decision rule was derived to rule out CVST. These results require validation before adoption into clinical practice.
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Affiliation(s)
- Stephen Edward Asha
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
- St George and Sutherland Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Janani Prageshan
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - Zachariah Seidman
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
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McNab L, Lee R, Chiew AL. Evaluating Clinical Prediction Rules for Bacteremia Detection in the Emergency Department: A Retrospective Review. J Emerg Med 2024; 66:e432-e440. [PMID: 38462392 DOI: 10.1016/j.jemermed.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Bacteremia is a major cause of morbidity. Blood cultures are the gold standard for diagnosing bacteremia. OBJECTIVE To compare previously published clinical decision rules for predicting a true positive blood culture (bacteremia) in the emergency department. METHODS Retrospective analysis of medical records of patients who had a blood culture performed in a tertiary hospital emergency department in 2020 (12 months). Positive blood cultures were compared with randomly selected negative blood cultures (1:4 ratio). Blood cultures were analyzed per patient presentation. Clinical data from patient presentations were extracted and appraised against the modified-Shapiro (mShapiro) rule and systemic inflammatory response syndrome (SIRS) criteria to calculate diagnostic accuracy to detect bacteremia. RESULTS During the study period, 3870 blood cultures were taken from 2921 patients: 476 (12.3%) cultures were positive for bacterial growth, from 421 individual patient presentations (10 excluded as incomplete data). Of included patients, 338 were true positives and 73 contaminates, these were compared with 1446 patients with negative blood culture presentations. Evaluating mShapiro's rule and SIRS criteria to detect bacteremia vs. no bacteremia (negative + contaminated cultures) had a sensitivity of 94.4% (95% confidence interval [CI] 91.4-96.4%) and 84.9% (95% CI 80.7-88.3%), respectively, and a specificity of 37.9% (95% CI 35.5-40.1%) and 33.8% (95% CI 31.5-36.3%), respectively. Both had a high negative predictive value for bacteremia of 96.8% (95% CI 95.1-98.0) and 91.0% (95% CI 88.3-93.1) for mShapiro's rule and SIRS criteria, respectively. CONCLUSIONS In this cohort, mShapiro's rule performed better than the SIRS criteria at predicting bacteremia.
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Affiliation(s)
- Lincoln McNab
- Prince of Wales Clinical School, University of New South Wales (UNSW) Medicine, Sydney, NSW, Australia
| | - Rachelle Lee
- Prince of Wales Clinical School, University of New South Wales (UNSW) Medicine, Sydney, NSW, Australia
| | - Angela L Chiew
- Department of Emergency Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
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11
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Window P, Raymer M, McPhail SM, Vicenzino B, Hislop A, Vallini A, Elwell B, O'Gorman H, Phillips B, Wake A, Cush A, McCaskill S, Garsden L, Dillon M, McLennan A, O'Leary S. Prospective validity of a clinical prediction rule for response to non-surgical multidisciplinary management of knee osteoarthritis in tertiary care: a multisite prospective longitudinal study. BMJ Open 2024; 14:e078531. [PMID: 38521532 PMCID: PMC10961565 DOI: 10.1136/bmjopen-2023-078531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVES We tested a previously developed clinical prediction tool-a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological degeneration) that were related to poor response to non-surgical management of knee osteoarthritis. This study sought to prospectively evaluate the predictive validity of this nomogram to identify patients most likely to respond poorly to non-surgical management of knee osteoarthritis. DESIGN Multisite prospective longitudinal study. SETTING Advanced practice physiotherapist-led multidisciplinary service across six tertiary hospitals. PARTICIPANTS Participants with knee osteoarthritis deemed appropriate for trial of non-surgical management following an initial assessment from an advanced practice physiotherapist were eligible for inclusion. INTERVENTIONS Baseline clinical nomogram scores were collected before a trial of individualised non-surgical management commenced. PRIMARY OUTCOME MEASURE Clinical outcome (Global Rating of Change) was collected 6 months following commencement of non-surgical management and dichotomised to responder (a little better to a very great deal better) or poor responder (almost the same to a very great deal worse). Clinical nomogram accuracy was evaluated from receiver operating characteristics curve analysis and area under the curve, and sensitivity/specificity and positive/negative likelihood ratios were calculated. RESULTS A total of 242 participants enrolled. Follow-up scores were obtained from 210 participants (87% response rate). The clinical nomogram demonstrated an area under the curve of 0.70 (p<0.001), with greatest combined sensitivity 0.65 and specificity 0.64. The positive likelihood ratio was 1.81 (95% CI 1.32 to 2.36) and negative likelihood ratio 0.55 (95% CI 0.41 to 0.75). CONCLUSIONS The knee osteoarthritis clinical nomogram prediction tool may have capacity to identify patients at risk of poor response to non-surgical management. Further work is required to determine the implications for service delivery, feasibility and impact of implementing the nomogram in clinical practice.
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Affiliation(s)
- Peter Window
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service, Metro North Health and University of Queensland, Brisbane, Queensland, Australia
| | - Maree Raymer
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation (AusHSI), Centre for Healthcare Transformation and School of Public Health & Social Work, Faculty of Health, QUT, Brisbane, Queensland, Australia
| | - Bill Vicenzino
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
| | - Andrew Hislop
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
- Physiotherapy Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Alex Vallini
- Physiotherapy Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Bula Elwell
- Physiotherapy Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Helen O'Gorman
- Physiotherapy Department, Mater Hospital, South Brisbane, Queensland, Australia
| | - Ben Phillips
- Physiotherapy Department, Townsville Hospital, Townsville, Queensland, Australia
| | - Anneke Wake
- Physiotherapy Department, Townsville Hospital, Townsville, Queensland, Australia
| | - Adrian Cush
- Physiotherapy Department, Queen Elizabeth II Hospital, Coopers Plains, Queensland, Australia
| | - Stuart McCaskill
- Physiotherapy Department, Queen Elizabeth II Hospital, Coopers Plains, Queensland, Australia
| | - Linda Garsden
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Miriam Dillon
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Andrew McLennan
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Shaun O'Leary
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
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12
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Tamura S, Kobayashi S, Takeda R, Kaizu Y, Iwamura T, Saito S, Iwamoto H, Miyata K. Clinical prediction rules for multi surfaces walking independence using the Berg Balance Scale or Mini-Balance Evaluation Systems Test in persons with stroke. Top Stroke Rehabil 2024; 31:135-144. [PMID: 37535456 DOI: 10.1080/10749357.2023.2238437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/15/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND A Clinical prediction rule (CPR) for determining multi surfaces walking independence in persons with stroke has not been established. OBJECTIVES To develop a CPR for determining multi surfaces walking independence in persons with stroke. METHODS This was a multicenter retrospective analysis of 419 persons with stroke. We developed a Berg Balance Scale (BBS)-model CPR combining the BBS, comfortable walking speed (CWS) and cognitive impairment, and a Mini-Balance Evaluation Systems Test (Mini-BESTest)-model CPR combining the Mini-BESTest, CWS, and cognitive impairment. A logistic regression analysis was conducted with multi surfaces walking independence as the dependent variable and each factor as an independent variable. The identified factors were scored (0, 1) based on reported cutoff values. The CPR's accuracy was verified by the area under the curve (AUC). We used a bootstrap method internal validation and calculated the CPR's posttest probability. RESULTS The logistic regression analysis showed that the BBS, CWS, and cognitive impairment were factors in the BBS model, and the Mini-BESTest was a factor in the Mini-BESTest model. The CPRs were 0-3 points for the BBS model and 0-1 points for the Mini-BESTest model. The AUCs (bootstrap mean AUC) of the CPR score were 0.89 (0.90) for the BBS model and 0.72 (0.72) for the Mini-BESTest model. The negative predictive value (negative likelihood ratio) was 97% (0.054) for CPR scores < 2 for the BBS model and 94% (0.060) for CPR scores < 1 for the Mini-BESTest model. CONCLUSIONS The CPR developed herein is useful for determining multi surfaces walking independence.
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Affiliation(s)
- Shuntaro Tamura
- Department of Rehabilitation, Fujioka General Hospital, Fujioka, Japan
| | - Sota Kobayashi
- Department of Rehabilitation, Public Nanokaichi Hospital, Tomioka, Japan
- Department of Rehabilitation Sciences, Gunma University Graduate School of Health Sciences, Maebashi, Japan
| | - Ren Takeda
- Department of Rehabilitation, Numata Neurosurgery and Heart Disease Hospital, Numata, Japan
| | - Yoichi Kaizu
- Department of Rehabilitation Center, Hidaka Hospital, Takasaki, Japan
| | - Taiki Iwamura
- Department of Rehabilitation, Azumabashi Orthopedics, Tokyo, Japan
| | - Shota Saito
- Department of Rehabilitation, Fujioka General Hospital, Fujioka, Japan
| | - Hiroki Iwamoto
- Department of Rehabilitation, Hidaka Rehabilitation Hospital, Takasaki, Japan
| | - Kazuhiro Miyata
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
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13
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Boyles RH, Alexander CM, Belsi A, Strutton PH. Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice. Top Spinal Cord Inj Rehabil 2024; 30:45-58. [PMID: 38433737 PMCID: PMC10906376 DOI: 10.46292/sci23-00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Background Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice. Objectives To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom. Methods An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients. Results One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future. Conclusion The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.
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Affiliation(s)
- Rowan H. Boyles
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Therapies, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Caroline M. Alexander
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Therapies, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Athina Belsi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Paul H. Strutton
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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14
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Khadem Charvadeh Y, Yi GY. Accommodating misclassification effects on optimizing dynamic treatment regimes with Q-learning. Stat Med 2024; 43:578-605. [PMID: 38213277 DOI: 10.1002/sim.9973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 01/13/2024]
Abstract
Research on dynamic treatment regimes has enticed extensive interest. Many methods have been proposed in the literature, which, however, are vulnerable to the presence of misclassification in covariates. In particular, although Q-learning has received considerable attention, its applicability to data with misclassified covariates is unclear. In this article, we investigate how ignoring misclassification in binary covariates can impact the determination of optimal decision rules in randomized treatment settings, and demonstrate its deleterious effects on Q-learning through empirical studies. We present two correction methods to address misclassification effects on Q-learning. Numerical studies reveal that misclassification in covariates induces non-negligible estimation bias and that the correction methods successfully ameliorate bias in parameter estimation.
