STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration

Prediction of vesicouterine adhesions by transvaginal sonographic sliding sign technique: validation study

OBJECTIVE

Adhesions between the uterus, bladder and anterior abdominal wall are associated with clinical sequelae, including chronic pelvic pain and dyspareunia, and can also yield complications during surgery. The transvaginal sonographic (TVS) sliding bladder sign is a minimally invasive diagnostic tool to evaluate the presence of vesicouterine adhesions. This study aimed to determine the predictive value and intra- and interobserver variation of the TVS sliding bladder sign in the assessment of vesicouterine adhesions.

METHODS

This was a prospective observational double-blind diagnostic accuracy study conducted at the Amsterdam University Medical Center. Patients scheduled for gynecological laparoscopic surgery for a benign disorder between January 2020 and December 2022 were included consecutively. All patients underwent preoperative TVS, including a dynamic sliding bladder sign examination in our outpatient clinic. Videoclips of the TVS scans were stored for offline assessment and used as an index test. The recordings of both TVS and laparoscopy were evaluated for diagnostic characteristics of vesicouterine adhesions by independent assessors, who were blinded to the clinical situation in addition to the laparoscopic findings when assessing recordings of TVS and vice versa. The presence of adhesions on laparoscopy was used as the reference standard. The positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity of the sliding bladder sign were calculated. In addition, inter- and intraobserver variability of the sliding bladder sign on TVS were assessed.

RESULTS

Of 116 included women, 57 had a negative sliding bladder sign on TVS, while on laparoscopy, 51 women had mild and 28 had severe vesicouterine adhesions. A negative sliding bladder sign had a PPV of 94.7% (95% CI, 88.9-100%) for the presence of any vesicouterine adhesions, and a positive sliding bladder sign had a specificity of 91.9% (95% CI, 83.1-100%). For severe adhesions, the negative sliding bladder sign had a sensitivity of 89.3% (95% CI, 77.8-100%) and a positive sliding bladder sign had a NPV of 94.9% (95% CI, 89.3-100%). When using Cohen's kappa coefficient, inter- and intraobserver agreement between assessors was good.

CONCLUSIONS

Sliding bladder sign evaluation using TVS is a reliable diagnostic tool for the prediction of vesicouterine adhesions on laparoscopy. A negative sliding bladder sign indicates the presence of vesicouterine adhesions, while a positive sliding bladder sign makes the presence of severe adhesions unlikely. Establishing vesicouterine adhesions by TVS may optimize preoperative planning, and can be used for future studies to evaluate the relationship between symptomatology and vesicouterine adhesions and, subsequently, the effect of adhesion-prevention interventions. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Match detection analysis on SentiMag® system and standard technique in SLNB of breast cancer

INTRODUCTION

In breast cancer surgery, there are techniques for sentinel lymph node biopsy (SLNB) that do not require Nuclear Medicine, such SentiMag®, which uses ferromagnetic particles. The main purpose of this analysis is to study the degree of concordance in SLNB between SentiMag® and the standard method (Tc99 radiotracer). The secondary objective is to identify factors that impact in sentinel node detection rate and matching detection rate between both probes.

METHODS

Observational and retrospective study performed from January to December 2021 focused on patients undergoing breast surgery and SLNB who were injected with both tracers, the ferromagnetic SentiMag® and Tc99 radiotracer. Once the diagnostic accuracy tests were performed, a further evaluation of the detection rate for each probe and the concordance between probes were accomplished. After those results, a deeper analysis of differences in detection rates for each probe and concordance between probes were assessed for various factors: neoadjuvant therapy, BMI, mitotic index, and triple-negative immunohistochemical profile.

RESULTS

The clinical study had a sample size of 70 patients. The overall false-negative rate (FNR) was 4.3%. The detection rate was the same for each technique (85.7%). A total of 106 nodes were biopsied, with a concordance rate of 70.75%. Significant differences were found in concordant nodes according to neoadjuvant therapy (p-value 0.012). For the Ki-67 factor (<20 or ≥20), significant differences were found in detected nodes (p-value 0.031 gamma probe; p-value 0.124 SentiMag®).

CONCLUSIONS

The detection rates of SentiMag® and the gamma probe are equivalent. The application of the dual technique minimizes the FNR. A high mitotic index affects the detection rate of the gamma probe, and neoadjuvant therapy negatively impacts the concordance rate.

Discriminability of the Beck Depression Inventory and its Abbreviations in an Adolescent Psychiatric Sample

Background

The Beck Depression Inventory (BDI) is a widely acknowledged self-report screening tool for evaluating the presence and intensity of depressive symptoms. The BDI-IA, although an older version, is highly correlated with the updated BDI-II, remains clinically valuable, and is widely used due to its free availability.

Aim

This study aimed to examine the psychometric properties of the BDI-IA and compare its diagnostic accuracy with the abbreviated BDI-SF, BDI-PC, and BDI-6 versions against gold-standard research diagnoses in a representative Finnish adolescent clinical population.

Methods

The participants were referred outpatient adolescents aged 13-20 years (N = 752, 73% female). We investigated structural validity with item factor analysis and evaluated the criterion validity of mean scores and factor scores with various diagnostic measures. Sample-optimal cut-offs (criterion unweighted Cohen's kappa) were estimated with a bootstrap procedure.

Results

The sample-optimal cut-off for the full BDI was 19, slightly higher than that suggested by the previous literature. The abbreviations of the BDI-IA were demonstrated to be as good as the full scale in detecting depressive symptoms in all three diagnostic categorizations.

Conclusion

The use of brief and user-friendly questionnaires such as the BDI-PC or BDI-6 is recommended to ensure optimal depression screening and minimize the administrative burden, especially in primary care settings where clinical decision-making and referrals often need to occur within a limited time frame.

Indocyanine Green Fluorescence Plus Blue Dye for Sentinel Lymph Node Biopsy in Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer: A Multicenter, Prospective Cohort Study

BACKGROUND

Sentinel lymph node biopsy (SLNB) using radioisotope tracer plus blue dye is the gold standard after neoadjuvant chemotherapy (NAC) in initially cN1 breast cancer patients, but clinical use still has limitations. This study aims to examine diagnostic performance of dual indocyanine green (ICG) and methylene blue tracing for SLNB in patients who have completed NAC for breast cancer with initially cN1 disease.

METHODS

Adult women (20-80 years of age) scheduled to undergo NAC for biopsy-proven cT0-3N1M0 primary invasive breast cancer were consecutively enrolled in this prospective, multicenter, cohort study. Upon the completion of NAC, SLNB was conducted using ICG and methylene blue, followed by axillary lymph node dissection. The primary outcome was the detection rate (DR); secondary outcomes included the false-negative rate (FNR) and adverse events associated with the use of tracers.

RESULTS

A total of 156 patients were enrolled; all underwent SLNB after NAC. The median number of lymph nodes retrieved during SLNB was 3 (range: 0-11). The DR was 97.4% (152/156; 95% CI, 93.6%-99.0%). The FNR was 6.7% (4/60; 95% CI, 2.6%-15.9%). Negative predictive value was 95.7% (88/92; 95% CI, 89.4%-98.3%). In the subgroup analysis stratified by ycN status, FNR was 4.0% (1/25; 95% CI, 0.7%-19.5%) and 8.6% (3/35; 95% CI, 3.0%-22.4%) in the ycN0 and ycN+ subgroups, respectively. No allergic reaction was reported.

CONCLUSIONS

SLNB with ICG plus methylene blue achieved a high DR and a very low FNR in breast cancer patients with initially cN1 disease.

TRIAL REGISTRATION

ClinicalTrials.gov (https://www.

CLINICALTRIALS

gov/), NCT02869815.

A Large Study About Reproductive Factors That Predict Hysterosalpingography-Identified Tubal Pathology: An Insight into the Necessity of Preconception Screening

Background/Objectives: Hysterosalpingography (HSG) is pivotal in delineating tubal pathology, but is associated with pain and exposure to ionizing radiation. This study investigated which reproductive factors predict HSG-identified tubal pathology. Methods: From May 2016 to August 2023, 3322 infertile females with HSG (mean age 33.9 ± 4.3 years) were assessed for fallopian tube status. Results: HSG indicated that 2764 had patent tubes while 558 (16.8%) had non-patent tubes. Unilateral and bilateral absence of free contrast spillage occurred in 377 (11.3%) and 181 (5.4%) cases, respectively. Non-spillage, denoted as non-patency, was seen in 148 (4.5%) and 153 (4.6%) right and left cases, respectively. Tubal occlusion was observed in 181 (5.4%) and 159 (5.4%) right and left cases, respectively. Hydrosalpinx was found in 37 (1.2%) right and 58 (1.7%) left cases. Multivariate logistic regression revealed CT-IgG positivity (odds ratio [OR]: 1.57), endometrioma (OR: 1.64), and fibroids (OR: 1.58) as independent factors for increased non-patency. CT-IgG positivity (OR: 1.92) and fibroids (OR: 1.88) were significant risk factors for occlusion. Painful defecation (OR: 2.79), CT-IgA positivity (OR: 2.09), CT-IgG positivity (OR: 2.07), and endometrioma (OR: 3.11) were significant risk factors for hydrosalpinx. Conclusions: In females with painful defecation, CT-IgG positivity, endometrioma, and fibroids, HSG may be used as a second-line investigation, with laparoscopy as the preferred assessment tool.

Beyond water: 3D laser scanning offers a cutting-edge alternative for upper limb volume assessment

OBJECTIVES

The primary aim of this study was to evaluate the reliability and efficiency of a 3D laser scanner as a tool for volumetric measurement of the upper limbs, comparing it with the gold standard method of non-reflux water displacement. The study sought to determine whether the 3D scanner could serve as a reliable and time-efficient alternative in clinical settings, particularly for managing conditions like lymphedema.

METHODS

A total of 30 healthy participants (18 women, 12 men) were recruited, and volumetric measurements were taken using both the 3D scanner and water displacement methods. Inter-rater and intra-rater reliability were calculated using the Intraclass Correlation Coefficient (ICC), and agreement between the methods was assessed using a Bland-Altman plot. The time required for each measurement and data processing were recorded and compared between the two methods.

