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Positive Likelihood Ratio (positive + likelihood_ratio)
Selected AbstractsDiagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopyACTA PAEDIATRICA, Issue 4 2010R Mori Abstract Background:, Prompt diagnosis of urinary tract infection (UTI) in children is needed to initiate treatment but is difficult to establish without urine testing, and reliance on culture leads to delay. Urine dipsticks are often used as an alternative to microscopy, although the diagnostic performance of dipsticks at different ages has not been established systematically. Method:, Studies comparing urine dipstick testing in infants versus older children and urine dipstick versus microscopy were systematically searched and reviewed. Meta-analysis of available studies was conducted. Results:, Six studies addressed these questions. The results of meta-analysis showed that the performance of urine dipstick testing was significantly less in the younger children when compared with older children (p < 0.01). Positive likelihood ratio (LR) of both nitrite and leucocyte positive 38.54 [95% confidence interval (CI) 22.49,65.31], negative LR for both negative 0.13 (95% CI 0.07,0.25) are reasonably good, and those for young infants are less reliable [positive LR 7.62 (95% CI 0.95,51.85) and negative LR 0.34 (95% CI 0.66,0.15)]. Comparing microscopy and urine dipstick testing, using bacterial colony count on urine culture showed no significant difference between the two methods. Conclusion:, Urine dipstick testing is more effective for diagnosis of UTI in children over 2 years than for younger children. [source] A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum womenACTA PSYCHIATRICA SCANDINAVICA, Issue 5 2009J. Gibson Objective:, The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008. Method:, Systematic review of validation studies of the EPDS included 1987,2008. Cut-off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used. Results:, Thirty-seven studies met the inclusion criteria. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78. Conclusion:, Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts. [source] Emergency Department Case-finding for High-risk Older Adults: The Brief Risk Identification for Geriatric Health Tool (BRIGHT)ACADEMIC EMERGENCY MEDICINE, Issue 7 2008Michal Boyd RN Abstract Objective:, The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment. Methods:, This was a cross-sectional study in which 139 persons ,75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A "yes" response to at least 3 of the 11 BRIGHT items was considered "positive." Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL). Results:, The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p < 0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR,) were 0.3, 0.4, and 0.3. Conclusions:, The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment. [source] Validity of suspected alcohol and drug violations in aviation employeesADDICTION, Issue 10 2010Guohua Li ABSTRACT Aims In the United States, transportation employees who are suspected of using alcohol and drugs are subject to reasonable-cause testing. This study aims to assess the validity of suspected alcohol and drug violations in aviation employees. Methods Using reasonable-cause testing and random testing data from the Federal Aviation Administration for the years 1995,2005, we calculated the positive predictive value (PPV) and positive likelihood ratio (LR+) of suspected alcohol and drug violations. The true status of violations was based on testing results, with an alcohol violation being defined as a blood alcohol concentration of ,0.04 mg/dl and a drug violation as a test positive for marijuana, cocaine, amphetamines, phencyclidine or opiates. Results During the 11-year study period, a total of 2284 alcohol tests and 2015 drug tests were performed under the reasonable-cause testing program. The PPV was 37.7% [95% confidence interval (CI), 35.7,39.7%] for suspected alcohol violations and 12.6% (95% CI, 11.2,14.1%) for suspected drug violations. Random testing revealed an overall prevalence of 0.09% for alcohol violations and 0.6% for drug violations. The LR+ was 653.6 (95% CI, 581.7,734.3) for suspected alcohol violations and 22.5 (95% CI, 19.6,25.7) for suspected drug violations. Conclusion The discriminative power of reasonable-cause testing suggests that, despite its limited positive predictive value, physical and behavioral observation represents an efficient screening method for detecting alcohol and drug violations. The limited positive predictive value of reasonable-cause testing in aviation employees is due in part to the very low prevalence of alcohol and drug violations. [source] Alanine transaminase rather than abdominal ultrasound alone is an important investigation to justify cholecystectomy in patients presenting with acute pancreatitisHPB, Issue 5 2010Kerry Anderson Abstract