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Affiliation(s)
- Yasin Khadem Charvadeh
- Department of Statistical and Actuarial Sciences, University of Western Ontario, London, Ontario, Canada
| | - Grace Y Yi
- Department of Statistical and Actuarial Sciences, University of Western Ontario, London, Ontario, Canada
- Department of Computer Science, University of Western Ontario, London, Ontario, Canada
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15
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Bakhit M, Gamage SK, Atkins T, Glasziou P, Hoffmann T, Jones M, Sanders S. Diagnostic performance of clinical prediction rules to detect group A beta-haemolytic streptococci in people with acute pharyngitis: a systematic review. Public Health 2024; 227:219-227. [PMID: 38241903 DOI: 10.1016/j.puhe.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To assess and compare the diagnostic performance of Clinical Prediction Rules (CPRs) developed to detect group A Beta-haemolytic streptococci in people with acute pharyngitis (or sore throat). STUDY DESIGN A systematic review. METHODS We searched PubMed, Embase and Web of Science (inception-September 2022) for studies deriving and/or validating CPRs comprised of ≥2 predictors from an individual's history or physical examination. Two authors independently screened articles, extracted data and assessed risk of bias in included studies. A meta-analysis was not possible due to heterogeneity. Instead we compared the performance of CPRs when they were validated in the same study population (head-to-head comparisons). We used a modified grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess certainty of the evidence. RESULTS We included 63 studies, all judged at high risk of bias. Of 24 derived CPRs, 7 were externally validated (in 46 external validations). Five validation studies provided data for head-to-head comparison of four pairs of CPRs. Very low certainty evidence favoured the Centor CPR over the McIsaac (2 studies) and FeverPain CPRs (1 study) and found the Centor CPR was equivalent to the Walsh CPR (1 study). The AbuReesh and Steinhoff 2005 CPRs had a similar poor discriminative ability (1 study). Within and between study comparisons suggested the performance of the Centor CPR may be better in adults (>18 years). CONCLUSION Very low certainty evidence suggests a better performance of the Centor CPR. When deciding about antibiotic prescribing for pharyngitis patients, involving patients in a shared decision making discussion about the likely benefits and harms, including antibiotic resistance, is recommended. Further research of higher rigour, which compares CPRs across multiple settings, is needed.
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Affiliation(s)
- Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | | | - Tiffany Atkins
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Sharon Sanders
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
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16
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Lloyd KE, Chambers CD. Registered Reports: benefits and challenges of implementing in medicine. Br J Gen Pract 2024; 74:58-59. [PMID: 38272700 PMCID: PMC10824340 DOI: 10.3399/bjgp24x736185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Affiliation(s)
- Kelly E Lloyd
- Leeds Institute of Health Sciences, University of Leeds, Leeds.
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Chang CH, Chen CJ, Ma YS, Shen YT, Sung MI, Hsu CC, Lin HJ, Chen ZC, Huang CC, Liu CF. Real-time artificial intelligence predicts adverse outcomes in acute pancreatitis in the emergency department: Comparison with clinical decision rule. Acad Emerg Med 2024; 31:149-155. [PMID: 37885118 DOI: 10.1111/acem.14824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Artificial intelligence (AI) prediction is increasingly used for decision making in health care, but its application for adverse outcomes in emergency department (ED) patients with acute pancreatitis (AP) is not well understood. This study aimed to clarify this aspect. METHODS Data from 8274 ED patients with AP in three hospitals from 2009 to 2018 were analyzed. Demographic data, comorbidities, laboratory results, and adverse outcomes were included. Six algorithms were evaluated, and the one with the highest area under the curve (AUC) was implemented into the hospital information system (HIS) for real-time prediction. Predictive accuracy was compared between the AI model and Bedside Index for Severity in Acute Pancreatitis (BISAP). RESULTS The mean ± SD age was 56.1 ± 16.7 years, with 67.7% being male. The AI model was successfully implemented in the HIS, with Light Gradient Boosting Machine (LightGBM) showing the highest AUC for sepsis (AUC 0.961) and intensive care unit (ICU) admission (AUC 0.973), and eXtreme Gradient Boosting (XGBoost) showing the highest AUC for mortality (AUC 0.975). Compared to BISAP, the AI model had superior AUC for sepsis (BISAP 0.785), ICU admission (BISAP 0.778), and mortality (BISAP 0.817). CONCLUSIONS The first real-time AI prediction model implemented in the HIS for predicting adverse outcomes in ED patients with AP shows favorable initial results. However, further external validation is needed to ensure its reliability and accuracy.
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Affiliation(s)
- Ching-Hung Chang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Jung Chen
- Department of Information Systems, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Shan Ma
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Ting Shen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Mei-I Sung
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
| | - Zhih-Cherng Chen
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
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Smith AC, Draganich C, Thornton WA, Berliner JC, Lennarson PJ, Rejc E, Sevigny M, Charlifue S, Tefertiller C, Weber KA. A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After Spinal Cord Injury. Arch Phys Med Rehabil 2024; 105:10-19. [PMID: 37414239 PMCID: PMC10766862 DOI: 10.1016/j.apmr.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/24/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To derive and validate a simple, accurate CPR to predict future independent walking ability after SCI at the bedside that does not rely on motor scores and is predictive for those initially classified in the middle of the SCI severity spectrum. DESIGN Retrospective cohort study. Binary variables were derived, indicating degrees of sensation to evaluate predictive value of pinprick and light touch variables across dermatomes. The optimal single sensory modality and dermatome was used to derive our CPR, which was validated on an independent dataset. SETTING Analysis of SCI Model Systems dataset. PARTICIPANTS Individuals with traumatic SCI. The data of 3679 participants (N=3679) were included with 623 participants comprising the derivation dataset and 3056 comprising the validation dataset. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported ability to walk both indoors and outdoors. RESULTS Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately identified future independent walkers 1 year after SCI. Normal pinprick in both lateral heels provided good prognosis, any pinprick sensation in either lateral heel provided fair prognosis, and no sensation provided poor prognosis. This CPR performed satisfactorily in the middle SCI severity subgroup. CONCLUSIONS In this large multi-site study, we derived and validated a simple, accurate CPR using only pinprick sensory testing at lateral heels that predicts future independent walking after SCI.
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Affiliation(s)
- Andrew C Smith
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO.
| | - Christina Draganich
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO; Craig Hospital, Englewood, CO
| | - Wesley A Thornton
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
| | - Jeffrey C Berliner
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
| | - Peter J Lennarson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO
| | - Enrico Rejc
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY; Department of Medicine, University of Udine, Udine, Italy
| | | | | | | | - Kenneth A Weber
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
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Pötsch N, Vatteroni G, Clauser P, Rainer E, Kapetas P, Milos R, Helbich TH, Baltzer P. Using the Kaiser Score as a clinical decision rule for breast lesion classification: Does computer-assisted curve type analysis improve diagnosis? Eur J Radiol 2024; 170:111271. [PMID: 38185026 DOI: 10.1016/j.ejrad.2023.111271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE We aimed to investigate the effect of using visual or automatic enhancement curve type assessment on the diagnostic performance of the Kaiser Score (KS), a clinical decision rule for breast MRI. METHOD This IRB-approved retrospective study analyzed consecutive conventional BI-RADS 0, 4 or 5 patients who underwent biopsy after 1.5T breast MRI according to EUSOBI recommendations between 2013 and 2015. The KS includes five criteria (spiculations; signal intensity (SI)-time curve type; margins of the lesion; internal enhancement; and presence of edema) resulting in scores from 1 (=lowest) to 11 (=highest risk of breast cancer). Enhancement curve types (Persistent, Plateau or Wash-out) were assessed by two radiologists independently visually and using a pixel-wise color-coded computed parametric map of curve types. KS diagnostic performance differences between readings were compared by ROC analysis. RESULTS In total 220 lesions (147 benign, 73 malignant) including mass (n = 148) and non-mass lesions (n = 72) were analyzed. KS reading performance in distinguishing benign from malignant lesions did not differ between visual analysis and parametric map (P = 0.119; visual: AUC 0.875, sensitivity 95 %, specificity 63 %; and map: AUC 0.901, sensitivity 97 %, specificity 65 %). Additionally, analyzing mass and non-mass lesions separately, showed no difference between parametric map based and visual curve type-based KS analysis as well (P = 0.130 and P = 0.787). CONCLUSIONS The performance of the Kaiser Score is largely independent of the curve type assessment methodology, confirming its robustness as a clinical decision rule for breast MRI in any type of breast lesion in clinical routine.
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Affiliation(s)
- N Pötsch
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - G Vatteroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - P Clauser
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - E Rainer
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - P Kapetas
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - R Milos
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - T H Helbich
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - P Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Pehlivan J, Douillet D, Jérémie R, Perraud C, Niset A, Eveillard M, Chenouard R, Mahieu R. A clinical decision rule to rule out bloodstream infection in the emergency department: retrospective multicentric observational cohort study. Emerg Med J 2023; 41:20-26. [PMID: 37940371 DOI: 10.1136/emermed-2022-212987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED. METHODS We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy. RESULTS We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6). CONCLUSION The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.