RESULTS

The 3D scanner demonstrated excellent inter-rater (ICC = 0.995) and intra-rater (ICC = 0.991) reliability, surpassing the water displacement method (ICC = 0.973 and 0.968, respectively). The Bland-Altman plot showed good agreement between the two methods, with only two measurements outside the 95% confidence limits. However, the 3D scanner required significantly more time for both measurement and data processing (28.55 seconds and 120 seconds, respectively) compared to water displacement (9.64 seconds).

CONCLUSIONS

The 3D scanner offers high reliability and precision for upper limb volumetric measurements, potentially improving clinical management of conditions such as lymphedema. Despite longer acquisition times, its accuracy and versatility make it a promising tool for future clinical use, especially in scenarios where precise monitoring is crucial.

Stool processing methods for Xpert Ultra testing in childhood tuberculosis: A prospective, multi-country accuracy study

Background

Centrifuge-free processing methods support stool Xpert Ultra testing for childhood tuberculosis (TB), but there are limited data on their accuracy, acceptability and usability.

Methods

We conducted a prospective evaluation of stool Xpert Ultra in India, South Africa, and Uganda with three methods: Stool Processing Kit (SPK), Simple One-Step (SOS), and Optimized Sucrose Flotation (OSF). Children <15 years old with presumptive TB had respiratory specimen testing with Xpert Ultra and culture. Stool was tested using Xpert Ultra after processing with each method. We compared the accuracy of each method to a microbiological reference standard (MRS) and a composite reference standard (CRS). We surveyed the laboratory staff to assess acceptability and usability of the methods.

Results

We included 607 children, of whom the median age was 3.5 years (IQR 1.3-7), 48% were female, and 15.5% were HIV positive. Against the MRS, the sensitivities of SPK, SOS and OSF were 36.9% (95% CI 28.6-45.8), 38.6% (95% CI 17.2-51), and 31.3% (95% CI 20.2-44.1), respectively. The specificities of SPK, SOS and OSF were 98.2% (95% CI 96.4-99.3), 97.3% (95% CI 93.7-99.1) and 97.1% (95% CI 93.3-99), respectively. Laboratory staff reported that the methods were acceptable and usable, but SOS was most feasible to implement in a peripheral facility. Sensitivity increased among children who were culture-positive (55-77.3%) and was low (13-16.7%) against the CRS.

Conclusions

Stool processing methods for Xpert Ultra were acceptable, usable, and performed similarly, with highest sensitivity among children with culture-positive TB.

Diagnostic accuracy of heart rate variability as a screening tool for mild neurocognitive disorder

Background

Mild neurocognitive disorder (mNCD) is recognized as an early stage of dementia and is gaining attention as a significant healthcare problem due to current demographic changes and increasing numbers of patients. Timely detection of mNCD provides an opportunity for early interventions that can potentially slow down or prevent cognitive decline. Heart rate variability (HRV) may be a promising measure, as it has been shown to be sensitive to cognitive impairment. However, there is currently no evidence regarding the diagnostic accuracy of HRV measurements in the context of the mNCD population. This study aimed to evaluate the diagnostic accuracy of vagally-mediated HRV (vm-HRV) as a screening tool for mNCD and to investigate the relationship between vm-HRV with executive functioning and depression in older adults who have mNCD.

Methods

We retrospectively analyzed data from healthy older adults (HOA) and individuals with a clinical diagnosis of mNCD with a biomarker-supported characterization of the etiology of mNCD. Diagnostic accuracy was evaluated using receiver operating characteristic curve analysis based on the area under the curve. Sensitivity and specificity were calculated based on the optimal threshold provided by Youden's Index. Multiple linear regression analyses were conducted to investigate the relationship between vm-HRV and executive functioning and depression.

Results

This analysis included 42 HOA and 29 individuals with mNCD. The relative power of high frequency was found to be increased in individuals with mNCD. The greatest AUC calculated was 0.68 (with 95% CI: 0.56, 0.81) for the relative power of high frequency. AUCs for other vm-HRV parameters were between 0.53 and 0.61. No consistent correlations were found between vm-HRV and executive functioning or depression.

Conclusion

It appears that vm-HRV parameters alone are insufficient to reliably distinguish between HOA and older adults with mNCD. Additionally, the relationship between vm-HRV and executive functioning remains unclear and requires further investigation. Prospective studies that encompass a broad range of neurocognitive disorders, HRV measurements, neuroimaging, and multimodal approaches that consider a variety of functional domains affected in mNCD are warranted to further investigate the potential of vm-HRV as part of a multimodal screening tool for mNCD. These multimodal measures have the potential to improve the early detection of mNCD in the future.

Fundamental Frequency of the Voice in Schizophrenia and Its Value as a Biomarker of the Disease

Recent research on schizophrenia seeks to identify objective biomarkers of the disease. The voice, and in particular the fundamental frequency (F0), could be one of them.

METHODOLOGY

We conducted a cross-sectional and descriptive study with a sample of 154 people. Of these, 46 were diagnosed with schizophrenia, 41 were at substance abuse, and 67 formed the control group, matched in variables of sex, age, and educational level, but without substance use compared with the high-risk group.

RESULTS

The biomechanical analyses of the voice indicated significant differences between the groups, differentiated by gender: in men (F = 5.316; P = 0.006) and in women (F = 4.13; P = 0.004). The greatest differences between groups were observed in the group of vulnerable individuals, with some stability of the F0 in people with schizophrenia. Furthermore, we found correlations between positive symptoms and decreased F0 (r = -0.353; P = 0.016).

CONCLUSIONS

Our study shows that schizophrenia is associated with decreased F0 in both men and women, and that medication could stabilize this decrease. These findings have important implications for the objective monitoring and diagnosis of schizophrenia.

Circulating Chromogranin A as a Surveillance Biomarker in Patients with Carcinoids-The CASPAR Study

PURPOSE

Gastroenteropancreatic neuroendocrine tumors (GEP-NET) are relatively indolent but can be more aggressive. The current recommendations for using serum chromogranin A (CgA) for patients with GEP-NET are equivocal. This study was designed to validate an automated CgA immunofluorescence assay for monitoring disease progression in patients with GEP-NET.

PATIENTS AND METHODS

A prospective, multicenter, blinded observational study was designed to validate an automated CgA immunofluorescence assay for monitoring disease progression in patients with GEP-NET. Tumor progression was evaluated with RECIST 1.1 by CT/MRI. An increase ≥50% above the prior CgA concentration to a value >100 ng/mL in the following CgA concentration was considered positive.

RESULTS

A total of 153 patients with GEP-NET were enrolled. Using the prespecified cut-off of CgA change for tumor progression, specificity was 93.4% (95% confidence interval, 90.4%-95.5%; P < 0.001), sensitivity 34.4% (25.6%-44.3%), positive predictive value 57.9% (45.0-69.8), negative predictive value 84.3% (80.5-87.6), and AUC 0.73 (0.67-0.79).

CONCLUSIONS

Changes in serial measurements of serum CgA had a favorable specificity and negative predictive value, making this test a useful adjunct to routine radiographic monitoring.

Performance Assessment of ELISA Using the Trypanosoma cruzi-Specific Antigen Tc323 for the Diagnosis of Chronic Chagas Disease

In the chronic phase of Chagas disease (CCD), diagnosis relies on detecting specific IgG antibodies due to the low or absent presence of the parasiteTrypanosoma cruzi in human blood. However, the performance of current serological tests is highly variable, lacking a "gold standard" assay with 100% sensitivity and specificity, which challenges the exploration of new biomarkers. In the present study, we evaluated the diagnostic accuracy of an optimized ELISA using the predicted immunogenic domains (called TcD3 and TcD6) of Tc323, a protein highly conserved among T. cruzi strains but absent in other clinically significant parasites such as Leishmania spp. This study was conducted using plasma or serum samples from CCD individuals with different clinical manifestations and living in endemic regions in Latin America, subjects with unrelated infectious diseases, and noninfected donors. The sensitivity and specificity of recombinant TcD3 were 90.8% and 92.6%, respectively, while rTcD6 displayed values of 93.1% and 93.6% for the same parameters. Area under curve (AUC) values were 0.949 for rTcD3 and 0.954 for rTcD6. The receiver operative characteristic (ROC) curve showed a highly significant difference between CCD individuals and noninfected donors. Cross-reactivity was 10.2% for rTcD3 and 8.2% for rTcD6 in subjects infected with leishmaniasis or with toxoplasmosis. In addition, the reactivity against rTcD3 differed among some geographical areas while no significant difference was found using both domains for the detection of T. cruzi-infected individuals with or without cardiac symptoms. Our findings show that the recombinant antigens rTcD3 and rTcD6 could be used as highly potential biomarkers for the serological diagnosis of CCD.

Enigma of social media use: complexities of social media addiction through the serial mediating effects of emotions and self-presentation

Introduction

Excessive social media use, though considered unhealthy, is no longer formally categorized as an addiction or disorder, leading to a lack of consensus on this behavior. It raises concerns regarding the exclusion of Internet Addiction Disorder from the DSM-5-TR due to insufficient empirical evidence. This study investigates the serial mediating effects of positive and negative affect, fear of missing out, and offline and online self-presentation in the relationship between social media use and social media addiction.

Method

The study was conducted in Hong Kong with 385 participants (84.2% F, age range = 18-60) of an online survey. This study administered the Social Media Use Scale, Positive and Negative Affect Schedule, Fear of Missing Out Scale, Presentation of Online Self Scale, and Bergen Social Media Addiction Scale.

Results

The results indicate that social media use plays a significant role in predicting both positive and negative affect. The findings further reveal that positive and negative affect, fear of missing out, and offline and online self-presentation act as serial mediators in the relationship between social media use and social media addiction. In other words, these variables work together in a sequential manner to mediate the impact of social media use on addiction. Additionally, the study indicates that social media use and social media addiction are fully mediated by both positive and negative affect, fear of missing out, and offline and online self-presentation.

Discussion

Social media use can evoke both positive and negative affect. The longer individuals are immersed in social media, the more their positive affect intensifies, exacerbating FoMO and fostering inconsistent offline and online self-presentation. Conversely, extended social media engagement can heighten negative affect, leading to anxiety about others having more rewarding experiences and concurrently inducing apprehension characterized by FoMO. To prevent addiction, the development of educational tools such as SimCity video games, scenario-based learning activities, and virtual reality experiences focused on social media use and social media addiction can offer a valuable opportunity for pre-exposure to the related risks and challenges.