Objectives:, The aims of this study were to investigate the predictive value of an elevated level of alanine transaminase (ALT) for biliary acute pancreatitis (AP) and to reconsider the role of abdominal ultrasound (AUS). Methods:, All patients admitted to Christchurch Public Hospital with AP between July 2005 and December 2008 were identified from a prospectively collected database. Peak ALT within 48 h of presentation was recorded. Aetiology was determined on the basis of history, AUS and other relevant investigations. Results:, A total of 543 patients met the inclusion criteria. Patients with biliary AP had significantly higher median (range) ALT than those with non-biliary causes (200 units/l [63,421 units/l] vs. 33 units/l [18,84 units/l]; P < 0.001). An ALT level of >300 units/l had a sensitivity of 36%, specificity of 94%, positive predictive value of 87% and positive likelihood ratio of 5.6 for gallstones. An elevated ALT and negative AUS had a probability of 21,80% for gallstones. Conclusions:, An elevated ALT strongly supports a diagnosis of gallstones in AP. Abdominal ultrasound effectively confirms this diagnosis; however, a negative ultrasound in the presence of a raised ALT does not exclude gallstones. In some patients consideration could be given to proceeding to laparoscopic cholecystectomy based on ALT alone. [source] The Use of Impedance Cardiography in Predicting Mortality in Emergency Department Patients With Severe Sepsis and Septic ShockACADEMIC EMERGENCY MEDICINE, Issue 4 2010Anthony M. Napoli MD Abstract Objectives:, Pulmonary artery catheterization poses significant risks and requires specialized training. Technological advances allow for more readily available, noninvasive clinical measurements of hemodynamics. Few studies exist that assess the efficacy of noninvasive hemodynamic monitoring in sepsis patients. The authors hypothesized that cardiac index, as measured noninvasively by impedance cardiography (ICG) in emergency department (ED) patients undergoing early goal-directed therapy (EGDT) for sepsis, would be associated with in-hospital mortality. Methods:, This was a prospective observational cohort study of patients age over 18 years meeting criteria for EGDT (lactate > 4 or systolic blood pressure < 90 after 2 L of normal saline). Initial measurements of cardiac index were obtained by ICG. Patients were followed throughout their hospital course until discharge or in-hospital death. Cardiac index measures in survivors and nonsurvivors are presented as means and 95% confidence intervals (CI). Diagnostic performance of ICG in predicting mortality was tested by receiver operating characteristic (ROC) curve and areas under the ROC curves (AUC) were compared using Wilcoxon test. Results:, Fifty-six patients were enrolled; one was excluded due to an inability to complete data acquisition. The mean cardiac index in nonsurvivors (2.3 L/min·m2, 95% CI = 1.6 to 3.0) was less than that for survivors (3.2, 95% CI = 2.9 to 3.5) with mean difference of 0.9 (95% CI = 0.12 to 1.71). The AUC for ICG in predicting mortality was 0.71 (95% CI = 0.58 to 0.88; p = 0.004). A cardiac index of < 2 L/min·m2 had a sensitivity of 43% (95% CI = 18% to 71%), specificity of 93% (95% CI = 80% to 95%), positive likelihood ratio of 5.9, and negative likelihood ratio of 0.6 for predicting in-hospital mortality. Conclusions:, Early, noninvasive measurement of the cardiac index in critically ill severe sepsis and septic shock patients can be performed in the ED for those who meet criteria for EGDT. There appears to be an association between an initial lower cardiac index as measured noninvasively and in-hospital mortality. ACADEMIC EMERGENCY MEDICINE 2010; 17:452,455 © 2010 by the Society for Academic Emergency Medicine [source] Prognosis of stage I pressure ulcers and related factorsINTERNATIONAL WOUND JOURNAL, Issue 4 2006Miwa Sato Abstract The prognosis of stage I pressure ulcers cannot be predicted; therefore, nursing interventions for preventing their deterioration have not been clearly established. This study describes the clinical course of stage I pressure ulcers and prospectively investigates the factors related to their deterioration. Thirty-one stage I pressure ulcers in 30 patients in a long-term care facility were studied, and morphological changes were assessed every day until the ulcers healed or deteriorated. The physiological changes were assessed by ultrasonography and thermography. Twenty ulcers healed, and 11 deteriorated. The characteristics of deterioration were as follows: (1) double erythema; (2) non blanchable erythema across the whole area determined by glass plate compression; (3) erythema away from the tip of the bony prominence; and (4) expanding erythema on the following day. We analysed the sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio for the diagnostic utility of the indicators of deterioration double erythema and distance from the tip of