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Affiliation(s)
- Jonathan Pehlivan
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
- UMR MitoVasc CNRS 6015-INSERM 1083, University of Angers, Angers, France
| | - Riou Jérémie
- Micro et Nano médecines translationnelles, MINT, UMR INSERM 1066, UMR CNRS 6021, University of Angers, Angers, France
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, CHU Angers, Angers, France
| | - Clément Perraud
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
| | - Alexandre Niset
- Emergency Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Hopital à Bruxelles-Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Matthieu Eveillard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rachel Chenouard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rafael Mahieu
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, CHU Angers Maladies infectieuses et tropicales, Angers, France
- Faculty of Medicine, Université de Nantes, Inserm, CRCINA, SFR ICAT, University of Angers, Angers, France
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Dietzel M, Bernathova M, Clauser P, Kapetas P, Uder M, Baltzer PAT. Added value of clinical decision rules for the management of enhancing breast MRI lesions: A systematic comparison of the Kaiser score and the Göttingen score. Eur J Radiol 2023; 169:111185. [PMID: 37939606 DOI: 10.1016/j.ejrad.2023.111185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE We investigated the added value of two internationally used clinical decision rules in the management of enhancing lesions on breast MRI. METHODS This retrospective, institutional review board approved study included consecutive patients from two different populations. Patients received breast MRI according to the recommendations of the European Society of Breast Imaging (EUSOBI). Initially, all examinations were assessed by expert readers without using clinical decision rules. All lesions rated as category 4 or 5 according to the Breast Imaging Reporting and Data System were histologically confirmed. These lesions were re-evaluated by an expert reader blinded to the histology. He assigned each lesion a Göttingen score (GS) and a Kaiser score (KS) on different occasions. To provide an estimate on inter-reader agreement, a second fellowship-trained reader assessed a subset of these lesions. Subgroup analyses based on lesion type (mass vs. non-mass), size (>1 cm vs. ≤ 1 cm), menopausal status, and significant background parenchymal enhancement were conducted. The areas under the ROC curves (AUCs) for the GS and KS were compared, and the potential to avoid unnecessary biopsies was determined according to previously established cutoffs (KS > 4, GS > 3) RESULTS: 527 lesions in 506 patients were included (mean age: 51.8 years, inter-quartile-range: 43.0-61.0 years). 131/527 lesions were malignant (24.9 %; 95 %-confidence-interval: 21.3-28.8). In all subgroups, the AUCs of the KS (median = 0.91) were higher than those of the GS (median = 0.83). Except for "premenopausal patients" (p = 0.057), these differences were statistically significant (p ≤ 0.01). Kappa agreement was higher for the KS (0.922) than for the GS (0.358). CONCLUSION Both the KS and the GS provided added value for the management of enhancing lesions on breast MRI. The KS was superior to the GS in terms of avoiding unnecessary biopsies and showed superior inter-reader agreement; therefore, it may be regarded as the clinical decision rule of choice.
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Affiliation(s)
- Matthias Dietzel
- Department of Radiology, University Hospital Erlangen, Maximiliansplatz 3, 91054 Erlangen, Germany.
| | - Maria Bernathova
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer-Guertel 18-20, Vienna, Austria.
| | - Paola Clauser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer-Guertel 18-20, Vienna, Austria.
| | - Panagiotis Kapetas
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer-Guertel 18-20, Vienna, Austria.
| | - Michael Uder
- Department of Radiology, University Hospital Erlangen, Maximiliansplatz 3, 91054 Erlangen, Germany.
| | - Pascal A T Baltzer
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Waehringer-Guertel 18-20, Vienna, Austria.
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Blok G, Burger H, van der Lei J, Berger M, Holtman G. Development and validation of a clinical prediction rule for acute appendicitis in children in primary care. Eur J Gen Pract 2023; 29:2233053. [PMID: 37578416 PMCID: PMC10431724 DOI: 10.1080/13814788.2023.2233053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Recognising acute appendicitis in children presenting with acute abdominal pain in primary care is challenging. General practitioners (GPs) may benefit from a clinical prediction rule. OBJECTIVES To develop and validate a clinical prediction rule for acute appendicitis in children presenting with acute abdominal pain in primary care. METHODS In a historical cohort study data was retrieved from GP electronic health records included in the Integrated Primary Care Information database. We assigned children aged 4-18 years presenting with acute abdominal pain (≤ 7 days) to development (2010-2012) and validation (2013-2016) cohorts, using acute appendicitis within six weeks as the outcome. Multiple logistic regression was used to develop a prediction model based on predictors with > 50% data availability derived from existing rules for secondary care. We performed internal and external temporal validation and derived a point score to stratify risk of appendicitis into three groups, i.e. low-risk, medium-risk and high-risk. RESULTS The development and validation cohorts included 2,041 and 3,650 children, of whom 95 (4.6%) and 195 (5.3%) had acute appendicitis. The model included male sex, pain duration (<24, 24-48, > 48 h), nausea/vomiting, elevated temperature (≥ 37.3 °C), abnormal bowel sounds, right lower quadrant tenderness, and peritoneal irritation. Internal and temporal validation showed good discrimination (C-statistics: 0.93 and 0.90, respectively) and excellent calibration. In the three groups, the risks of acute appendicitis were 0.5%, 7.5%, and 41%. CONCLUSION Combined with further testing in the medium-risk group, the prediction rule could improve clinical decision making and outcomes.
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Affiliation(s)
- Guus Blok
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Huib Burger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gea Holtman
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Bolia R. Diagnosing Appendicitis on the Basis of Clinical Prediction Rules: Are We There Yet? Indian J Pediatr 2023; 90:1173-1174. [PMID: 37477860 DOI: 10.1007/s12098-023-04771-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology, Hepatology and Liver Transplant, Children's Health Queensland Hospital and Health Service, Level 7d, Surgical Directorate, Queensland Children's Hospital, South Brisbane, QLD, 4101, Australia.
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Zhang J, Wu N, Li M. A prediction model for cesarean delivery based on the glycemia in the second trimester: a nested case control study from two centers. J Matern Fetal Neonatal Med 2023; 36:2222208. [PMID: 37332139 DOI: 10.1080/14767058.2023.2222208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 12/20/2022] [Accepted: 06/01/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Maternal glycemia is associated with the risk of cesarean delivery (CD); therefore, our study aims to developed a prediction model based on glucose indicators in the second trimester to earlier identify the risk of CD. METHODS This was a nested case-control study, and data were collected from the 5th Central Hospital of Tianjin (training set) and Changzhou Second People's Hospital (testing set) from 2020 to 2021. Variables with significant difference in training set were incorporated to develop the random forest model. Model performance was assessed by calculating the area under the curve (AUC) and Komogorov-Smirnoff (KS), as well as accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS A total of 504 eligible women were enrolled; of these, 169 underwent CD. Pre-pregnancy body mass index (BMI), first pregnancy, history of full-term birth, history of livebirth, 1 h plasma glucose (1hPG), glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2 h plasma glucose (2hPG) were used to develop the model. The model showed a good performance, with an AUC of 0.852 [95% confidence interval (CI): 0.809-0.895]. The pre-pregnancy BMI, 1hPG, 2hPG, HbA1c, and FPG were identifies as the more significant predictors. External validation confirmed the good performance of our model, with an AUC of 0.734 (95%CI: 0.664-0.804). CONCLUSIONS Our model based on glucose indicators in the second trimester performed well to predict the risk of CD, which may reach the earlier identification of CD risk and may be beneficial to make interventions in time to decrease the risk of CD.
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Affiliation(s)
- Junping Zhang
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Naiqian Wu
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Minhui Li
- Department of Obstetrics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, P.R. China
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Perelas A, Kirincich J, Yadav R, Ennala S, Wang X, Sadana D, Duggal A, Krishnan S. Diagnostic Yield, Radiation Exposure, and the Role of Clinical Decision Rules to Limit Computed Tomographic Pulmonary Angiography-Associated Complications. J Patient Saf 2023; 19:532-538. [PMID: 37883056 DOI: 10.1097/pts.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Computed tomographic pulmonary angiography (CT-PA) is associated with significant cost, contrast, and radiation exposure. Clinical decision rules (CDRs) reduce the need for diagnostic imaging; however, their utility in the medical intensive care unit (MICU) remains unknown. We explored the diagnostic yield and complications associated with CT-PA (radiation exposure and contrast-induced acute kidney injury [AKI]) while investigating the efficacy of CDRs to reduce unnecessary testing. METHODS All CT-PAs performed in an academic MICU for 4 years were retrospectively reviewed. The Wells and revised Geneva scores (CDRs) and radiation dose per CT-PA were calculated, and the incidence of post-CT-PA AKI was recorded. RESULTS A total of 439 studies were analyzed; the diagnostic yield was 11% (48 PEs). Positive CT-PAs were associated with a higher Wells score (5.8 versus 3.2, P < 0.001), but similar revised Geneva scores (6.4 versus 6.0, P = 0.32). A Wells score of ≥4 had a positive likelihood ratio of 2.1 with a negative predictive value of 98.2. More than half (88.9%) of patients with a Wells score of ≤4 developed an AKI, with 55.6% of those having recovery of renal function. CONCLUSIONS There is overutilization of CT-PA in the MICU. The Wells score retains its negative predictive value in critically ill adult patients and may aid to limit radiation exposure and contrast-induced AKI in MICU.
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Affiliation(s)
| | | | | | | | - Xiaofeng Wang
- Quantitative Health Sciences Department, Cleveland Clinic Foundation, Cleveland, Ohio
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Hill CJ, Banerjee A, Hill J, Stapleton C. Diagnostic clinical prediction rules for categorising low back pain: A systematic review. Musculoskeletal Care 2023; 21:1482-1496. [PMID: 37807828 DOI: 10.1002/msc.1816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision-making. A review of LBP diagnostic-CPRs by Haskins et al. (2015) identified six diagnostic-CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic-CPRs and evaluate their readiness for implementation. METHODS A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand-searching and citation-tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies-2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive). RESULTS Of 5021 studies screened, 11 diagnostic-CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic-CPRs include the Lumbar-Spinal-Stenosis-Self-Administered-Self-Reported-History-Questionnaire and Diagnosis-Support-Tool-to-Identify-Lumbar-Spinal-Stenosis, and the StEP-tool which differentiates radicular from axial-LBP. CONCLUSIONS This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision-making.