Anti-CdtB and anti-vinculin antibodies to diagnose irritable bowel syndrome in inflammatory bowel disease patients

BACKGROUND

Despite adequate treatment, a subgroup of patients with inflammatory bowel disease (IBD), including Crohn`s disease and ulcerative colitis, have persistent gastrointestinal symptoms that are not always related to mucosal damage. Recently, two autoantibodies, anti-CdtB and anti-vinculin, were validated as post-infectious IBS (PI-IBS) markers, however there is limited evidence of its diagnostic role in IBD population.

METHODS

Patients with more than 3 bowel movements/day and indication of colonoscopy were enrolled. Samples were collected at the time of colonoscopy for assessment of serum levels of anti-CdtB and anti-vinculin antibodies.

RESULTS

A total of 160 subjects were included in 4 groups: active IBD (n = 44); quiescent IBD and chronic diarrhea IBD-IBS (n = 25); predominant-diarrhea IBS (n = 45) and controls (n = 46). The mean value of the optical density for anti-CdtB was 1.2 ± 0.65 in group 1, 1.27 ± 0.64 in group 2, 1.49 ± 0.47 in the group 3 and 1.6 ± 0.68 in group 4, p = 0.012. For anti-vinculin, optical densities were: 1.34 ± 0.78 in group 1, 1.46 ± 0.92 in group 2, 1.31 ± 0.79 in group 3 and 1.41 ± 0.86 for controls (p = 0.875). Using a cut-off of 1.56 for anti-CdtB, the positivity between groups was n = 10 (22.7%) in group 1, n = 9 (34.6%) in group 2, 19 (43.2%) in group 3, 21 (45.7%) in group 4 (p = 0.106). The positivity of anti-vinculin using a cut-off of 1.6 was n = 18 (40.9%) in group 1, n = 11 (42.3%), n = 15 (34.1%), n = 22 (47.8%) (p = 0.622).

CONCLUSIONS

Our findings show that anti-CdtB and anti-vinculin could not identify IBD-IBS patients or discriminate IBS-D from healthy controls.

Diagnostic performance of a point-of-care high-sensitivity cardiac troponin I assay among Chinese patients with chest pain

BACKGROUND

A novel handheld point-of-care high-sensitivity cardiac troponin I analyser has recently been introduced to the market. Evaluating its diagnostic performance against laboratory standards is imperative, given the variations in cardiac troponin levels across populations. This study compared the diagnostic performance between the point-of-care high-sensitivity cardiac troponin I assay (Siemens Healthineers Atellica VTLi) and a laboratory high-sensitivity cardiac troponin I assay (Abbott ARCHITECT STAT High Sensitive Troponin-I) performed using blood samples from various populations (overall, male, female, younger and older) of Chinese patients with chest pain.

METHODS

This cross-sectional study included 585 consecutive Chinese patients (age ≥18 year) who presented to an emergency department with chest pain (lasting >5 min) and were managed following the chest pain protocol between 1 August 2023 and 12 June 2024. For both assays, blood samples were collected at two time points (0 hour (initial) and 3 hour (subsequent)). The primary outcome was the diagnostic performance of the two assays, evaluated with their 99th percentile upper reference limits used as the cut-off values for diagnosing myocardial infarction. The gold standard for comparison was the final diagnoses made by attending physicians.

RESULTS

The point-of-care and laboratory assays exhibited equivalent sensitivity and negative predictive values (both 100%) for blood samples collected at both time points. However, the point-of-care assay outperformed the laboratory assay in terms of specificity (initial: 90.5% to 96.3% vs 79.8% to 94.7%; subsequent: 87.8% to 94.8% vs 77.7% to 92.4%) and positive predictive value (initial: 24.4% to 30.8% vs 11.6% to 23.5%; subsequent: 12.5% to 25.0% vs 5.9% to 18.8%), particularly in older patients.

CONCLUSION

The point-of-care assay is recommended for rapid clinical decision-making. Future studies should explore the effects of its integration into clinical practice and the feasibility of using sex-race-age-specific 99th percentile upper reference limits to enhance its diagnostic performance.

Diagnostic performance of axial T2-weighted MRI sequence for exclusion of brain tumour in paediatric patients with non-localizing symptoms

OBJECTIVE

To establish diagnostic performance of a single axial T2-weighted sequence for detection of brain tumours in children with non-localizing symptoms, compared to a standard MRI protocol.

METHODS

Retrospective analysis of children undergoing MRI brain imaging for suspected brain tumours with non-localizing symptoms over a 3-year period. Axial T2-weighted images were blindly reviewed by 2 experienced paediatric neuroradiologists. Primary analysis was calculation of diagnostic performance metrics for tumour identification using axial T2-weighted image only compared to the standard MRI protocol.

RESULTS

For 312 children undergoing MRI brain during the study period, sensitivity and specificity for brain tumour detection based on axial T2-weighted images in children with non-localizing symptoms were 1.000 (95% CIs 0.598, 1.000) and 0.998 (95% CI 0.990, 0.999), respectively. Based on T2-weighted images alone, 50 patients (16%) were flagged as needing recall for further imaging compared to 14 (4.5%) recalled after the standard protocol.

CONCLUSIONS

Axial T2-weighted images have high sensitivity and specificity for detection of brain tumours in children with non-localizing symptoms but are associated with increased imaging recall rates. Prospective evaluation of this approach to identify patients requiring more comprehensive imaging is warranted.

ADVANCES IN KNOWLEDGE

A truncated MRI protocol with single axial T2-weighted sequence has high diagnostic performance for brain tumour detection in children with non-localizing features. Radiologists can be reassured that a child with this presentation who is unable to complete the full MRI scan protocol is very unlikely to have a brain tumour missed provided an axial T2-weighted sequence is obtained.

Diagnostic performance of Shape-Sensing Robotic-Assisted bronchoscopy with mobile Cone-Beam CT for cystic and cavitary pulmonary lesions

INTRODUCTION

Cystic and cavitary pulmonary lesions (PLs) frequently require histologic confirmation for an accurate diagnosis. Shape-sensing robotic-assisted bronchoscopy (ssRAB) with mobile cone beam computed tomography (mCBCT) offers a minimally invasive alternative to traditional biopsy techniques like CT-guided transthoracic biopsy. This study aimed to evaluate the diagnostic performance and safety of ssRAB in cystic and cavitary PLs.

MATERIAL AND METHODS

A retrospective study was conducted at Mayo Clinic Florida, of patients who underwent ssRAB with mCBCT for cavitary and cystic PLs from October 2020 to February 2024. Baseline clinical, demographic, lesion characteristics, and procedure-related data were collected. Diagnostic yield, accuracy, sensitivity for malignancy and complication rates were calculated while logistic models identified associations between variables and diagnostic yield.

RESULTS

52 patients were included, 54 nodules were sampled. ssRAB provided a diagnostic yield of 83 % and a diagnostic accuracy of 83 %, with a sensitivity for malignancy of 97 % and specificity of 58 %. Pneumothorax occurred in 4 % of cases, with one requiring chest tube insertion. Nashville bleeding scale ≥ 2 occurred in 4 % of procedures. There was no significant association between lesion size, distance to chest wall, type of lesion and diagnostic yield.

CONCLUSION

ssRAB with mCBCT demonstrated high diagnostic yield and sensitivity for malignancy in cavitary and cystic PLs, with a low complication rate. Its ability to perform mediastinal staging in the same anesthetic event, along with its safety profile, suggests ssRAB as a valuable tool in the assessment of air-filled pulmonary lesions.

Multiple diffusion models for predicting pathologic response of esophageal squamous cell carcinoma to neoadjuvant chemotherapy

BACKGROUND

To assess the feasibility and diagnostic performance of the fractional order calculus (FROC), continuous-time random-walk (CTRW), diffusion kurtosis imaging (DKI), intravoxel incoherent motion (IVIM), mono-exponential (MEM) and stretched exponential models (SEM) for predicting response to neoadjuvant chemotherapy (NACT) in patients with esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

This study prospectively included consecutive ESCC patients with baseline and follow up MR imaging and pathologically confirmed cT1-4aN + M0 or T3-4aN0M0 and underwent radical resection after neoadjuvant chemotherapy (NACT) between July 2019 and January 2023. Patients were divided into pCR (TRG 0) and non-pCR (TRG1 + 2 + 3) groups according to tumor regression grading (TRG). The Pre-, Post- and Delta-treatment models were built. 18 predictive models were generated according to different feature categories, based on six models by five-fold cross-validation. Areas under the curve (AUCs) of the models were compared by using DeLong method.

RESULTS

Overall, 90 patients (71 men, 19 women; mean age, 64 years ± 6 [SD]) received NACT and underwent baseline and Post-NACT esophageal MRI, with 29 patients in the pCR group and 61 patients in the non-pCR group. Among 18 predictive models, The Pre-, Post-, and Delta-CTRW model showed good predictive efficacy (AUC = 0.722, 0.833 and 0.790). Additionally, the Post-FROC model (AUC = 0.907) also exhibited good diagnostic performance.

CONCLUSIONS

Our study indicates that the CTRW model, along with the Post-FROC model, holds significant promise for the future of NACT efficacy prediction in ESCC patients.

Ultrasound Imaging for the Evaluation of Anterior Talofibular Ligament Remnants in 547 Ankles With Chronic Lateral Ankle Instability

BACKGROUND

There are few reports on the intra- and interobserver agreement and parameters for the diagnostic accuracy of ultrasound (US) imaging for chronic lateral ankle instability (LAI). The purpose of this study was to investigate the reliability and validity of US imaging for identifying anterior talofibular ligament (ATFL) remnants in patients with LAI.

METHODS

A total of 547 ankles from 406 patients underwent surgery for LAI between 2019 and 2022. If ligament fibers remained in US images, they were evaluated as positive. If the ligament was not visualized, it was evaluated as negative. Two observers performed repeated measurements. Arthroscopic findings were considered the "gold standard" for validity and diagnostic test accuracy purposes. The intra- and interobserver agreements and parameters for diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative US imaging as intraoperative arthroscopic findings were used as reference standards.

RESULTS

The intraobserver agreement was substantial, with an agreement of 98.54% and a kappa coefficient of 0.76. The interobserver agreement was also substantial, with an agreement of 98.72% and a kappa coefficient of 0.75. The sensitivity, specificity, and accuracy of preoperative US imaging were 98.7%, 100%, and 98.7%, respectively. The PPV and NPV of US imaging were 100% and 61.1%, respectively. In the arthroscopic evaluation of the 7 cases in which US imaging showed false negative results, the ATFL ruptured at the fibular attachment and ran in contact with the talus.