bony prominence, which can be instantly assessed without the use of any special device. The values were 36·4%, 95·0%, 80·0%, 73·1% and 7·28, respectively. These results suggest that clinicians can predict the prognosis of stage I pressure ulcers by initial assessment and provide appropriate care based on the assessment. [source] Fine mapping and detection of the causative mutation underlying Quantitative Trait LociJOURNAL OF ANIMAL BREEDING AND GENETICS, Issue 5 2010E. Uleberg Summary The effect on power and precision of including the causative SNP amongst the investigated markers in Quantitative Trait Loci (QTL) mapping experiments was investigated. Three fine mapping methods were tested to see which was most efficient in finding the causative mutation: combined linkage and linkage disequilibrium mapping (LLD); association mapping (MARK); a combination of LLD and association mapping (LLDMARK). Two simulated data sets were analysed: in one set, the causative SNP was included amongst the markers, while in the other set the causative SNP was masked between markers. Including the causative SNP amongst the markers increased both precision and power in the analyses. For the LLD method the number of correctly positioned QTL increased from 17 for the analysis without the causative SNP to 77 for the analysis including the causative SNP. The likelihood of the data analysis increased from 3.4 to 13.3 likelihood units for the MARK method when the causative SNP was included. When the causative SNP was masked between the analysed markers, the LLD method was most efficient in detecting the correct QTL position, while the MARK method was most efficient when the causative SNP was included as a marker in the analysis. The LLDMARK method, combining association mapping and LLD, assumes a QTL as the null hypothesis (using LLD method) and tests whether the ,putative causative SNP' explains significantly more variance than a QTL in the region. Thus, if the putative causative SNP does not only give an Identical-By-Descent (IBD) signal, but also an Alike-In-State (AIS) signal, LLDMARK gives a positive likelihood ratio. LLDMARK detected less than half as many causative SNPs as the other methods, and also had a relatively high false discovery rate when the QTL effect was large. LLDMARK may however be more robust against spurious associations, because the regional IBD is largely corrected for by fitting a QTL effect in the null hypothesis model. [source] Recommended dietary allowance for vitamin C in the United States is also applicable to a population of young Japanese womenJOURNAL OF CLINICAL LABORATORY ANALYSIS, Issue 6 2004Hiroshi Ihara Abstract The recommended dietary allowance (RDA) for ascorbic acid (AA) in Canada and the United States has been set for several years at 75 mg/day for women 19,30 years old. Recently this level was questioned, and an increase to 90 mg/day was suggested. For Japanese women in the same age group, we found that the RDA for AA is currently 100 mg/day. Our goal was to determine which RDA is sufficient for maintaining a serum concentration of AA in young Japanese women above the lower reference limit of 7.0 mg/L. We measured serum AA concentrations by an ascorbate oxidase method in 176 healthy Japanese women (19,26 years old). We also performed an ROC analysis to estimate the optimal cutoff value for oral dosage to distinguish individuals with hypovitaminosis-C (<7.0 mg/L) from those with a normal serum AA. We evaluated the Japanese RDA using the 75 or 90 mg/day U.S. RDA and the weight ratio between Japanese and U.S. women, and discovered that the RDA value ranged between 66 and 79 mg/day. From the ROC analysis, we found that the optimal daily dosage of AA is approximately 75 mg/day. This value gave the highest efficiency, sensitivity, negative predictive value, and positive likelihood ratio, and the lowest negative likelihood ratio. Therefore, an RDA of 100 mg/day may be unnecessarily high for young Japanese women. J. Clin. Lab. Anal. 18:305,308, 2004. © 2004 Wiley-Liss, Inc. [source] The Accuracy of Transcranial Doppler in the Diagnosis of Stenosis or Occlusion of the Terminal Internal Carotid ArteryJOURNAL OF NEUROIMAGING, Issue 4 2004Jose C. Navarro MD ABSTRACT Background and Purpose. Transcranial Doppler (TCD) can detect intracranial stenoses and occlusions that can help in the diagnosis and management of ischemic stroke. The accuracy parameters for lesions located in the terminal internal carotid artery (TICA) are less known, unlike other basal cerebral vessels. Patients and Methods. The authors studied consecutive patients referred for TCD who underwent contrast angiography or magnetic resonance angiography. They calculated the sensi tivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios. Results. Forty-three patients had TCD and angiography: mean age was 57 ± 20 years, and 65% were men. Twenty-two patients were diagnosed with TICA stenosis or occlusion on TCD underwent