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Rajchagool B, Wongyikul P, Lumkul L, Phinyo P, Pattanakuhar S. Performance of the Dutch clinical prediction rule for the ambulation outcome after spinal cord injury in a middle-income country clinical setting: an external validation study in the Thai retrospective cohort. Spinal Cord 2023; 61:608-614. [PMID: 37488352 DOI: 10.1038/s41393-023-00917-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE To perform external geographic and domain validation of the clinical prediction rule (CPR) of the ambulation outcome of patients with traumatic spinal cord injury (SCI) originally developed by van Middendorp, et al. (2011) in Thais with traumatic and non-traumatic SCI. STUDY DESIGN Retrospective cohort study. SETTING A tertiary rehabilitation facility in Chiang Mai, Thailand. METHODS A validation data set, including predictive (age and four neurological variables) and outcome (ambulation status) parameters was retrospectively collected from medical records of patients with traumatic and non-traumatic SCI admitted between December 2007 and December 2019. The performance of the original model was evaluated in both discrimination and calibration aspects, using an area under the receiver-operating characteristic curve (auROC) and calibration curves, respectively. RESULTS Three hundred and thirty-three patients with SCI were included in the validation set. The prevalence of ambulators was 59% (197 of 333 participants). An auROC of 0.93 (95% CI 0.90-0.96) indicated excellent discrimination whereas the calibration curve demonstrated underestimation, especially in patients with AIS grade D. Performance of the CPR was decreased but acceptable in patients with non-traumatic SCI. CONCLUSIONS Our external validation study demonstrated excellent discrimination but slightly underestimated calibration of the CPR of ambulation outcome after SCI. Regardless of the geographic and etiologic background of the population, the Dutch CPR could be applied to predict the ambulation outcome in patients with SCI.
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Affiliation(s)
- Buddharaksa Rajchagool
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lalita Lumkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sintip Pattanakuhar
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Health Services and Clinical Care Unit, Swiss Paraplegic Research, Nottwil, Switzerland.
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Oh JS, Jayasimhan D, Sithamparanathan S. Diagnostic test accuracy of D-dimer with or without a clinical decision rule in peripartum patients with suspected venous thromboembolism: A systematic review and meta-analysis. Intern Med J 2023; 53:2093-2101. [PMID: 36645305 DOI: 10.1111/imj.16021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pregnancy and the peripartum period is a hypercoagulable state increasing the risk of venous thromboembolism (VTE). There may be a role in utilising D-dimer in the peripartum setting. AIMS The purpose of this review was to summarise the latest evidence regarding the diagnostic accuracy of D-dimer in the peripartum setting with or without the addition of clinical decision rules. METHODS We searched PubMed and CENTRAL databases to identify articles that included studies of women who had suspected VTE, underwent a D-dimer index test to rule out VTE and where radiological imaging or clinical follow-up, to a minimum of 30 days, was used as the reference standard. RESULTS We included 11 studies in the systematic review and meta-analysis. The log diagnostic odds ratio (DOR) for identifying VTE using D-dimer was 1.56 (95% confidence interval (CI) 0.59-2.52). The pooled sensitivity was 87% (95% CI 76.8-93%), specificity was 63.2% (95% CI 47.1-76.7%), and the area under receiver operator characteristic (ROC) curves was 0.76. We included four studies evaluating D-dimer combined with YEARS to detect VTE. The log DOR for identifying VTE using D-dimer combined with YEARS was 1.13 (95% CI 0.005-2.25). The pooled sensitivity was 89.8% (95% CI 60.2-98.1%), specificity was 65.7% (95% CI 54.7-75.2%) and the area under ROC for studies included with the YEARS clinical decision rule was 0.49. CONCLUSION This review highlighted that D-dimer use in the peripartum period for detection of VTE had a high sensitivity and high DOR but a poor area under ROC, which may limit its use in clinical practice.
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Affiliation(s)
- Jeong S Oh
- Department of Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Dilip Jayasimhan
- Department of Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
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Billings WZ, Cleven A, Dworaczyk J, Dale AP, Ebell M, McKay B, Handel A. Use of Patient-Reported Symptom Data in Clinical Decision Rules for Predicting Influenza in a Telemedicine Setting. J Am Board Fam Med 2023; 36:766-776. [PMID: 37775324 PMCID: PMC10688580 DOI: 10.3122/jabfm.2023.230126r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION Increased use of telemedicine could potentially streamline influenza diagnosis and reduce transmission. However, telemedicine diagnoses are dependent on accurate symptom reporting by patients. If patients disagree with clinicians on symptoms, previously derived diagnostic rules may be inaccurate. METHODS We performed a secondary data analysis of a prospective, nonrandomized cohort study at a university student health center. Patients who reported an upper respiratory complaint were required to report symptoms, and their clinician was required to report the same list of symptoms. We examined the performance of 5 previously developed clinical decision rules (CDRs) for influenza on both symptom reports. These predictions were compared against PCR diagnoses. We analyzed the agreement between symptom reports, and we built new predictive models using both sets of data. RESULTS CDR performance was always lower for the patient-reported symptom data, compared with clinician-reported symptom data. CDRs often resulted in different predictions for the same individual, driven by disagreement in symptom reporting. We were able to fit new models to the patient-reported data, which performed slightly worse than previously derived CDRs. These models and models built on clinician-reported data both suffered from calibration issues. DISCUSSION Patients and clinicians frequently disagree about symptom presence, which leads to reduced accuracy when CDRs built with clinician data are applied to patient-reported symptoms. Predictive models using patient-reported symptom data performed worse than models using clinician-reported data and prior results in the literature. However, the differences are minor, and developing new models with more data may be possible.
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Affiliation(s)
- W Zane Billings
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Annika Cleven
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Jacqueline Dworaczyk
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Ariella Perry Dale
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Mark Ebell
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Brian McKay
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM)
| | - Andreas Handel
- From the Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA (WZB, APD, ME, AH); Department of Mathematics, St. Olaf College, Northfield, MN (AC); Ira A. Fulton Schools of Engineering, Arizona State University, Tempe, AZ (JD); Department of Family and Consumer Sciences, University of Georgia, Athens, GA (BM).
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Ban JW, Perera R, Williams V. Influence of research evidence on the use of cardiovascular clinical prediction rules in primary care: an exploratory qualitative interview study. BMC Prim Care 2023; 24:194. [PMID: 37730553 PMCID: PMC10512575 DOI: 10.1186/s12875-023-02155-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians' perceptions of and experiences with research influence their use of cardiovascular CPRs. METHODS We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes. RESULTS Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians' perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: "Seek and judge" and "be acquainted and assume." When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs. CONCLUSIONS Clinicians' perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians' unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.
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Affiliation(s)
- Jong- Wook Ban
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK.
- Department for Continuing Education, University of Oxford, Oxford, UK.
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Copaescu AM, Vogrin S, James F, Chua KYL, Rose MT, De Luca J, Waldron J, Awad A, Godsell J, Mitri E, Lambros B, Douglas A, Youcef Khoudja R, Isabwe GAC, Genest G, Fein M, Radojicic C, Collier A, Lugar P, Stone C, Ben-Shoshan M, Turner NA, Holmes NE, Phillips EJ, Trubiano JA. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med 2023; 183:944-952. [PMID: 37459086 PMCID: PMC10352926 DOI: 10.1001/jamainternmed.2023.2986] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/17/2023] [Indexed: 07/20/2023]
Abstract
Importance Fewer than 5% of patients labeled with a penicillin allergy are truly allergic. The standard of care to remove the penicillin allergy label in adults is specialized testing involving prick and intradermal skin testing followed by an oral challenge with penicillin. Skin testing is resource intensive, limits practice to specialist-trained physicians, and restricts the global population who could undergo penicillin allergy delabeling. Objective To determine whether a direct oral penicillin challenge is noninferior to the standard of care of penicillin skin testing followed by an oral challenge in patients with a low-risk penicillin allergy. Design, Setting, and Participants This parallel, 2-arm, noninferiority, open-label, multicenter, international randomized clinical trial occurred in 6 specialized centers, 3 in North America (US and Canada) and 3 in Australia, from June 18, 2021, to December 2, 2022. Eligible adults had a PEN-FAST score lower than 3. PEN-FAST is a prospectively derived and internationally validated clinical decision rule that enables point-of-care risk assessment for adults reporting penicillin allergies. Interventions Patients were randomly assigned to either direct oral challenge with penicillin (intervention arm) or a standard-of-care arm of penicillin skin testing followed by oral challenge with penicillin (control arm). Main Outcome and Measure The primary outcome was a physician-verified positive immune-mediated oral penicillin challenge within 1 hour postintervention in the intention-to-treat population. Noninferiority was achieved if a 1-sided 95% CI of the risk difference (RD) did not exceed 5 percentage points (pp). Results A total of 382 adults were randomized, with 377 patients (median [IQR] age, 51 [35-65] years; 247 [65.5%] female) included in the analysis: 187 in the intervention group and 190 in the control group. Most patients had a PEN-FAST score of 0 or 1. The primary outcome occurred in 1 patient (0.5%) in the intervention group and 1 patient (0.5%) in the control group, with an RD of 0.0084 pp (90% CI, -1.22 to 1.24 pp). The 1-sided 95% CI was below the noninferiority margin of 5 pp. In the 5 days following the oral penicillin challenge, 9 immune-mediated adverse events were recorded in the intervention group and 10 in the control group (RD, -0.45 pp; 95% CI, -4.87 to 3.96 pp). No serious adverse events occurred. Conclusions and Relevance In this randomized clinical trial, direct oral penicillin challenge in patients with a low-risk penicillin allergy was noninferior compared with standard-of-care skin testing followed by oral challenge. In patients with a low-risk history, direct oral penicillin challenge is a safe procedure to facilitate the removal of a penicillin allergy label. Trial Registration ClinicalTrials.gov Identifier: NCT04454229.