CONCLUSION

A US examination finding of an intact ATFL is highly likely to be correct. An US examination finding of a ruptured ATFL can be false and may require arthroscopic confirmation.

How I Write Manuscripts for Peer-Reviewed Medical Journals

Writing manuscripts is an integral part of the research journey. Despite the availability of various guidelines to inform study reporting and manuscript preparation requirements by peer-reviewed medical journals, developing manuscripts that effectively communicate study findings or new knowledge requires a range of communication skills that evolve with successes and failures. In this manuscript, I feature some personal learnings and acquired habits in manuscript development and publication planning from my 15-year experience as a scholar, including insights on authorship matters, journal selection, manuscript type choices, medical writing of various data-driven and non-data-driven manuscript types, and handling revisions.

Development of a New Screening Tool for Pediatric Septic Shock

STUDY OBJECTIVE

Existing screening tools for sepsis in children are limited by suboptimal sensitivity. Our objective was to develop a new, more sensitive screening tool for pediatric septic shock by enhancing 2 aspects of the 4-point Liverpool quick Sequential Organ Failure Assessment (LqSOFA) tool.

METHODS

We performed a secondary analysis of a cohort of children (1 month to 18 years) who presented to a pediatric emergency department (ED) with suspected infection over a 10-year period. Septic shock was defined as intravenous vasoactive infusion within 24-hours of arrival for children with suspected infection and intravenous antibiotics administered. We developed the 4-point quick Pediatric Septic Shock Screening Score (qPS4) by making 2 changes to the 4-point LqSOFA: (1) the pulse rate parameter was replaced with the recently derived Temperature and Age-adjusted Mean Shock Index and (2) standard respiratory rate cutoffs for tachypnea were replaced by cutoffs derived empirically from the study cohort. The other 2 LqSOFA criteria were unchanged (abnormal mentation and capillary refill ≥3 seconds). We defined a positive qPS4 as ≥2 criteria (consistent with LqSOFA). We used the training cohort from the parent study to derive cutoffs for respiratory rate and the validation cohort to compare the qPS4 with LqSOFA and qSOFA.

RESULTS

Among the 47,231 encounters in the validation cohort from the parent study, with median age of 4.5 years, qPS4 had an area under the receiver operating characteristic curve for septic shock of 0.94 (95% confidence interval [CI] 0.92 to 0.96). qPS4 ≥2 had a sensitivity of 89.7% (95% CI 84.9% to 94.5%), and a specificity of 92.2% (95% CI 92.0% to 92.5%) for septic shock. In comparison, the LqSOFA achieved an area under the receiver operating characteristic curve of 0.86 (95% CI 0.82 to 0.89), a sensitivity of 56.1% (95% CI 48.3% to 63.9%), and a specificity of 96.8% (95% CI 96.6% to 96.9%). The median time from first positive qPS4 to initiation of an intravenous vasoactive infusion was 2.5 hours (IQR 0.9 to 6.1) compared to 0.7 hours (IQR 0.0 to 4.5) for LqSOFA.

CONCLUSION

The qPS4, with 2 enhancements to the LqSOFA, demonstrated overall improved sensitivity and specificity for pediatric septic shock.

Is Italian Dentists' Knowledge of Enamel Development Defects Adequate? A Nationwide Survey

OBJECTIVES

Correct identification and management of Developmental Defects of Enamel (DDEs) are essential to provide the best possible treatment. The present survey aims to investigate Italian dentists' knowledge of DDEs, their ability to recognise the different clinical pictures, and to choose the most appropriate clinical approach.

METHODS

A cross-sectional survey was planned based on a questionnaire including 27 closed-ended questions, and that proposed 4 clinical pictures, molar incisor hypomineralisation (MIH), amelogenesis imperfecta (AI), dental fluorosis (DF), and an initial caries lesion (ICL). It was distributed by e-mail to all Italian dentists (N = 63,883) through the Italian Federation of Doctors and Dentists. Discrete variables were expressed as absolute and relative frequencies (%). A multivariate analysis assessed whether socio-demographic variables correlated with the answers' truthfulness.

RESULTS

About 5017 questionnaires were included and analysed. Although 90.19% of the sample stated that they had received information on DDEs, a significant percentage did not recognise MIH (36.36%), AI (48.34%), DF (71.50%), and ICL (46.62%). Only 57.07% correctly classified enamel hypomineralisation as a qualitative defect, and even fewer, 54.45%, classified enamel hypoplasia as a quantitative defect. According to the logistic regressions, female dentists, dentists who treat mainly children and received information about DDEs, were more likely to recognise the 4 clinical pictures (P < .01).

CONCLUSIONS

Italian dentists showed many knowledge gaps on DDEs that need to be filled; those who received formal training were more capable of correctly identifying the defects and were more likely to prescribe an appropriate management approach for the defects.

CLINICAL SIGNIFICANCE

Increasing university courses and continuing education on diagnosing and managing DDEs seems reasonable to fill the knowledge gap on DDEs.

COMPARISON OF INTRAORAL CAMERAS AND SMARTPHONES IN EARLY CHILDHOOD CARIES DETECTION: A DIAGNOSTIC ACCURACY STUDY

OBJECTIVES

Early Childhood Caries (ECC) is a major public health problem affecting children worldwide. Teledentistry offers innovative approaches for ECC detection, particularly in areas with limited access to care. This study compared the accuracy of intraoral cameras and smartphones in relation to visual clinical examination in detecting ECC.

METHODS

A prospective diagnostic accuracy study was conducted in a rural area near Alexandria, Egypt, involving children under 6 years old. An intraoral camera (C50 Full HD with fluorescence) or a smartphone (Samsung Galaxy A24) captured intraoral structures after randomizing the children into 2 groups. The reference standard was visual clinical examination under daylight without magnification or drying. Teeth were categorized using the Caries Assessment Spectrum and Treatment (CAST) index criteria based on clinical examination, intraoral camera videos and smartphone photos. Sensitivity, specificity, and accuracy were calculated for the 2 methods at 3 thresholds: enamel caries, dentin caries and enamel/dentin caries combined.

RESULTS

The study included 116 children, mean (SD) age = 4.3 (1.0) years, 83.6% with untreated decay and mean (SD) number of decayed teeth = 4.03 (3.50). Both the intraoral camera and the smartphone had high specificity and accuracy at the 3 thresholds (≥90%). The lowest sensitivity was in the case of detecting enamel lesion (intraoral camera = 77.5% and smartphone = 68.5%).

CONCLUSION

Enamel caries was detected by the intraoral camera more accurately than the smartphone. Despite this, both devices exhibited high specificity and accuracy at all diagnostic thresholds. Smartphones present a good alternative for intraoral cameras in underserved areas, improving ECC detection and care.

Comparison of two rapid host-response tests for distinguishing bacterial and viral infection in adults with acute respiratory infection

OBJECTIVES

Distinguishing bacterial from viral acute respiratory infection (ARI) is challenging, leading to inappropriate antimicrobial use and antimicrobial resistance. We evaluated the accuracy of two host-response tests to differentiate bacterial and viral infection.

METHODS

This study used patient blood samples previously collected during a randomised controlled trial of adults hospitalised with ARI. The aetiology for each patient was clinically adjudicated. PAXgene blood RNA samples were tested using the TriVerity test (which measures 29 mRNAs) and serum samples were tested using the MeMed BV test (which measures 3 proteins). Diagnostic accuracy was calculated against adjudicated aetiology.

RESULTS

169 patients were tested. Median age was 60 (45-74) years and 152 (90%) received antibiotics. 60 (36%) were adjudicated as bacterial, 54 (32%) as viral, 26 (15%) as viral/bacterial co-infection, and 29 (17%) as non-infected. For bacterial (including bacterial/viral co-infection) versus non-bacterial infection, the TriVerity bacterial score had a Positive Percentage Agreement (PPA) of 81% (95%CI 70-89) and a Negative Percentage Agreement (NPA) of 66% (95%CI 55-79) and the MeMed BV score had a PPA of 96% (95%CI 90-99) and NPA of 34% (95%CI 23-47). The AUROC for the two tests was 0.77 (95%CI 0.70-0.84) and 0.81 (95%CI 0.74-0.87) respectively, p = 0.388.

CONCLUSIONS

Both tests demonstrated similar overall accuracy for distinguishing bacterial infection with the Triverity test missing some bacterial infections and MeMed BV misclassifying most viral infections as bacterial. Prospective impact studies evaluating antibiotic use, safety and cost effectiveness are now required.

Clinical accuracy of OncoPredict HPV Quantitative Typing (QT) assay on self-samples

BACKGROUND

The VALHUDES initiative was established to assess the clinical accuracy of HPV assays to detect cervical precancers using urine and vaginal self-samples compared to cervical clinician-collected samples. Here, the clinical performance of OncoPredict HPV Quantitative Typing (QT) assay (OncoPredict QT) was evaluated.

METHODS

490 women referred to colposcopy self-collected a urine and a vaginal specimen using Colli-Pee and FLOQSwab, respectively. Subsequently, a colposcopy was performed, and a cervical sample was collected with Cervex-Brush, followed by biopsy if clinically indicated. Vaginal samples were transported dry and resuspended in 5 mL of eNAT medium, whilst cervical brushings were immediately transferred in 20 mL ThinPrep.

RESULTS

The clinical sensitivity of OncoPredict HPV QT testing for CIN2+ in urine and vaginal self-samples was similar to cervical samples (ratios of 0.99 [95 % CI 0.94-1.05] and 1.00 [95 % CI 0.96-1.04]), respectively, when manufacturer's cut-offs were applied. The specificity for

CONCLUSION

Following cut-off optimisation OncoPredict HPV QT assay demonstrated similar accuracy on self-collected versus cervical samples.