angiography. Four patients had abnormal TCD findings that were not confirmed by angiography. Two of 21 patients with normal TCD showed mod erate (< 50%) stenosis of the TICA and cavernous segment of the internal carotid artery at angiography. Accuracy parameters for TCD were as follows: sensitivity = 90% (confidence interval [CI], 63%-96%), specificity = 83% (CI, 61%-94%), PPV = 82%, NPV = 86%, positive likelihood ratio = 5, and negative likelihood ratio = 0.17. Conclusions. TCD is a sensitive screening tool for the lesions in the TICA. Specificity is likely affected by a wide spectrum of the stenosis severity shown at angiography and time lags between the studies. [source] Comparison of ultrasonography and magnetic resonance imaging in the evaluation of temporomandibular joint disc displacementJOURNAL OF ORAL REHABILITATION, Issue 4 2005F. TOGNINI summary, The aim of this work was to evaluate the accuracy and reliability of ultrasonography in the diagnosis of temporomandibular joint (TMJ) disc position abnormalities compared with magnetic resonance imaging (MRI). Participants in this study were 41 consecutive patients with signs and symptoms of temporomandibular disorders. All 82 TMJs were evaluated to detect disc position abnormalities by means of ultrasonography and MRI, performed by blinded operators. The accuracy of ultrasonography was evaluated with respect to MRI. Ultrasonography demonstrated good accuracy in the evaluation of disc position, showing a sensitivity of 65·8% and a specificity of 80·4%, resulting in a positive likelihood ratio of 3·35, a negative likelihood ratio of 0·42, and a diagnostic odds ratio of 7·97. The predictive positive and negatives values were respectively 77·1% and 70·2% and the overall agreement between the two radiological techniques was 73·1%. Ultrasonography proved to be accurate in detecting normal disc position and the presence of abnormalities in disc,condyle relationship but not so useful for the distinction between disc displacement with and without reduction. [source] The Patient Health Questionnaire 12 Somatic Symptom scale as a predictor of symptom severity and consulting behaviour in patients with irritable bowel syndrome and symptomatic diverticular diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2010R. C. Spiller Summary Background, Anxiety, depression and nongastrointestinal symptoms are often prominent in irritable bowel syndrome (IBS), but their relative value in patient management has not been quantitatively assessed. We modified the Patient Health Questionnaire 15 (PHQ-15) by excluding three gastrointestinal items to create the PHQ-12 Somatic Symptom (PHQ-12 SS) scale. Aims, To compare the value of the PHQ-12 SS scale with the Hospital Anxiety and Depression (HAD) scale in predicting symptoms and patient behaviour in IBS and diverticular disease. Methods, We compared 151 healthy volunteers (HV), 319 IBS patients and 296 patients with diverticular disease (DD), 113 asymptomatic [ASYMPDD] and 173 symptomatic DD (SYMPDD). Results, Patient Health Questionnaire 12 SS scores for IBS and SYMPDD were significantly higher than HV. Receiver,operator curves showed a PHQ-12 SS >6, gave a sensitivity for IBS of 66.4% with a specificity of 94.7% and a positive likelihood ratio (PLR) = 13.2, significantly better than that associated with an HAD anxiety score >7, PLR = 3.0 and depression score >7 PLR = 6.5. PHQ-12 SS correlated strongly with IBS severity scale and GP visits in both IBS and DD. Conclusion, The PHQ-12 SS scale is a useful clinical tool which correlates with patient behaviour in both IBS and symptomatic DD. [source] Preemptive treatment of fungal infection: has its time arrived in liver transplantation?LIVER TRANSPLANTATION, Issue 3 2008James D. Perkins M.D. Special Editor Background Invasive fungal infection remains a major challenge in liver transplantation and the mortality rate is high. Early diagnosis and treatment are required for better results. Patients We prospectively measured plasma (1 , 3),-d glucan (BDG) levels in 180 living donor liver transplant recipients for 1 year after surgery. Fungal infection was defined as proposed by the European Organization for Research and Treatment of Cancer/Mycoses Study Group. Preemptive treatment (intravenous fluconazole and trimethoprim-sulfamethoxazole) was started when the BDG level was greater than 40 pg/ml. Results Twenty-four patients (13%) were diagnosed with invasive fungal infection. The responsible pathogens included Candida spp. in 14 cases, Aspergillus fumigatus in 5, Cryptococcus neoformans in 3, and Pneumocystis jiroveci in 2. Preemptive treatment was performed in 22% of patients (n = 40). Renal impairment and mild gastrointestinal intolerance due to the drugs were observed in 28% (11/40) of patients during treatment. Among them 14 patients were diagnosed with fungal infection including seven candidiasis, five aspergillosis, and two Pneumocystis jiroveci