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Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent’s Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Kyra Y. L. Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Morgan T. Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph De Luca
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jamie Waldron
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Awad
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Jack Godsell
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Clinical Immunology and Allergy, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elise Mitri
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Belinda Lambros
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Abby Douglas
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rabea Youcef Khoudja
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Ghislaine A. C. Isabwe
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Genevieve Genest
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Michael Fein
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Cristine Radojicic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ann Collier
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Cosby Stone
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre McGill University, Montreal, Quebec, Canada
| | - Nicholas A. Turner
- Department of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Natasha E. Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth J. Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Jason A. Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
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Bastida Paz G, Merino Ochoa O, Aguas Peris M, Barreiro-de Acosta M, Zabana Y, Ginard Vicens D, Ceballos Santos D, Muñoz Núñez F, Monfort I Miquel D, Catalán-Serra I, García Sánchez V, Loras Alastruey C, Lucendo Villarín A, Huguet JM, de la Coba Ortiz C, Aldeguer Manté X, Palau Canós A, Domènech Morral E, Nos P. The Risk of Developing Disabling Crohn's Disease: Validation of a Clinical Prediction Rule to Improve Treatment Decision Making. Dig Dis 2023; 41:879-889. [PMID: 37611561 DOI: 10.1159/000531789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/20/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Crohn's disease (CD) is characterized by the development of complications over the course of the disease. It is crucial to identify predictive factors of disabling disease, in order to target patients for early intervention. We evaluated risk factors of disabling CD and developed a prognostic model. METHODS In total, 511 CD patients were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to identify demographic, clinical, and biological risk factors. A predictive nomogram model was developed in a subgroup of patients with noncomplicated CD (inflammatory pattern and no perianal disease). RESULTS The rate of disabling CD within 5 years after diagnosis was 74.6%. Disabling disease was associated with gender, location of disease, requirement of steroids for the first flare, and perianal lesions. In the subgroup of patients (310) with noncomplicated CD, the rate of disabling CD was 80%. In the multivariate analysis age at onset <40 years (OR = 3.46, 95% confidence interval [CI] = 1.52-7.90), extensive disease (L3/L4) (OR = 2.67, 95% CI = 1.18-6.06), smoking habit (OR = 2.09, 95% CI = 1.03-4.27), requirement of steroids at the first flare (OR = 2.20, 95% CI = 1.09-4.45), and albumin (OR = 0.59, 95% CI = 0.36-0.96) were associated with development of disabling disease. The developed predictive nomogram based on these factors presented good discrimination, with an area under the receiver operating characteristic curve of 0.723 (95% CI: 0.670-0.830). CONCLUSION We identified predictive factors of disabling CD and developed an easy-to-use prognostic model that may be used in clinical practice to help identify patients at high risk and address treatment effectively.
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Affiliation(s)
- Guillermo Bastida Paz
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Olga Merino Ochoa
- Gastroenterology, Hospital Universitario de Cruces, Barakaldo, Spain
| | - Mariam Aguas Peris
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Yamile Zabana
- Gastroenterology Department, Fundació per la Recerca Mútua Terrassa, Hospital Universitari Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Fernando Muñoz Núñez
- University Hospital of Salamanca, Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | | | - Ignacio Catalán-Serra
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
- Centre of Molecular Inflammation Research (CEMIR) and Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | | | - Carmen Loras Alastruey
- Gastroenterology Department, Fundació per la Recerca Mútua Terrassa, Hospital Universitari Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | | | | | | | - Eugeni Domènech Morral
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Pilar Nos
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Qi Y, Lin X, Pan W, Zhang X, Ding Y, Chen S, Zhang L, Zhou D, Ge J. A prediction model for permanent pacemaker implantation after transcatheter aortic valve replacement. Eur J Med Res 2023; 28:262. [PMID: 37516891 PMCID: PMC10387194 DOI: 10.1186/s40001-023-01237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 07/18/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND This study aims to develop a post-procedural risk prediction model for permanent pacemaker implantation (PPMI) in patients treated with transcatheter aortic valve replacement (TAVR). METHODS 336 patients undergoing TAVR at a single institution were included for model derivation. For primary analysis, multivariate logistic regression model was used to evaluate predictors and a risk score system was devised based on the prediction model. For secondary analysis, a Cox proportion hazard model was performed to assess characteristics associated with the time from TAVR to PPMI. The model was validated internally via bootstrap and externally using an independent cohort. RESULTS 48 (14.3%) patients in the derivation set had PPMI after TAVR. Prior right bundle branch block (RBBB, OR: 10.46; p < 0.001), pre-procedural aortic valve area (AVA, OR: 1.41; p = 0.004) and post- to pre-procedural AVA ratio (OR: 1.72; p = 0.043) were identified as independent predictors for PPMI. AUC was 0.7 and 0.71 in the derivation and external validation set. Prior RBBB (HR: 5.07; p < 0.001), pre-procedural AVA (HR: 1.33; p = 0.001), post-procedural AVA to prosthetic nominal area ratio (HR: 0.02; p = 0.039) and post- to pre-procedural troponin-T difference (HR: 1.72; p = 0.017) are independently associated with time to PPMI. CONCLUSIONS The post-procedural prediction model achieved high discriminative power and accuracy for PPMI. The risk score system was constructed and validated, providing an accessible tool in clinical setting regarding the Chinese population.
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Affiliation(s)
- Yiming Qi
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiaolei Lin
- School of Data Science, Fudan University, Shanghai, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yuefan Ding
- School of Data Science, Fudan University, Shanghai, China
| | - Shasha Chen
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Lei Zhang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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Rushton AB, Jadhakhan F, Verra ML, Emms A, Heneghan NR, Falla D, Reddington M, Cole AA, Willems PC, Benneker L, Selvey D, Hutton M, Heymans MW, Staal JB. Predictors of poor outcome following lumbar spinal fusion surgery: a prospective observational study to derive two clinical prediction rules using British Spine Registry data. Eur Spine J 2023; 32:2303-2318. [PMID: 37237240 DOI: 10.1007/s00586-023-07754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/14/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation. METHODS A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported. RESULTS Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination. CONCLUSIONS BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.
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Affiliation(s)
- Alison B Rushton
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada.
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.
| | - Feroz Jadhakhan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Martin L Verra
- Department of Physiotherapy, Berne University Hospital, Bern, Switzerland
| | - Andrew Emms
- Department of Physiotherapy, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Michael Reddington
- Physiotherapy Department, Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, UK
| | - Ashley A Cole
- Department of Orthopaedics and Trauma, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul C Willems
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Lorin Benneker
- Department of Orthopaedic Surgery Inselspital, University of Bern, Bern, Switzerland
| | - David Selvey
- Amplitude Clinical, Host of the British Spine Registry, Droitwich, UK
| | - Michael Hutton
- Princess Elizabeth Orthopaedic Centre (PEOC), Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J Bart Staal
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
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van den Bulk S, Petrus AHJ, Willemsen RTA, Boogers MJ, Meeder JG, Rahel BM, van den Akker-van Marle ME, Numans ME, Dinant GJ, Bonten TN. Ruling out acute coronary syndrome in primary care with a clinical decision rule and a capillary, high-sensitive troponin I point of care test: study protocol of a diagnostic RCT in the Netherlands (POB HELP). BMJ Open 2023; 13:e071822. [PMID: 37290947 PMCID: PMC10255045 DOI: 10.1136/bmjopen-2023-071822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/12/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Chest pain is a common reason for consultation in primary care. To rule out acute coronary syndrome (ACS), general practitioners (GP) refer 40%-70% of patients with chest pain to the emergency department (ED). Only 10%-20% of those referred, are diagnosed with ACS. A clinical decision rule, including a high-sensitive cardiac troponin-I point-of-care test (hs-cTnI-POCT), may safely rule out ACS in primary care. Being able to safely rule out ACS at the GP level reduces referrals and thereby alleviates the burden on the ED. Moreover, prompt feedback to the patients may reduce anxiety and stress. METHODS AND ANALYSIS The POB HELP study is a clustered randomised controlled diagnostic trial investigating the (cost-)effectiveness and diagnostic accuracy of a primary care decision rule for acute chest pain, consisting of the Marburg Heart Score combined with a hs-cTnI-POCT (limit of detection 1.6 ng/L, 99th percentile 23 ng/L, cut-off value between negative and positive used in this study 3.8 ng/L). General practices are 2:1 randomised to the intervention group (clinical decision rule) or control group (regular care). In total 1500 patients with acute chest pain are planned to be included by GPs in three regions in The Netherlands. Primary endpoints are the number of hospital referrals and the diagnostic accuracy of the decision rule 24 hours, 6 weeks and 6 months after inclusion. ETHICS AND DISSEMINATION The medical ethics committee Leiden-Den Haag-Delft (the Netherlands) has approved this trial. Written informed consent will be obtained from all participating patients. The results of this trial will be disseminated in one main paper and additional papers on secondary endpoints and subgroup analyses. TRIAL REGISTRATION NUMBERS NL9525 and NCT05827237.