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Key Words

• Cervical cancer prevention
• Diagnostic accuracy study
• HPV
• OncoPredict
• Self-sampling
• VALHUDES

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MESH Headings

• Humans
• Female
• Papillomavirus Infections/diagnosis
• Papillomavirus Infections/virology
• Sensitivity and Specificity
• Adult
• Papillomaviridae/genetics
• Papillomaviridae/isolation & purification
• Papillomaviridae/classification
• Middle Aged
• Uterine Cervical Neoplasms/virology
• Uterine Cervical Neoplasms/diagnosis
• Vagina/virology
• Uterine Cervical Dysplasia/virology
• Uterine Cervical Dysplasia/diagnosis
• Specimen Handling/methods
• Cervix Uteri/virology
• Cervix Uteri/pathology
• Viral Load
• Colposcopy
• Young Adult
• Early Detection of Cancer/methods

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Affiliation(s)

Ardashel Latsuzbaia Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
Marianna Martinelli School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Chiara Giubbi School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Kate Cuschieri Scottish HPV Reference Laboratory, Dept of Lab Medicine Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK; HPV Research Group, Centre for Reproductive Health, University of Edinburgh, UK
Hana Elasifer Scottish HPV Reference Laboratory, Dept of Lab Medicine Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK; HPV Research Group, Centre for Reproductive Health, University of Edinburgh, UK
Anna D Iacobone Preventive Gynecology Unit, European Institute of Oncology IRCCS, Milan, Italy
Fabio Bottari General Clinical Laboratory with Specialized Areas Clinical Pathology - Microbiology and Virology, European Institute of Oncology IRCCS, Milan, Italy
Andrea F Piana Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
Roberto Pietri U.O. Coordinamento Consultori Familiari, ASSL Sassari - ATS Sardegna, Sassari, Italy
Giancarlo Tisi Gynecologic and Obstetrical Division, University of Brescia-Spedali Civili di Brescia, Brescia, Italy
Franco Odicino Gynecologic and Obstetrical Division, University of Brescia-Spedali Civili di Brescia, Brescia, Italy
Clementina E Cocuzza School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
Marc Arbyn Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium; Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium

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False Positive Rate from Prospective Studies of PET-CT in Cutaneous Malignant Melanoma: A Systematic Review and Meta-Analysis

BACKGROUND

Cutaneous malignant melanoma (CMM) is increasing in prevalence and possesses the highest mortality rate of any skin cancer. Positron Emission Tomography and Computed Tomography (PET-CT) may be utilised in either radiological staging or surveillance, primarily in stage III-IV disease. False positive (FP) results lead to patient distress, increased costs, and unnecessary follow-up. The FP rate in CMM literature varies widely, altering calculations of positive predictive value and has not undergone pooled meta-analytic.

MATERIALS AND METHODS

A systematic review and meta-analysis of FP results in prospective studies of PET-CT in CMM was performed in accordance with PRISMA guidelines.

RESULTS

The systematic review produced 14 trials for inclusion. Patient-based reporting had the lowest pooled proportion of FP results with 5.8 % (95 % CI = 3.3 % to 8.8 %), lesion-based was highest with 9.1 % (95 % CI = 3.4 % to 17.2 %) and combined was 6.1 % (95 % CI = 4.3 % to 8.1 %). Bias was low to unclear other than for FP reporting. Heterogeneity (I2) was variable across all analyses. FP findings were mainly lymphatic, dermatological, respiratory, or skeletal. Diagnostic information was not provided.

CONCLUSIONS

This study was the first attempt to quantify the pooled proportion of FP results from PET-CT in CMM. A small number of studies (n = 14) were available due to the predominance of retrospective methodology. Due to inconsistent reporting the true proportion of FP results is unclear. Systemic distribution was expected but limited diagnostic information was provided. Repeat meta-analysis using retrospective work should be performed. Future work should be prospective with clearly documented FP proportion, distribution, diagnosis, and follow-up.

Diagnostic Test Accuracy of Urinary DNA Methylation-based Biomarkers for the Detection of Primary and Recurrent Bladder Cancer: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Diagnosis of primary and relapsed bladder carcinomas is accomplished by urethrocystoscopy, an invasive procedure, combined with urinary cytology, with limited sensitivity, resulting in a substantial burden. Thus, noninvasive biomarkers have been investigated, among which DNA methylation has shown promise. This systematic review and meta-analysis sought to assess the diagnostic accuracy of DNA methylation biomarkers reported in the literature for bladder cancer detection, pinpointing the most informative one.

METHODS

The search for this systematic review and meta-analysis was conducted on PubMed, Scopus, and Cochrane Library for relevant studies published until December 31, 2022. A meta-analysis was performed using a random-effect model, to compute the pooled sensitivity and specificity of the markers. PROSPERO's registration ID for the study is CRD42023397703.

KEY FINDINGS AND LIMITATIONS

Out of the 2297 studies retrieved, 68 were included in the final analysis, despite considerable heterogeneity. These involved 12 696 participants, of whom 5557 were diagnosed with bladder cancer. Using diagnostic odds ratio (DOR) as a comparative measure, the five most promising markers (pooled sensitivity, specificity, and DOR) were SALL3 (61%, 97%, and 55.67, respectively), PENK (77%, 93%, and 47.90, respectively), ZNF154 (87%, 90%, and 45.07, respectively), VIM (82%, 90%, and 44.81, respectively), and POU4F2 (81%, 89%, and 34.89, respectively). Urinary cytology identified bladder cancer with 55% sensitivity, 92% specificity, and 14.37 DOR.

CONCLUSIONS AND CLINICAL IMPLICATIONS

DNA methylation biomarkers disclose high accuracy for bladder cancer detection in urine. Nonetheless, validation studies in different clinical settings are scarce, hampering clinical use. The identified biomarkers should be prioritized in future validation studies.

PATIENT SUMMARY

In this meta-analysis, we include previously published studies that used urine samples of bladder cancer patients' from all around the globe. We were able to compare the diagnostic accuracy of noninvasive markers across different populations. We were able to conclude on the most promising DNA methylation markers to detect bladder cancer using urine.

Surgeon-performed intraoperative transoral ultrasound improves the detection of human papillomavirus-positive head and neck cancers of unknown primary

BACKGROUND

Squamous cell carcinomas of unknown primary (SCCUP) are often Human Papillomavirus (HPV)-positive. Due to their small size, extensive surgical workup is required to locate the primary tumors. High-frequency transoral ultrasound (US) may provide improved visualization of these small tumors. Our study aimed to explore whether surgeon-performed intraoperative transoral US for patients with HPV-positiveSCCUP could improve primary tumor detection during panendoscopy.

METHODS

This was a single-center, prospective diagnostic study including patients undergoing panendoscopy under general anesthesia with HPV-positive SCCUP. Preoperative MRIs, PET/CTs, and HPV DNA-testing of lymph node metastases were performed in all patients. Intraoperative transoral US was performed prior to panendoscopy. Frozen section biopsies were performed unblinded to US results, and transoral US-guided biopsies were attempted if initial biopsies were negative. Final histopathology was obtained with palatine- and/or lingual tonsillectomy if frozen section was negative. The main outcome was the primary tumor detection rate with intraoperative transoral US and panendoscopy.

RESULTS

Thirty patients were included: 24 (80 %) were men, and the median age was 60 years [range 35-79 years]. Twenty-nine primary tumors (97 %) were confirmed; 18 (62 %) and 10 (34 %) in the lingual- and palatine tonsils, respectively, and one (3 %) in the posterior oropharynx. Transoral US had a significantly higher sensitivity than panendoscopy to locate the primary tumor (93 % vs 76 %, p = 0.02), and significantly higher than pre-operative PET/CT (62 %, p = 0.002), CT (45 %, p < 0.001), and MRI (28 %, p < 0.001).

CONCLUSIONS

Intraoperative transoral US during panendoscopy is a promising diagnostic tool that may improve the detection of HPV-positive SCCUP.

An immunochromatographic test using whole blood for rapid diagnosis of human paragonimiasis and its diagnostic usefulness

Paragonimiasis is a harmful food-borne zoonosis caused by lung flukes of the genus Paragonimus. The disease is found on most continents, several million people are at risk of infection, and it is a re-emerging disease in developing countries. The gold standard for diagnosis of pulmonary paragonimiasis requires the finding of eggs in sputa and/or fecal samples. In ectopic paragonimiasis cases, eggs are typically not seen, and supportive information is required such as a history of eating freshwater crabs or crayfishes, radiographic findings and immunological tests. Here, we developed a proof of concept based on lateral flow assay, an immunochromatographic test kit, named the paragonimiasis whole-blood test kit, for detection of specific IgG antibody in simulated whole-blood samples (WBSs) using worm excretory-secretory antigens to diagnose human paragonimiasis. The laboratory diagnostic values of this kit were compared with the detected IgG in serum samples. In simulated WBSs, the diagnostic sensitivity and specificity were 97.8 % and 96.1 %, respectively, while for serum samples, these values were 100.0 % and 94.8 %, respectively. The comparative IgG antibody detections whether a result was positive or negative between simulated WBSs and serum samples did not differ significantly with a concordance of 97.8 % in laboratory conditions using a circumscribed set of samples. The tool is fast and easy to use. The next step involves observing and evaluating native whole blood samples and using specific recombinant antigens need to be evaluated for support diagnosis of paragonimiasis caused by P. heterotremus, P. westermani and P. miyazakii at the bedside or at local and remote hospitals with limited facilities. It will also be valuable for epidemiological surveys in Asia where paragonimiasis is endemic.

Appropriate Statistical Methods to Assess Cross-study Diagnostic 23-Gene Expression Profile Test Performance for Cutaneous Melanocytic Neoplasms

ABSTRACT

Comparing studies of molecular ancillary diagnostic tests for difficult-to-diagnose cutaneous melanocytic neoplasms presents a methodological challenge, given the disparate ways accuracy metrics are calculated. A recent report by Boothby-Shoemaker et al investigating the real-world accuracy of the 23-gene expression profile (23-GEP) test highlights this methodological difficulty, reporting lower accuracy than previously observed. However, their calculation method-with indeterminate test results defined as either false positive or false negative-was different than those used in previous studies. We corrected for these differences and recalculated their reported accuracy metrics in the same manner as the previous studies to enable appropriate comparison with previously published reports. This corrected analysis showed a sensitivity of 92.1% (95% confidence interval [CI], 82.1%-100%) and specificity of 94.4% (91.6%-96.9%). We then compared these results directly to previous studies with >25 benign and >25 malignant cases with outcomes and/or concordant histopathological diagnosis by ≥3 dermatopathologists. All studies assessed had enrollment imbalances of benign versus malignant patients (0.8-7.0 ratio), so balanced cohorts were resampled according to the lowest common denominator to calculate point estimates and CIs for accuracy metrics. Overall, we found no statistically significant differences in the ranges of 23-GEP sensitivity, 90.4%-96.3% (95% CI, 80.8%-100%), specificity, 87.3%-96.2% (78.2%-100%), positive predictive value, 88.5%-96.1% (81.5%-100%), or negative predictive value, 91.1%-96.3% (83.6%-100%) between previous studies and the cohort from Boothby-Shoemaker et al with this unified methodological approach. Rigorous standardization of calculation methods is necessary when the goal is direct cross-study comparability.