pneumonia. The sensitivity and specificity of BDG for overall fungal infection was 58% and 83%, respectively, with a positive predictive value of 35% and a negative predictive value of 93%, and a positive likelihood ratio of 3.41 and a negative likelihood ratio of 1.98. The overall mortality for fungal infection in our series was 0.6%. Conclusion Although the sensitivity and positive predictive value were low, the low mortality rate after fungal infection and the mild side effects of the preemptive treatment might justify our therapeutic strategy. Based on the effectiveness, this strategy warrants further investigation. [source] Utility of pulse oximetry in the detection of arterial hypoxemia in liver transplant candidatesLIVER TRANSPLANTATION, Issue 4 2002Gary A. Abrams MD Assistant Professor of Medicine Hepatopulmonary syndrome, arterial hypoxemia caused by intrapulmonary vasodilatation, occurs in approximately 10% of patients with cirrhosis. The severity of hypoxemia affects liver transplant candidacy and is associated with increased morbidity and mortality posttransplantation. Screening guidelines for detecting the presence of arterial hypoxemia do not exist. The aim of this study is to investigate the accuracy and utility of pulse oximetry in the detection of hypoxemia (PaO2 < 70 mm Hg) in patients with cirrhosis. Two hundred prospective liver transplant candidates were compared with 94 controls. Arterial oxyhemoglobin saturation was obtained by pulse oximetry (SpO2) and compared with simultaneous arterial blood gas (ABG) oxyhemoglobin values (SaO2; bias = the difference). PaO2, carboxyhemoglobin, methemoglobin, and routine clinical and biochemical parameters were investigated to account for the bias. SpO2 overestimated SaO2 in 98% of patients with cirrhosis (mean bias, 3.37%; range, ,1% to 10%). Forty-four percent of patients with cirrhosis and controls had a bias of 4% or greater. No clinical or biochemical parameters of cirrhosis accounted for the overestimation of pulse oximetry. Twenty-five subjects with cirrhosis were hypoxemic, and an SpO2 of 97% or less showed a sensitivity of 96% and a positive likelihood ratio of 3.9 for detecting hypoxemia. An SpO2 of 94% or less detected all subjects with an arterial PaO2 less than 60 mm Hg. Pulse oximetry significantly overestimates arterial oxygenation, and the inaccuracy is not influenced by liver disease. Nevertheless, pulse oximetry can be a useful screening tool to detect arterial hypoxemia in patients with cirrhosis, but a higher threshold for obtaining an ABG must be used. [source] ORIGINAL ARTICLE: Endometrial Osteopontin mRNA Expression and Plasma Osteopontin Levels are Increased in Patients with EndometriosisAMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Issue 4 2009SiHyun Cho Problem, The aim of this study was to evaluate osteopontin (OPN) mRNA expression in eutopic endometrium and plasma OPN levels in patients with endometriosis. Method of study, A total of 79 patients with histologically confirmed endometriosis and 43 patients without endometriosis participated in this study. OPN mRNA expression in endometrial tissues was measured by real-time quantitative polymerase chain reaction (PCR) and plasma concentrations of OPN were quantified using a specific commercial sandwich enzyme-linked immunosorbent assays (ELISA). Results, Osteopontin mRNA expression in endometrial tissue was significantly higher in women with endometriosis than in controls (P = 0.010). The mean plasma levels of OPN (mean ± S.E.M.) in patients with endometriosis and controls were 407.31 ± 37.80 ng/mL and 165.84 ± 19.29 ng/mL, respectively (P < 0.001). Receiver operating characteristic (ROC) analysis for plasma OPN revealed an area under the curve (AUC) of 0.894, with a sensitivity of 93.0%, specificity of 72.4%, positive likelihood ratio of 3.37, and negative likelihood ratio of 0.1 using a cut-off value of 167.68 ng/mL. Conclusion, Osteopontin may be involved in the pathogenesis of endometriosis and plasma OPN may be a useful non-invasive marker for the diagnosis of endometriosis. [source] Perception Versus Reality?: Virtual Crossmatch,How to Overcome Some of the Technical and Logistic LimitationsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 8 2009A. R. Tambur The goal of this work was to evaluate concordance between (a) actual flow cytometric crossmatch (FCXM) that is performed by the OPO laboratory servicing our transplant center and (b) virtual XM (vXM) prediction based on antibody identification by solid-phase methods performed in our laboratory. A total of 1586 FCXM, performed between June 2007 and September 2008, between all potential deceased donors in our region and sera from patients awaiting kidney or kidney,pancreas transplant, listed at Northwestern Memorial Hospital were evaluated. A key finding of this analysis was the understanding that a thorough vXM cannot be performed in some donor/recipient pairs due to the lack of