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Affiliation(s)
- Simone van den Bulk
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Annelieke H J Petrus
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Mark J Boogers
- Cardiology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Joan G Meeder
- Cardiology, VieCuri Medisch Centrum voor Noord-Limburg, Venlo, The Netherlands
| | - Braim M Rahel
- Cardiology, VieCuri Medisch Centrum voor Noord-Limburg, Venlo, The Netherlands
| | | | - Mattijs E Numans
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Tobias N Bonten
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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Ji X, Zhang J, Li Y, Hu L. Influencing Factors of Quality of Life and Prediction Model Building in Patients with Primary Nephrotic Syndrome: A Single-Centre Retrospective Study. ARCH ESP UROL 2023; 76:283-289. [PMID: 37455527 DOI: 10.56434/j.arch.esp.urol.20237604.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE This study aimed to explore the influencing factors of quality of life (QOL) and establish a prediction model in patients with primary nephrotic syndrome (PNS). METHODS A single-centre retrospective study was conducted on 245 patients with PNS admitted to Zibo Central Hospital from August 2020 to August 2022. According to the 36-Item Short-Form Health Survey (SF-36) for QOL evaluation, the patients were divided into the good QOL group (the total score ≥50 points) and poor QOL group (the total score <50 points). Univariate analysis was conducted by collecting clinical data from patients, and multiple logistic regression analysis was carried out on single factors with statistically significant differences to construct a clinical prediction model. The diagnostic efficacy of the prediction model was evaluated using the receiver operating characteristic (ROC) curve. RESULTS A total of 245 questionnaires were distributed, and 243 valid questionnaires were recovered, in which 143 cases had good QOL, with an average score of (71.86 ± 10.83) points, and 100 cases had poor QOL, with an average score of (40.03 ± 5.95) points. Statistical differences were observed in age, education level, monthly family average income, payment methods of medical expenses, albumin, 24-hour urinary protein quantification (24 h UPro) and serum uric acid (SUA) in both groups (p < 0.05), whereas no statistical difference was found in gender, body mass index (BMI) and marital status (p > 0.05). The multiple logistic regression analysis showed that age (X1), monthly family average income (X2), payment methods of medical expenses (X3), albumin (X4), 24 h UPro (X5) and SUA (X6) were risk factors for the QOL of patients with PNS, with Y = -12.105 + 0.130X1 + 0.457X2 + 0.448X3 + -0.161X4 + 0.823X5 + 0.025X6 as the regression prediction model. The results of ROC curve showed that the area under the curve (AUC) was 0.987 with standard error of 0.005 (p < 0.001), and 95% CI was 0.976-0.998. CONCLUSIONS Age, monthly family average income, payment methods of medical expenses, albumin, 24 h UPro and SUA are risk factors that affect the QOL of patients with PNS, and the construction of prediction model has good evaluation value and can provide a reference for clinical practice.
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Affiliation(s)
- Xiaohong Ji
- Nursing Department, Zibo Central Hospital, 255000 Zibo, Shandong, China
| | - Jianfang Zhang
- Internal Medicine-Neurology, Zibo Central Hospital, 255000 Zibo, Shandong, China
| | - Yuanyuan Li
- Department of Hematology, West Hospital of Zibo Central Hospital, 255000 Zibo, Shandong, China
| | - Lin Hu
- Electrocardiogram Diagnosis Department, Zibo Central Hospital, 255000 Zibo, Shandong, China
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Gutierrez CM, Malia L, Ng LK, Dayan PS, Rabiner JE. Validation of a Clinical Decision Rule for Ultrasound Identification of MRSA Skin Abscesses in Children. Pediatr Emerg Care 2023; 39:438-442. [PMID: 36730897 DOI: 10.1097/pec.0000000000002869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to validate an adult-derived clinical decision rule for ultrasound identification of methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses in a pediatric cohort. METHODS We conducted a retrospective study of skin and soft tissue infections in patients <21 years presenting to the emergency department who had radiology performed ultrasounds completed and wound cultures obtained. Ultrasound scans were reviewed for edge definition, volume, and shape by 2 pediatric emergency physicians with expertise in point-of-care ultrasound, with approximately 25% of scans reviewed by both experts to evaluate interrater reliability. A third, blinded expert weighed in for discrepancies before analysis. Test performance characteristics were calculated for the clinical decision rule in children. RESULTS Two hundred nine patients were enrolled, with mean age of 9.8 (±6.7) years; 87 (42%) were male. Sixty-nine (33%) patients had a wound culture positive for MRSA. The clinical decision rule had a sensitivity of 86% (95% confidence interval [CI], 75%-93%), specificity of 32% (95% CI, 25%-41%), positive predictive value of 38% (95% CI, 35%-42%), negative predictive value of 82% (95% CI, 71%-89%), positive likelihood ratio of 1.26 (95% CI, 1.08-1.46), negative likelihood ratio of 0.45 (95% CI, 0.24-0.84), and an odds ratio of 2.8 (95% CI, 1.31-5.97). CONCLUSIONS This clinical decision rule for ultrasound identification of MRSA abscesses had moderately high sensitivity and negative predictive value in pediatric patients, with similar sensitivity compared with the original adult validation group. Ultrasound may help identify MRSA abscesses, allowing for improved antibiotic choices and outcomes for children with MRSA abscesses.
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Affiliation(s)
- Christie M Gutierrez
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
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Luo E, Zhong Q, Wen Y, Cai J, Xie X, Zhou L. Development and external validation of a prognostic tool for nonsevere COVID-19 inpatients. Epidemiol Infect 2023; 151:e128. [PMID: 37202367 PMCID: PMC10540186 DOI: 10.1017/s0950268823000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023] Open
Abstract
To develop a machine learning model and nomogram to predict the probability of persistent virus shedding (PVS) in hospitalized patients with coronavirus disease 2019 (COVID-19), the clinical symptoms and signs, laboratory parameters, cytokines, and immune cell data of 429 patients with nonsevere COVID-19 were retrospectively reviewed. Two models were developed using the Akaike information criterion (AIC). The performance of these two models was analyzed and compared by the receiver operating characteristic (ROC) curve, calibration curve, net reclassification index (NRI), and integrated discrimination improvement (IDI). The final model included the following independent predictors of PVS: sex, C-reactive protein (CRP) level, interleukin-6 (IL-6) level, the neutrophil-lymphocyte ratio (NLR), monocyte count (MC), albumin (ALB) level, and serum potassium level. The model performed well in both the internal validation (corrected C-statistic = 0.748, corrected Brier score = 0.201) and external validation datasets (corrected C-statistic = 0.793, corrected Brier score = 0.190). The internal calibration was very good (corrected slope = 0.910). The model developed in this study showed high discriminant performance in predicting PVS in nonsevere COVID-19 patients. Because of the availability and accessibility of the model, the nomogram designed in this study could provide a useful prognostic tool for clinicians and medical decision-makers.
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Affiliation(s)
- Ensi Luo
- Department of Endocrinology, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Qingyang Zhong
- Medical Department, The Ninth People’s Hospital of Dongguan, Dongguan, China
| | - Yongtao Wen
- Department of Respiratory Medicine, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Jie Cai
- Department of Respiratory Medicine, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Xia Xie
- Pain Department, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Lingjuan Zhou
- Nursing Department, Binhaiwan Central Hospital of Dongguan, Dongguan, China
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Covino M, De Vita A, d'Aiello A, Ravenna SE, Ruggio A, Genuardi L, Simeoni B, Piccioni A, De Matteis G, Murri R, Leone AM, Flex A, Gasbarrini A, Liuzzo G, Massetti M, Franceschi F. A New Clinical Prediction Rule for Infective Endocarditis in Emergency Department Patients With Fever: Definition and First Validation of the CREED Score. J Am Heart Assoc 2023; 12:e027650. [PMID: 37119081 PMCID: PMC10227214 DOI: 10.1161/jaha.122.027650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/23/2023] [Indexed: 04/30/2023]
Abstract
Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy-to-use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56-81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849-0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848-0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort (P=0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.
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Affiliation(s)
- Marcello Covino
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
| | - Antonio De Vita
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Alessia d'Aiello
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | | | - Aureliano Ruggio
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Lorenzo Genuardi
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Benedetta Simeoni
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Andrea Piccioni
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Giuseppe De Matteis
- Department of Internal MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Rita Murri
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Infectious DiseaseFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Antonio Maria Leone
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Andrea Flex
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Antonio Gasbarrini
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Internal MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Giovanna Liuzzo
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Massimo Massetti
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Francesco Franceschi
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
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Fazel S, Vazquez-Montes MDLA, Molero Y, Runeson B, D'Onofrio BM, Larsson H, Lichtenstein P, Walker J, Sharpe M, Fanshawe TR. Risk of death by suicide following self-harm presentations to healthcare: development and validation of a multivariable clinical prediction rule (OxSATS). BMJ Ment Health 2023; 26:e300673. [PMID: 37385664 PMCID: PMC10335583 DOI: 10.1136/bmjment-2023-300673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/21/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Assessment of suicide risk in individuals who have self-harmed is common in emergency departments, but is often based on tools developed for other purposes. OBJECTIVE We developed and validated a predictive model for suicide following self-harm. METHODS We used data from Swedish population-based registers. A cohort of 53 172 individuals aged 10+ years, with healthcare episodes of self-harm, was split into development (37 523 individuals, of whom 391 died from suicide within 12 months) and validation (15 649 individuals, 178 suicides within 12 months) samples. We fitted a multivariable accelerated failure time model for the association between risk factors and time to suicide. The final model contains 11 factors: age, sex, and variables related to substance misuse, mental health and treatment, and history of self-harm. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis guidelines were followed for the design and reporting of this work. FINDINGS An 11-item risk model to predict suicide was developed using sociodemographic and clinical risk factors, and showed good discrimination (c-index 0.77, 95% CI 0.75 to 0.78) and calibration in external validation. For risk of suicide within 12 months, using a 1% cut-off, sensitivity was 82% (75% to 87%) and specificity was 54% (53% to 55%). A web-based risk calculator is available (Oxford Suicide Assessment Tool for Self-harm or OxSATS). CONCLUSIONS OxSATS accurately predicts 12-month risk of suicide. Further validations and linkage to effective interventions are required to examine clinical utility. CLINICAL IMPLICATIONS Using a clinical prediction score may assist clinical decision-making and resource allocation.