Predicting autism traits from baby wellness records: A machine learning approach

LAY ABSTRACT

Timely identification of autism spectrum conditions is a necessity to enable children to receive the most benefit from early interventions. Emerging technological advancements provide avenues for detecting subtle, early indicators of autism from routinely collected health information. This study tested a model that provides a likelihood score for autism diagnosis from baby wellness visit records collected during the first 2 years of life. It included records of 591,989 non-autistic children and 12,846 children with autism. The model identified two-thirds of the autism spectrum condition group (boys 63% and girls 66%). Sex-specific models had several predictive features in common. These included language development, fine motor skills, and social milestones from visits at 12-24 months, mother's age, and lower initial growth but higher last growth measurements. Parental concerns about development or hearing impairment were other predictors. The models differed in other growth measurements and birth parameters. These models can support the detection of early signs of autism in girls and boys by using information routinely recorded during the first 2 years of life.

Clinical evaluation of a multiplex PCR-based test for joint infection: a prospective diagnostic accuracy study of forty-nine patients

PURPOSE

The purpose of this study was to evaluate the diagnostic accuracy (sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)) of the PCR-based BioFire® Joint Infection Panel (BJI Panel) against microbiological culture growth for patients suspected of having a native or prosthetic joint infection.

METHODS

Synovial fluid and tissue biopsies were prospectively collected from patients from June 2022 to June 2023. The results of the BJI Panel were compared with those of culture growth.

RESULTS

51 samples were included. Including all pathogens, the sensitivity was 69%, the specificity 89%, the PPV 73% and the NPV 86%. Including only pathogens in the BJI Panel, the sensitivity was 100%, the specificity 90%, the PPV 73% and the NPV 100%.

CONCLUSION

The BJI Panel has a high accuracy for detecting the pathogens in its panel, but the absence of important common pathogens from the panel reduces its sensitivity and NPV. With a short turnaround time and precise pathogen detection, the BJI Panel has the potential to add value as a complementary diagnostic method.

Evaluation of QuantiFERON-TB Gold for the Diagnosis of Mycobacterium tuberculosis Infection in HTLV-1-Infected Patients

Human T-cell leukemia virus type 1 (HTLV-1) is associated with an increased risk of tuberculosis (TB). This study aimed to evaluate the performance of the QuantiFERON-TB Gold (QFT) test for the diagnosis of Mycobacterium tuberculosis (MTB) infection in HTLV-1-infected individuals. HTLV-1-infected participants were divided into four groups: HTLV-1-infected individuals with a history of tuberculosis (HTLV/TB), individuals with positive HTLV and tuberculin skin tests (HTLV/TST+) or negative TST (HTLV/TST-), and HTLV-1-negative individuals with positive TST results (HN/TST+). We compared the diagnostic performance of the QFT assay with that of the TST as a reference and evaluated test sensitivity, specificity, accuracy, likelihood ratio, and diagnostic odds ratio. The results showed a higher frequency of positive TST results and induration diameter ≥10 mm in HTLV-1-infected individuals than in the controls. The QFT test was more frequently positive in the HTLV/TB group than in the other groups, while a combined analysis of HTLV/TB and HTLV/TST+ indicated a QFT sensitivity of 57.5%. No significant differences were found in the other diagnostic performance measures, as QFT test results were in agreement with TST results, particularly in TST-negative individuals. Given the low sensitivity of QFT for LTBI in individuals infected with HTLV-1, the TST may be preferable in regions where both infections are endemic.

Accuracy of the Standard and Distal-to-Proximal Sequence of the Upper Limb Neurodynamic Test 1 for the Diagnosis of Carpal Tunnel Syndrome: The Role of Side-to-Side Comparisons

Background/Objective: This study aimed to evaluate the diagnostic accuracy of two upper limb neurodynamic test 1 (ULNT1) sequences for detecting carpal tunnel syndrome (CTS) in patients with unilateral symptoms. The standard sequence (ULNT1-STD) and a distal-to-proximal sequence (ULNT1-DIST) were investigated. A local-initiated sequence may facilitate symptoms reproduction in CTS, and comparing the affected side with the unaffected side could improve the detection of altered median nerve mechanosensitivity when symptoms are not directly reproduced. Methods: A total of 134 consecutive patients with clinically suspected unilateral CTS were recruited. Nerve conduction studies were used as a reference test. Results: When considering only symptom reproduction as the criterion for a positive test, ULNT1-STD showed a sensitivity of 0.398 and a specificity of 0.780 (positive likelihood ratio [+LR]: 1.81; negative likelihood ratio [-LR]: 0.77); whereas ULNT1-DIST demonstrated a sensitivity of 0.548 with a specificity of 0.732 (+LR: 2.04; -LR: 0.62). When a positive test was defined by symptom reproduction or inter-limb asymmetry (in range of motion or sensory response), ULNT1-STD showed an improved sensitivity of 0.613 but a reduced specificity of 0.537 (+LR: 1.32; -LR: 0.72). In comparison, ULNT1-DIST increased its sensitivity to 0.871 with a specificity of 0.683 (+LR: 2.75; -LR: 0.19). Conclusions: ULNT1-DIST offers better diagnostic accuracy for CTS compared to the ULNT1-STD sequence, especially when interlimb asymmetries in range of motion or sensory response are considered. However, side-to-side comparisons have reduced utility in cases with bilateral symptoms, limiting their application in clinical practice.

Cerebrospinal fluid soluble CD27 is a sensitive biomarker of inflammation in autoimmune encephalitis

BACKGROUND

Autoimmune encephalitis (AE) comprises a group of rare, severe neuroinflammatory conditions. Current biomarkers of neuroinflammation are often normal in AE which therefore can be difficult to rule out in patients with seizures, cognitive and/or neuropsychiatric symptoms. Cerebrospinal fluid (CSF) soluble CD27 (sCD27) and soluble B-cell maturation antigen (sBCMA) have high sensitivity for neuroinflammation in other neuroinflammatory conditions. In this exploratory study we investigate the potential of sCD27 and sBCMA in CSF as biomarkers of neuroinflammation in AE.

METHODS

Concentrations of sCD27 and sBCMA were measured in CSF from 40 AE patients (20 patients were untreated (12 with anti-N-Methyl-d-Aspartate receptor antibodies (NMDA) and 8 with anti-Leucine-rich Glioma-Inactivated 1 antibodies (LGI1)), and 37 symptomatic controls (SCs).

RESULTS

CSF concentrations of sCD27 were increased in untreated NMDA AE patients (median 1571 pg/ml; p < 0.001) and untreated LGI1 AE patients (median 551 pg/ml; p < 0.05) compared to SCs (median 250 pg/ml). CSF sBCMA was increased in untreated NMDA AE patients (median 832 pg/ml) compared to SCs (median 429 pg/ml). CSF sCD27 and sBCMA correlated with the CSF cell count. Receiver operating characteristic curve analysis of untreated AE patients versus SCs showed an area under the curve of 0.97 for sCD27 and 0.76 for sBCMA.

CONCLUSION

CSF sCD27 is a suitable biomarker of neuroinflammation in AE with an ability to discriminate patients with NMDA AE and LGI1 AE from symptomatic controls. CSF sCD27 may be suited for ruling out AE and other neuroinflammatory conditions in the early phase of the diagnostic work-up.

Performance of a Deep Learning System and Performance of Optometrists for the Detection of Glaucomatous Optic Neuropathy Using Colour Retinal Photographs

BACKGROUND/OBJECTIVES

Glaucoma is the leading cause of irreversible blindness, with a significant proportion of cases remaining undiagnosed globally. The interpretation of optic disc and retinal nerve fibre layer images poses challenges for optometrists and ophthalmologists, often leading to misdiagnosis. AI has the potential to improve diagnosis. This study aims to validate an AI system (a convolutional neural network based on the Inception-v3 architecture) for detecting glaucomatous optic neuropathy (GON) using colour fundus photographs from a UK population and to compare its performance against Australian optometrists.

METHODS

A retrospective external validation study was conducted, comparing AI's performance with that of 11 AHPRA-registered optometrists in Australia on colour retinal photographs, evaluated against a reference (gold) standard established by a panel of glaucoma specialists. Statistical analyses were performed using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC).

RESULTS

For referable GON, the sensitivity of the AI (33.3% [95%CI: 32.4-34.3) was significantly lower than that of optometrists (65.1% [95%CI: 64.1-66.0]), p < 0.0001, although with significantly higher specificity (AI: 97.4% [95%CI: 97.0-97.7]; optometrists: 85.5% [95%CI: 84.8-86.2], p < 0.0001). The optometrists demonstrated significantly higher AUROC (0.753 [95%CI: 0.744-0.762]) compared to AI (0.654 [95%CI: 0.645-0.662], p < 0.0001).

CONCLUSION

The AI system exhibited lower performance than optometrists in detecting referable glaucoma. Our findings suggest that while AI can serve as a screening tool, both AI and optometrists have suboptimal performance for the nuanced diagnosis of glaucoma using fundus photographs alone. Enhanced training with diverse populations for AI is essential for improving GON detection and addressing the significant challenge of undiagnosed cases.

A Phase 2 Sensitivity and Selectivity Study of High-Dose 5-Aminolevulinic Acid in Adult Patients Undergoing Resection of a Newly Diagnosed or Recurrent Glioblastoma

BACKGROUND AND OBJECTIVES

The utility of oral 5-aminolevulinic acid (5-ALA)/protoporphyrin fluorescence for the resection of high-grade gliomas is well documented, but the problem of false-negative observations remains. This study compares high-grade glioma visualization with low/standard dose 5-ALA (<30 mg/kg) to high-dose 5-ALA (>40 mg/kg) to see if by using this higher dose, it is possible to reduce the rate of false-negative observations without increasing the rate of false-positive (FP) observations and therefore increase the sensitivity.

METHODS

This is a prospective study of consecutive patients with radiological evidence of presumed high-grade glioma. We reviewed the data from patients who received preoperative low/standard doses and patients who received a preoperative high dose of 5-ALA. Adverse events, dose to observation time, intensity of tumor fluorescence, and results of biopsies in areas of tumor and tumor bed under deep blue light were recorded.

RESULTS

A total of 22 patients with high-grade glioma received a dose >40 mg/kg (high-dose) and 9 patients received <30 mg/kg (low/standard dose). There were no serious adverse events related to 5-ALA in any subject. There was a very high sensitivity and specificity of 5-ALA for the presence of tumor in both groups. There were no FP observations (fluorescence with no tumor) in either group. The specificity and the positive predictive value were 100% in both groups. The sensitivity and the negative predictive value were 53.3% and 30.0% in the low/standard dose group and 59.5% and 31.8% in the high-dose group, respectively.

CONCLUSION

High-dose oral 5-aminolevulinic/protoporphyrin fluorescence is a safe and effective aid to the intraoperative detection of high-grade gliomas with high sensitivity and specificity. False-negative observations with a high dose do not seem to be less than that with a low/standard dose. The rate of FP observations with both groups remains very low.

eTWST: An Extension to the Timed Water Swallow Test for Increased Dysphagia Screening Accuracy

We aimed to fine-tuning the Timed Water Swallow Test (TWST) screening procedure to provide the most reliable prediction of the Flexible Endoscopic Evaluation of Swallowing (FEES) assessment outcomes, with age, sex, and the presence of clinical signs of dysphagia being considered in the assessment. Participants were healthy people and patients with suspected dysphagia. TWST performance and participants' reported dysphagia symptoms were assessed in terms of their utility in predicting the outcome of a FEES assessment the same day. The FEES assessors were blinded to the nature of the TWST performance. The water swallowing capacity levels and clinical observations during a screening performance that were indicative of dysphagia/no symptoms in FEES were determined. Convergent validity was assessed as the agreement with the Functional Oral Intake Scale (FOIS) in the FEES assessment. TWST predicted FEES findings (aspiration and dysphagia) with a sensitivity of 72 and 45% and a specificity of 75% and 80%, respectively. Extended analysis of the TWST procedure (eTWST) identified aspiration (sensitivity = 92%, specificity = 62%) and dysphagia (sensitivity = 70%, and specificity = 72%) more accurately and showed a high correlation with FOIS (ɸ = 0.37). Excellent inter-rater reliability was further observed (Kw = 0.83). The extended evaluation of TWST performance has superior criterion validity to that of TWST. eTWST displayed high convergent validity and excellent interrater reliability. We therefore believe that eTWST can be highly relevant for clinical dysphagia screening.

The accuracy of respiratory muscle strength in identifying systolic dysfunction in patients with Chagas cardiomyopathy

PURPOSE

To verify the accuracy of respiratory muscle strength in identifying systolic dysfunction in patients with Chagas cardiomyopathy (ChC), and to validate optimal cutoff points based on respiratory muscle strength.

METHODS

First, 72 patients with ChC were enrolled and underwent echocardiography and assessment of respiratory muscle strength by manovacuometry. Inspiratory and expiratory muscle strength was defined by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), respectively. Systolic dysfunction was defined by left ventricular ejection fraction (LVEF) values below 52% (for men) or 54% (for women). Then, the validation of the cutoff points was verified by the percentage of true and false positives in another 30 ChC patients.

RESULTS

The MIP showed adequate accuracy (p = 0.004) in identifying patients with systolic dysfunction (AUC = 0.73). The MEP did not show satisfactory accuracy in identifying those patients. The optimal MIP cutoff point to identify systolic dysfunction in ChC was ≤62 cmH2O, with a positive predictive value of 87%. In the validation analysis, MIP values below 62 cmH2O were able to identify 77% of patients with systolic dysfunction.

CONCLUSION

MIP has potential value in identifying systolic dysfunction in patients with ChC. This finding may aid in screening and risk stratification when echocardiography is not available.

Diagnostic accuracy of TB screening tests in a prospective multinational cohort: Chest-X-ray with computer-aided detection, Xpert TB host response, and C-reactive protein

BACKGROUND

Accessible, accurate screening tests are necessary to advance tuberculosis (TB) case finding and early detection in high-burden countries.

METHODS

We prospectively screened adults with ≥2 weeks of cough at primary health centers in the Philippines, Vietnam, South Africa, Uganda, and India. Participants received chest-X-ray, Cepheid Xpert TB Host Response (Xpert HR) testing, and point-of-care C-reactive protein (CRP) testing (Boditech). Chest-X-ray images were processed using CAD4TB v7, a computer-aided detection algorithm. We assessed diagnostic accuracy against a microbiologic reference standard (sputum Xpert Ultra, culture). Optimal cut-points were chosen to maximize specificity at 90% sensitivity. Two-test screening algorithms were considered, using 1) sequential negative serial screening (positive defined as positive on either test) and 2) sequential positive serial screening (positive defined as positive on both tests).

RESULTS

Between July 2021 and August 2022, 1,392 participants with presumptive TB had valid index tests and reference standard results, and 303 (22%) had confirmed TB. In head-to-head comparisons, CAD4TB v7 showed the highest specificity at 90% sensitivity (70.3% vs. 65.1% for Xpert HR, difference 95% CI 1.6 to 8.9; 49.7% for CRP, difference 95% CI 17.0 to 24.3). Three two-test screening algorithms met WHO target product profile (TPP) minimum accuracy thresholds and had higher accuracy than any test alone. At 90% sensitivity, the specificity was 79.6% for Xpert HR-CAD4TB [sequential negative], 75.9% for CRP-CAD4TB [sequential negative], and 73.7% for Xpert HR-CAD4TB [sequential positive].

CONCLUSIONS

CAD4TB achieves TPP targets and outperforms Xpert HR and CRP. Combining screening tests further increased accuracy.

REGISTRATION

NCT04923958.

Stent Retriever AssIsted Lysis Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting

BACKGROUND AND PURPOSE

Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement.

MATERIALS AND METHODS

Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban before the intended angioplasty and stent placement. SAIL consisted of deploying a stent retriever through the occluding lesion to create a bypass channel and infuse 10 mL of tirofiban for 10 minutes either intra-arterially or IV. The stent retriever was re-sheathed before retrieval. The primary end points were successful reperfusion (expanded TICI 2b-3) and symptomatic intracerebral hemorrhage. Additional end points included 90-day mRS 0-2 and mortality.

RESULTS

After a median of 3 (interquartile range, 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban, and later they were considered potential candidates for angioplasty and stent placement bailout (43.2%, intra-arterial SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A notable residual stenosis (>50%) after successful SAIL was observed in 45.7%. No significant differences were detected according to post-SAIL: successful reperfusion (intra-arterial SAIL, 80.0% versus IV-SAIL, 78.9%; P = .932), significant stenosis (33.3% versus 55.0%; P = .203), early symptomatic re-occlusion (0% versus 8.0%; P = .207), or symptomatic intracerebral hemorrhage (5.3% versus 8.0%; P = .721). Rescue angioplasty and stent placement were finally performed in 15 (34.1%) patients (intra-arterial SAIL 21.0% versus IV-SAIL 44%; P = .112). At 90 days, mRS 0-2 (intra-arterial SAIL 50.0% versus IV-SAIL 43.5%; P = .086) and mortality (26.3% versus 12.0%; P = .223) were also similar.

CONCLUSIONS

In patients with stroke in which angioplasty and stent placement are considered, SAIL with tirofiban, either intra-arterial or IV, seems to safely induce sustained recanalization, offering a potential alternative to definitive angioplasty and stent placement.

Artificial intelligence tools trained on human-labeled data reflect human biases: a case study in a large clinical consecutive knee osteoarthritis cohort

Humans have been shown to have biases when reading medical images, raising questions about whether humans are uniform in their disease gradings. Artificial intelligence (AI) tools trained on human-labeled data may have inherent human non-uniformity. In this study, we used a radiographic knee osteoarthritis external validation dataset of 50 patients and a six-year retrospective consecutive clinical cohort of 8,273 patients. An FDA-approved and CE-marked AI tool was tested for potential non-uniformity in Kellgren-Lawrence grades between the right and left sides of the images. We flipped the images horizontally so that a left knee looked like a right knee and vice versa. According to human review, the AI tool showed non-uniformity with 20-22% disagreements on the external validation dataset and 13.6% on the cohort. However, we found no evidence of a significant difference in the accuracy compared to senior radiologists on the external validation dataset, or age bias or sex bias on the cohort. AI non-uniformity can boost the evaluated performance against humans, but image areas with inferior performance should be investigated.

Validation of the adult asthma epidemiological score: a secondary analysis of the EPI-ASTHMA population-based study

OBJECTIVE

The A2 score is an eight-question patient-reported outcome measure that has been validated for ruling in (score ≥4) and ruling out (score 0-1) asthma. However, this screening tool has been validated in a cohort similar to the derivation cohort used. This study aims to validate the predictive accuracy of the A2 score in a primary care population against general practitioner (GP) clinical assessment and to determine whether the proposed cut-offs are the most appropriate.

DESIGN

This accuracy study is a secondary analysis of the EPI-ASTHMA population-based study.

SETTING

Primary care centres in Portugal.

PARTICIPANTS

Random adult participants answered the A2 score by phone interview.

OUTCOMES

Those with an A2 score ≥1 (plus 5% with an A2 score of 0) were invited to a diagnostic visit carried out by a GP to confirm or not a diagnosis of asthma. Diagnostic accuracy was assessed using receiver operating characteristic (ROC) curves.

RESULTS

A total of 1283 participants (median 54 (p25-p75 43-66) years; 60% women) were analysed. The A2 score showed high discriminatory power in identifying asthma, with an area under the ROC curve of 82.9% (95% CI 80.4% to 85.4%). The proposed cut-off ≥4 was the most appropriate to rule in asthma (specificity 83.1%, positive predictive value 62.4%, accuracy 78%). Similarly, the proposed cut-off<2 was the most suitable for excluding asthma (sensitivity 92.7%, negative predictive value 93.7%, accuracy 60.5%).

CONCLUSIONS

The A2 score is a useful tool to identify patients with asthma in a primary care population.

TRIAL REGISTRATION NUMBER

NCT0516961.