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Affiliation(s)
- Seena Fazel
- Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | | | - Yasmina Molero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Bo Runeson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm, Sweden
| | - Brian M D'Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- School of Medical Sciences, Örebro Universitet, Orebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Jane Walker
- Psychological Medicine Research Department of Psychiatry, University of Oxford, Oxford, UK
| | - Michael Sharpe
- Psychological Medicine Research Department of Psychiatry, University of Oxford, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
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Qi D, Li J, Quarles CC, Fonkem E, Wu E. Assessment and prediction of glioblastoma therapy response: challenges and opportunities. Brain 2023; 146:1281-1298. [PMID: 36445396 PMCID: PMC10319779 DOI: 10.1093/brain/awac450] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
Glioblastoma is the most aggressive type of primary adult brain tumour. The median survival of patients with glioblastoma remains approximately 15 months, and the 5-year survival rate is <10%. Current treatment options are limited, and the standard of care has remained relatively constant since 2011. Over the last decade, a range of different treatment regimens have been investigated with very limited success. Tumour recurrence is almost inevitable with the current treatment strategies, as glioblastoma tumours are highly heterogeneous and invasive. Additionally, another challenging issue facing patients with glioblastoma is how to distinguish between tumour progression and treatment effects, especially when relying on routine diagnostic imaging techniques in the clinic. The specificity of routine imaging for identifying tumour progression early or in a timely manner is poor due to the appearance similarity of post-treatment effects. Here, we concisely describe the current status and challenges in the assessment and early prediction of therapy response and the early detection of tumour progression or recurrence. We also summarize and discuss studies of advanced approaches such as quantitative imaging, liquid biomarker discovery and machine intelligence that hold exceptional potential to aid in the therapy monitoring of this malignancy and early prediction of therapy response, which may decisively transform the conventional detection methods in the era of precision medicine.
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Affiliation(s)
- Dan Qi
- Department of Neurosurgery and Neuroscience Institute, Baylor Scott & White Health, Temple, TX 76502, USA
| | - Jing Li
- School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - C Chad Quarles
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA
| | - Ekokobe Fonkem
- Department of Neurosurgery and Neuroscience Institute, Baylor Scott & White Health, Temple, TX 76502, USA
- Department of Medical Education, School of Medicine, Texas A&M University, Bryan, TX 77807, USA
| | - Erxi Wu
- Department of Neurosurgery and Neuroscience Institute, Baylor Scott & White Health, Temple, TX 76502, USA
- Department of Medical Education, School of Medicine, Texas A&M University, Bryan, TX 77807, USA
- Department of Pharmaceutical Sciences, Irma Lerma Rangel School of Pharmacy, Texas A&M University, College Station, TX 77843, USA
- Department of Oncology and LIVESTRONG Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA
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Efthimiou O, Hoogland J, Debray TP, Seo M, Furukawa TA, Egger M, White IR. Measuring the performance of prediction models to personalize treatment choice. Stat Med 2023; 42:1188-1206. [PMID: 36700492 PMCID: PMC7615726 DOI: 10.1002/sim.9665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/07/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
When data are available from individual patients receiving either a treatment or a control intervention in a randomized trial, various statistical and machine learning methods can be used to develop models for predicting future outcomes under the two conditions, and thus to predict treatment effect at the patient level. These predictions can subsequently guide personalized treatment choices. Although several methods for validating prediction models are available, little attention has been given to measuring the performance of predictions of personalized treatment effect. In this article, we propose a range of measures that can be used to this end. We start by defining two dimensions of model accuracy for treatment effects, for a single outcome: discrimination for benefit and calibration for benefit. We then amalgamate these two dimensions into an additional concept, decision accuracy, which quantifies the model's ability to identify patients for whom the benefit from treatment exceeds a given threshold. Subsequently, we propose a series of performance measures related to these dimensions and discuss estimating procedures, focusing on randomized data. Our methods are applicable for continuous or binary outcomes, for any type of prediction model, as long as it uses baseline covariates to predict outcomes under treatment and control. We illustrate all methods using two simulated datasets and a real dataset from a trial in depression. We implement all methods in the R package predieval. Results suggest that the proposed measures can be useful in evaluating and comparing the performance of competing models in predicting individualized treatment effect.
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Affiliation(s)
- Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Institute of Primary Health Care (BIHAM), University of BernBernSwitzerland
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jeroen Hoogland
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of Epidemiology and Data ScienceAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Thomas P.A. Debray
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Smart Data Analysis and Statistics B.V.UtrechtThe Netherlands
| | - Michael Seo
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Graduate School for Health SciencesUniversity of BernBernSwitzerland
| | - Toshiaki A. Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical EpidemiologyKyoto University Graduate School of Medicine/School of Public HealthKyotoJapan
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Ian R. White
- MRC Clinical Trials Unit at UCLUniversity College LondonLondonUK
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Siddiqui MS, Bui AT, Syed T, Tseng M, Hassouneh R, Bhati CS. Performance of Vibration-Controlled Transient Elastography and Clinical Prediction Models In Liver Transplant Recipients. Clin Gastroenterol Hepatol 2023; 21:1100-1102.e2. [PMID: 35181567 PMCID: PMC9376192 DOI: 10.1016/j.cgh.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023]
Abstract
Hepatic fibrosis is a strong predictor of clinical outcomes following liver transplantation (LT).1 Despite the centrality of hepatic fibrosis in clinical outcomes, the published literature with noninvasive fibrosis assessment in LT recipients is limited and liver biopsy, despite its invasive nature, remains the reference standard. Vibration-controlled transient elastography (VCTE) and clinical prediction models (CPM) are point-of-care tests that can provide noninvasive assessment of hepatic fibrosis2-4; however, the data comparing the diagnostic performance of VCTE and CPM in LT recipients are lacking. The current study evaluated the diagnostic performance of VCTE and CPM in LT recipients using best practices in regulatory sciences for biomarker development.
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Affiliation(s)
- Mohammad Shadab Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia.
| | - Anh T Bui
- Department of Statistical Sciences & Operations Research, Virginia Commonwealth University, Richmond, Virginia
| | - Taseen Syed
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Tseng
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ramzi Hassouneh
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Chandra S Bhati
- Division of Transplant Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
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Kiros M, Memirie ST, Tolla MTT, Palm MT, Hailu D, Norheim OF. Cost-effectiveness of running a paediatric oncology unit in Ethiopia. BMJ Open 2023; 13:e068210. [PMID: 36918241 PMCID: PMC10016307 DOI: 10.1136/bmjopen-2022-068210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of running a paediatric oncology unit in Ethiopia to inform the revision of the Ethiopia Essential Health Service Package (EEHSP), which ranks the treatment of childhood cancers at a low and medium priority. METHODS We built a decision analytical model-a decision tree-to estimate the cost-effectiveness of running a paediatric oncology unit compared with a do-nothing scenario (no paediatric oncology care) from a healthcare provider perspective. We used the recently (2018-2019) conducted costing estimate for running the paediatric oncology unit at Tikur Anbessa Specialized Hospital (TASH) and employed a mixed costing approach (top-down and bottom-up). We used data on health outcomes from other studies in similar settings to estimate the disability-adjusted life years (DALYs) averted of running a paediatric oncology unit compared with a do-nothing scenario over a lifetime horizon. Both costs and effects were discounted (3%) to the present value. The primary outcome was incremental cost in US dollars (USDs) per DALY averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian gross domestic product per capita (USD 477 in 2019). Uncertainty was tested using one-way and probabilistic sensitivity analyses. RESULTS The incremental cost and DALYs averted per child treated in the paediatric oncology unit at TASH were USD 876 and 2.4, respectively, compared with no paediatric oncology care. The incremental cost-effectiveness ratio of running a paediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100 000 Monte Carlo iterations at a USD 477 WTP threshold. CONCLUSIONS The provision of paediatric cancer services using a specialised oncology unit is most likely cost-effective in Ethiopia, at least for easily treatable cancer types in centres with minimal to moderate capability. We recommend reassessing the priority-level decision of childhood cancer treatment in the current EEHSP.
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Affiliation(s)
- Mizan Kiros
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Solomon Tessema Memirie
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Addis Center for Ethics and Priority Setting, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Mieraf Taddesse Taddesse Tolla
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Michael Tekle Palm
- Department of Health Financing, Clinton Health Access Initiative, Addis Ababa, Ethiopia
| | - Daniel Hailu
- Department of Pediatrics and Child Health, Pediatric Hematology/Oncology Unit, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Ole F Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Na L, Li J, Pan C, Zhan Y, Bai S. Development and validation of a predictive model for major complications after extracorporeal shockwave lithotripsy in patients with ureteral stones: based on a large prospective cohort. Urolithiasis 2023; 51:42. [PMID: 36862228 PMCID: PMC9979111 DOI: 10.1007/s00240-023-01417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
The risk factors of complications after SWL are not well characterized. Therefore, based on a large prospective cohort, we aimed to develop and validate a nomogram for predicting major complications after extracorporeal shockwave lithotripsy (SWL) in patients with ureteral stones. The development cohort included 1522 patients with ureteral stones who underwent SWL between June 2020 and August 2021 in our hospital. Five hundred and fifty-three patients with ureteral stones participated in the validation cohort from September 2020 to April 2022. The data were prospectively recorded. Backward stepwise selection was applied using the likelihood ratio test with Akaike's information criterion as the stopping rule. The efficacy of this predictive model was assessed concerning its clinical usefulness, calibration, and discrimination. Finally, 7.2% (110/1522) of patients in the development cohort and 8.7% (48/553) of those in the validation cohort suffered from major complications. We identified five predictive factors for major complications: age, gender, stone size, Hounsfield unit of stone, and hydronephrosis. This model showed good discrimination with an area under the receiver operating characteristic curves of 0.885 (0.872-0.940) and good calibration (P = 0.139). The decision curve analysis showed that the model was clinically valuable. In this large prospective cohort, we found that older age, female gender, higher Hounsfield unit, size, and grade of hydronephrosis were risk predictors of major complications after SWL. This nomogram will be helpful in preoperative risk stratification to provide individualized treatment recommendations for each patient. Furthermore, early identification and appropriate management of high-risk patients may decrease postoperative morbidity.