Foreign body-intestinal canal angle guides management of ingested foreign bodies in the lower gastrointestinal tract

BACKGROUND

Determining whether prompt surgery is required for patient with ingested foreign bodies is clinically important.

PURPOSE

To evaluate the potential value of computed tomography (CT) in guiding the selection of surgical treatment for patients with ingested foreign bodies in the lower gastrointestinal tract.

METHODS

Between January 2014 and December 2023, we analyzed the data of 58 patients (median age: 65.4 years; range, 31-96 years) with ingested foreign bodies in the lower gastrointestinal tract who underwent CT examinations. Patients were treated either conservatively (35 cases) or surgically (23 cases). The angle between the long axis of the foreign body and the intestinal canal (FB-IC angle) was measured. CT findings and clinical variables were evaluated to identify potential indicators for surgical treatment through univariate and multivariate logistic regression analyses.

RESULTS

Univariate analysis revealed the FB-IC angle (P = 0.002), presence of free peritoneal gas (P = 0.002), white blood cell count (P = 0.018), and neutrophil count (P = 0.007) as significant factors associated with surgical treatment. Multivariate analysis demonstrated that the FB-IC angle (odds ratio, 1.033; P = 0.045) and the presence of free peritoneal gas (odds ratio, 41.335; P = 0.002) are independent indicators for surgical management. The FB-IC angle showed an area under the receiver operating characteristic curve of 0.755, with a cutoff value of 51.25 degrees.

CONCLUSION

The FB-IC angle and presence of free peritoneal gas serve as potential predictive imaging markers for surgical intervention.

A machine-learning algorithm to grade heart murmurs and stage preclinical myxomatous mitral valve disease in dogs

BACKGROUND

The presence and intensity of heart murmurs are sensitive indicators of several cardiac diseases in dogs, particularly myxomatous mitral valve disease (MMVD), but accurate interpretation requires substantial clinical expertise.

OBJECTIVES

Assess if a machine-learning algorithm can be trained to accurately detect and grade heart murmurs in dogs and detect cardiac disease in electronic stethoscope recordings.

ANIMALS

Dogs (n = 756) with and without cardiac disease attending referral centers in the United Kingdom.

METHODS

All dogs received full physical and echocardiographic examinations by a cardiologist to grade any murmurs and identify cardiac disease. A recurrent neural network algorithm, originally trained for heart murmur detection in humans, was fine-tuned on a subset of the dog data to predict the cardiologist's murmur grade from the audio recordings.

RESULTS

The algorithm detected murmurs of any grade with a sensitivity of 87.9% (95% confidence interval [CI], 83.8%-92.1%) and a specificity of 81.7% (95% CI, 72.8%-89.0%). The predicted grade exactly matched the cardiologist's grade in 57.0% of recordings (95% CI, 52.8%-61.0%). The algorithm's prediction of loud or thrilling murmurs effectively differentiated between stage B1 and B2 preclinical MMVD (area under the curve [AUC], 0.861; 95% CI, 0.791-0.922), with a sensitivity of 81.4% (95% CI, 68.3%-93.3%) and a specificity of 73.9% (95% CI, 61.5%-84.9%).

CONCLUSION AND CLINICAL IMPORTANCE

A machine-learning algorithm trained on humans can be successfully adapted to grade heart murmurs in dogs caused by common cardiac diseases, and assist in differentiating preclinical MMVD. The model is a promising tool to enable accurate, low-cost screening in primary care.

CRP and sCD25 help distinguish between adult-onset Still's disease and HLH

OBJECTIVE

Adult-onset Still's disease (AOSD) and secondary hemophagocytic lymphohistiocytosis (sHLH) are both hyperferritinemic cytokine storm syndromes that can be difficult to distinguish from each other in hospitalized patients. The objective of this study was to compare the inflammatory markers ferritin, D-dimer, C-reactive protein (CRP), and soluble CD25 (sCD25) in patients with AOSD and sHLH. These four markers were chosen as they are widely available and represent different aspects of inflammatory diseases: macrophage activation (ferritin); endothelialopathy (D-dimer); interleukin-1/interleukin-6/tumour necrosis factor elevation (CRP) and T cell activation (sCD25).

METHODS

This was a single-center retrospective study. Patients diagnosed by the Hematology service at Vancouver General Hospital for AOSD or sHLH from 2009 to 2023 were included.

RESULTS

There were 16 AOSD and 44 sHLH patients identified. Ferritin was lower in AOSD than HLH (median 11 360 μg/L vs. 29 020 μg/L, p = .01) while D-dimer was not significantly different (median 5310 mg/L FEU vs. 7000 mg/L FEU, p = .3). CRP was higher (median 168 mg/L vs. 71 mg/L, p <.01) and sCD25 was lower (median 2220 vs. 7280 U/mL, p = .004) in AOSD compared to HLH. The combined ROC curve using CRP >130 mg/L and sCD25< 3900 U/mL to distinguish AOSD from HLH had an area under the curve (AUC) of 0.94 (95% confidence interval 0.93-0.97) with sensitivity 91% and specificity 93%.

CONCLUSIONS

These findings suggest that simple, widely available laboratory tests such as CRP and sCD25 can help clinicians distinguish AOSD from HLH in acutely ill adults with extreme hyperferritinemia. Larger studies examining a wider range of clinically available inflammatory biomarkers in a more diverse set of cytokine storm syndromes are warranted.

Role of inflammatory markers in the assessment of meningitis in adult patients with fever and headache

BACKGROUND

Meningitis, especially of bacterial origin, is a medical emergency that must be diagnosed promptly. However, due to the associated risks of complications of lumbar puncture, it is crucial to identify individuals who truly need it. The aim of this study was to assess the diagnostic role of inflammatory markers in distinguishing among patients without meningitis, those with aseptic meningitis, and those with bacterial meningitis.

METHODS

This was a retrospective, diagnostic study at an acute care hospital, involving adult patients who presented to either ambulatory care or the emergency department with fever and headache, but without altered mental status or neurological deficits. Inflammatory markers (C-reactive protein [CRP], mean platelet volume, neutrophil-lymphocyte ratio, and red cell distribution width) were assessed as index tests. An expert panel classified patients into three groups: no meningitis, aseptic meningitis, and bacterial meningitis using predefined criteria.

RESULTS

Of the 80 patients, 52 had no meningitis, 27 had aseptic meningitis, and 1 had bacterial meningitis. Of the inflammatory markers investigated, only CRP showed potential usefulness in differentiating these three diagnostic groups, with median values of 5.6 (interquartile range [IQR] 2.1, 11.3) mg/dL in those without meningitis, 0.2 (IQR 0.1, 1.2) mg/dL in those with aseptic meningitis, and notably elevated at 21.7 mg/dL in the patient with bacterial meningitis.

CONCLUSION

In adult patients presenting with fever and headache in an emergency setting, CRP was the only marker that demonstrated potential diagnostic utility in distinguishing among those with no meningitis, aseptic meningitis, and bacterial meningitis.

Establishing the cutoff value of near visual acuity for assessment of early presbyopia

PURPOSE

There is limited evidence to evaluate the numerical cutoff point for detecting early presbyopia. Thus, we aimed to establish a clinically relevant optimal cutoff value of near visual acuity for detecting early presbyopia.

STUDY DESIGN

Prospective diagnostic accuracy study.

METHODS

We included consecutive individuals aged ≥ 20 years with a binocular-corrected distance visual acuity of ≥ 20/25 who did not undergo ophthalmic surgery between December 17, 2020 and December 19, 2021, at two healthcare facilities in Japan. Binocular distance-corrected near visual acuity at 40 cm, accommodative amplitude, awareness of presbyopia, and Near Activity Visual Questionnaire scores were examined. The optimal cutoff values of distance-corrected near visual acuity for diagnosing early presbyopia were evaluated using receiver operating characteristic plots.

RESULTS

Among 115 participants, 74 (64.3%) had presbyopia. The proportion of participants with no difficulty performing near-vision tasks decreased markedly when near visual acuity decreased to 20/20 (> 0.00 logMAR). A cutoff value of 0.00 logMAR for distance-corrected near visual acuity was optimal, showing high sensitivity of 56.76% and specificity of 92.68%, as opposed to the commonly used cutoff value of 0.40 logMAR (20/50; sensitivity, 9.46% and specificity, 100%) for diagnosing early presbyopia.

CONCLUSION

Near visual acuity of 0.00 logMAR (20/20) could be the optimal cutoff value for diagnosing early presbyopia.

Diagnostic accuracy of Ages and Stages Questionnaire, Third Edition to identify abnormal or delayed gross motor development in high-risk infants

AIM

To investigate the diagnostic accuracy of parent-completed Ages and Stages Questionnaire, Third Edition (ASQ-3) to identify abnormal or delayed gross motor development in infants born less than 1000 g or less than 28 weeks gestation.

METHODS

Prospective cohort study of high-risk infants comparing ASQ-3 as the index test with concurrent score on Alberta Infant Motor Scale (AIMS) as the reference standard, at 4-, 8- and 12-month corrected (post-term) age. Reference standard positivity cut-offs were 'Abnormal motor development' (AIMS Clinical Range) and 'Motor delay' (AIMS score >1 SD below mean, not captured in Clinical Range).

RESULTS

Participating infants (n = 191) had mean gestational age (95% confidence interval (CI)) 26.8 weeks (26.6-27.1) and mean birthweight (95% CI) 870 g (844-896). AIMS rated 51%, 31% and 23% of infants as having 'Abnormal motor development' and 12%, 28% and 13% with 'Motor delay', at 4, 8 and 12 months, respectively. Diagnostic accuracy of ASQ-3 to identify abnormal motor development was acceptable for older infants only if 'Monitor' cut-off was used: sensitivity (95% CI) 33% (23-44), 86% (73-95) and 80% (63-92) and specificity (95% CI) 84% (74-92), 76% (66-84), and 76% (67-83) at 4, 8 and 12 months, respectively. ASQ-3 sensitivity to identify motor delay was low.

CONCLUSIONS

ASQ-3 has poor sensitivity to identify abnormal or delayed motor development at 4 months. Using the 'Monitor' cut-off improves the diagnostic accuracy of ASQ-3 for identification of older infants with abnormal motor development who are at high risk of motor disability. However, ASQ-3 has poor sensitivity to identify motor delay. Clinical motor assessment of high-risk infants is recommended, particularly in early infancy.