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Affiliation(s)
- Lei Na
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004 People’s Republic of China
| | - Jia Li
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004 People’s Republic of China
| | - Chunyu Pan
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004 People’s Republic of China
| | - Yunhong Zhan
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004 People’s Republic of China
| | - Song Bai
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004 People’s Republic of China
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Nurek M, Hay AD, Kostopoulou O. Comparing GPs' antibiotic prescribing decisions to a clinical prediction rule: an online vignette study. Br J Gen Pract 2023; 73:e176-e185. [PMID: 36823069 PMCID: PMC9975984 DOI: 10.3399/bjgp.2020.0802] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/02/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The 'STARWAVe' clinical prediction rule (CPR) uses seven factors to guide risk assessment and antibiotic prescribing in children with cough (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting). AIM To assess the influence of STARWAVe factors on GPs' unaided risk assessments and prescribing decisions. DESIGN AND SETTING Clinical vignettes administered to 188 UK GPs online. METHOD GPs were randomly assigned to view 32 (out of a possible 64) vignettes online depicting children with cough. The vignettes comprised the seven STARWAVe factors, which were varied systematically. For each vignette, GPs assessed risk of deterioration in one of two ways (sliding-scale versus risk-category selection) and indicated whether they would prescribe antibiotics. Finally, GPs saw an additional vignette, suggesting that the parent was concerned. Mixed-effects regressions were used to measure the influence of STARWAVe factors, risk-elicitation method, and parental concern on GPs' assessments and decisions. RESULTS Six STARWAVe risk factors correctly increased GPs' risk assessments (bssliding-scale≥0.66, odds ratios [ORs]category-selection≥1.75, Ps≤0.001), whereas one incorrectly reduced them (short illness duration: b sliding-scale -0.30, ORcategory-selection 0.80, P≤0.039). Conversely, one STARWAVe factor increased prescribing odds (temperature: OR 5.22, P<0.001), whereas the rest either reduced them (short illness duration, age, and recession: ORs≤0.70, Ps<0.001) or had no significant impact (wheeze, asthma, and vomiting: Ps≥0.065). Parental concern increased risk assessments (b sliding-scale 1.29, ORcategory-selection 2.82, P≤0.003) but not prescribing odds (P = 0.378). CONCLUSION GPs use some, but not all, STARWAVe factors when making unaided risk assessments and prescribing decisions. Such discrepancies must be considered when introducing CPRs to clinical practice.
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Affiliation(s)
- Martine Nurek
- Department of Surgery and Cancer, Imperial College London, London
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol
| | - Olga Kostopoulou
- Department of Surgery and Cancer, Imperial College London, London
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de Paor M, Boland F, Cai X, Smith S, Ebell MH, Mac Donncha E, Fahey T. Derivation and validation of clinical prediction rules for diagnosis of infectious mononucleosis: a prospective cohort study. BMJ Open 2023; 13:e068877. [PMID: 36849213 PMCID: PMC9972438 DOI: 10.1136/bmjopen-2022-068877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVES Infectious mononucleosis (IM) is a clinical syndrome that is characterised by lymphadenopathy, fever and sore throat. Although generally not considered a serious illness, IM can lead to significant loss of time from school or work due to profound fatigue, or the development of chronic illness. This study aimed to derive and externally validate clinical prediction rules (CPRs) for IM caused by Epstein-Barr virus (EBV). DESIGN Prospective cohort study. SETTING AND PARTICIPANTS 328 participants were recruited prospectively for the derivation cohort, from seven university-affiliated student health centres in Ireland. Participants were young adults (17-39 years old, mean age 20.6 years) with sore throat and one other additional symptom suggestive of IM. The validation cohort was a retrospective cohort of 1498 participants from a student health centre at the University of Georgia, USA. MAIN OUTCOME MEASURES Regression analyses were used to develop four CPR models, internally validated in the derivation cohort. External validation was carried out in the geographically separate validation cohort. RESULTS In the derivation cohort, there were 328 participants, of whom 42 (12.8%) had a positive EBV serology test result. Of 1498 participants in the validation cohort, 243 (16.2%) had positive heterophile antibody tests for IM. Four alternative CPR models were developed and compared. There was moderate discrimination and good calibration for all models. The sparsest CPR included presence of enlarged/tender posterior cervical lymph nodes and presence of exudate on the pharynx. This model had moderate discrimination (area under the receiver operating characteristic curve (AUC): 0.70; 95% CI: 0.62-0.79) and good calibration. On external validation, this model demonstrated reasonable discrimination (AUC: 0.69; 95% CI: 0.67-0.72) and good calibration. CONCLUSIONS The alternative CPRs proposed can provide quantitative probability estimates of IM. Used in conjunction with serological testing for atypical lymphocytosis and immunoglobulin testing for viral capsid antigen, CPRs can enhance diagnostic decision-making for IM in community settings.
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Affiliation(s)
- Muireann de Paor
- HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons Ireland, Dublin, Ireland
| | - Xinyan Cai
- Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Susan Smith
- Community Health and General Practice, Trinity College Dublin, Dublin, Ireland
| | - Mark H Ebell
- Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Eoin Mac Donncha
- Student Health Unit, National University of Ireland Galway, Galway, Ireland
| | - Tom Fahey
- HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons Ireland, Dublin, Ireland
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Li Y, Ding VY, Chen H, Zhu G, Jiang B, Boothroyd D, Rezaii PG, Bet AM, Paulino AD, Weber A, Glushakova OY, Hayes RL, Wintermark M. Comparing blood biomarkers to clinical decision rules to select patients suspected of traumatic brain injury for head computed tomography. Neuroradiol J 2023; 36:68-75. [PMID: 35588232 PMCID: PMC9893157 DOI: 10.1177/19714009221101306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major public health concern in the U.S. Recommendations for patients admitted in the emergency department (ED) to receive head computed tomography (CT) scan are currently guided by various clinical decision rules. OBJECTIVE To compare how a blood biomarker approach compares with clinical decision rules in terms of predicting a positive head CT in adult patients suspected of TBI. METHODS We retrospectively identified patients transported to our emergency department and underwent a noncontrast head CT due to suspicion of TBI and who had blood samples available. Published thresholds for serum and plasma glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1), and serum S100β were used to make CT recommendations. These blood biomarker-based recommendations were compared to those achieved under widely used clinical head CT decision rules (Canadian, New Orleans, NEXUS II, and ACEP Clinical Policy). RESULTS Our study included 463 patients, of which 122 (26.3%) had one or more abnormalities presenting on head CT. Individual blood biomarkers achieved high negative predictive value (NPV) for abnormal head CT findings (88%-98%), although positive predictive value (PPV) was consistently low (25%-42%). A composite biomarker-based decision rule (GFAP+UCH-L1)'s NPV of 100% and PPV of 29% were comparable or better than those achieved under the clinical decision rules. CONCLUSION Blood biomarkers perform at least as well as clinical rules in terms of selecting TBI patients for head CT and may be easier to implement in the clinical setting. A prospective study is necessary to validate this approach.
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Affiliation(s)
- Ying Li
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Victoria Y Ding
- Quantitative Sciences Unit,
Department of Medicine, Stanford University, Stanford, CA, USA
| | - Hui Chen
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Guangming Zhu
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Bin Jiang
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Derek Boothroyd
- Quantitative Sciences Unit,
Department of Medicine, Stanford University, Stanford, CA, USA
| | - Paymon G Rezaii
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | - Anthony M Bet
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
| | | | - Art Weber
- Banyan Biomarkers Inc., San Diego, CA, USA
| | - Olena Y Glushakova
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
| | - Ronald L Hayes
- Department of Neurosurgery, Virginia Commonwealth
University, Richmond, VA, USA
| | - Max Wintermark
- Department of Radiology,
Neuroradiology Division, Stanford University, Stanford, CA, USA
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Wongkanong C, Patumanond J, Ratanachu-ek T, Junrungsee S, Tantraworasin A. Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance. PLoS One 2023; 18:e0282899. [PMID: 36928213 PMCID: PMC10019717 DOI: 10.1371/journal.pone.0282899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/25/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION To develop a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions. METHODS This study included patients with CBD stones who underwent ERCP at Pattani Hospital between August 2017 and December 2021. Retrospective cohort data was collected and patients were categorized into two groups: bile duct stones successfully treated by endoscopic biliary sphincterotomy and extraction compared to the former method combined with EPLBD. We explored potential predictors using multivariable logistic regression. The chosen logistic coefficients were transformed into a scoring system based on risk with internal validation via bootstrapping procedure. RESULTS Among the 155 patients who had successful endoscopic therapy for bile duct stones, there were 79 (50.97%) cases of endoscopic biliary sphincterotomy, EPLBD and extraction versus 76 (49.03%) cases without EPLBD. The factors used to derive a scoring system included the size of CBD stones >15 mm, the difference between the stone and distal CBD diameter >2mm, distal CBD arm length <36 mm and stone shape. The score-based model's area under ROC was 0.88 (95% CI: 0.83, 0.93). For clinical use, the range of scores from 0 to 16, was divided into two subcategories based on CBD stone removal difficulty requiring EPLBD to derive the PPV. For scores <5 and ≥ 5, the PPV was 23.40 (p <0.001) and 93.44 (p <0.001) respectively. The Bootstrap sampling method indicated a prediction ability of 0.88 (AuROC, 95% CI: 0.83, 0.94). CONCLUSION This scoring system has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.
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Affiliation(s)
| | - Jayanton Patumanond
- Center for Clinical Epidemiology & Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thawee Ratanachu-ek
- Surgical Endoscopy Unit, Department of Surgery Rajavithi Hospital, Department of Medical Services, Ministry of Public Health, Mueang Nonthaburi, Thailand
| | - Sunhawit Junrungsee
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Center for Clinical Epidemiology & Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- * E-mail:
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50
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Javeed S, Greenberg JK, Zhang JK, Dibble CF, Khalifeh JM, Liu Y, Wilson TJ, Yang LJ, Park Y, Ray WZ. Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury. JAMA Netw Open 2022; 5:e2247949. [PMID: 36542381 PMCID: PMC9857030 DOI: 10.1001/jamanetworkopen.2022.47949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Traumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies. OBJECTIVE To develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI. DESIGN, SETTING, AND PARTICIPANTS This prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts. RESULTS Among 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.
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Affiliation(s)
- Saad Javeed
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Justin K. Zhang
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | | | - Jawad M. Khalifeh
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Ying Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Lynda J. Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Yikyung Park
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
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