certain antibody profile data specific to the donor in question. Obtaining more in depth and stringent information regarding antibody specificities, we demonstrate an excellent sensitivity and specificity of the vXM assays, 86.1% and 96.8%, respectively, with a positive likelihood ratio and negative likelihood ratios of 26.9 and 0.14, respectively. The vXM can serve as an outstanding tool to predict HLA compatibility between donor and recipient, with the caveat that the presence/absence of all antibodies against the potential donor and their strength have been thoroughly investigated. [source] Self-administered Vaginal Swabs Are a Feasible Alternative to Physician-assisted Cervical Swabs for Sexually Transmitted Infection Screening in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 4 2009Nicole Berwald MD Abstract Background:, Screening for sexually transmitted infections (STIs) in the emergency department (ED) is limited by the need for pelvic examination. It has been suggested that using self-administered vaginal swabs (SAVS) for this purpose may save time and resources and may be more comfortable for patients. Objectives:, The objective was to test the feasibility of using SAVS for STI screening in the ED. Methods:, This was a prospective study of female ED patients 18 to 55 years old who consented to physician-assisted cervical swab (PACS) and SAVS in two urban teaching hospitals. The ED personnel offered the test to all patients, whether or not a pelvic examination was indicated, based on their chief complaint. All specimens were analyzed by polymerase chain reaction (PCR) assay. Data are presented as mean ± standard deviation (SD). Categorical data are presented as percentages with 95% confidence intervals (CIs). Patients with a positive test result for Chlamydia trachomatis and/or Neisseria gonorrhoeae were considered positive for STI. PACS were used as the criterion standard. Results:, One-hundred sixty-two subjects were enrolled from July 2006 to July 2007 (mean [±SD] age = 32 [±10] years). Eighty-one percent of patients had a genitourinary symptom (most common: vaginal bleeding/spotting). SAVS had a sensitivity of 91% (95% CI = 60% to 99%), specificity of 99% (95% CI = 95% to 99%), positive likelihood ratio of 91, and negative likelihood ratio of 0.09 in diagnosing STIs. None of the patients reported difficulty or discomfort using this technique. Conclusions:, Self-administered vaginal swabs can be utilized as a feasible alternative to PACS for STI screening in the ED. [source] Emergency Thoracic Ultrasound in the Differentiation of the Etiology of Shortness of Breath (ETUDES): Sonographic B-lines and N-terminal Pro-brain-type Natriuretic Peptide in Diagnosing Congestive Heart FailureACADEMIC EMERGENCY MEDICINE, Issue 3 2009Andrew S. Liteplo MD Abstract Objectives:, Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used. Methods:, This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). Results:, One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR,) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR, of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP. Conclusions:, Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED. [source] The diagnostic accuracy of external pelvimetry and maternal height to predict dystocia in nulliparous women: a study in CameroonBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 5 2007AT Rozenholc Objective, In many developing countries, most women deliver at home or in facilities without operative capability. Identification before labour of women at risk of dystocia and timely referral to a district hospital for delivery is one strategy to reduce maternal and perinatal mortality and morbidity. Our objective was to assess the prediction of dystocia by the combination of maternal height with external pelvimetry, and with foot length and symphysis-fundus height. Design, A prospective cohort study. Setting, Three maternity units in Yaoundé, Cameroon. Population, A total of 807 consecutive nulliparous women at term who completed a trial of labour and delivered a single fetus in vertex presentation. Methods, Anthropometric measurements were recorded at the antenatal visit by a researcher and concealed from the staff managing labour. After delivery, the accuracy of individual and combined measurements in the prediction of dystocia was analysed. Main outcome measures, Dystocia, defined as caesarean section for dystocia; vacuum or forceps delivery after a prolonged labour (>12 hours); or spontaneous delivery after a prolonged labour associated with intrapartum death. Results, Ninety-eight women (12.1%) had dystocia. The combination of a maternal height less than or equal to the 5th percentile or a transverse diagonal of the Michaelis sacral rhomboid area less than or equal to the 10th percentile resulted in a sensitivity of 53.1% (95% CI 42.7,63.2), a specificity of 92.0% (95% CI 89.7,93.9), a positive predictive value of 47.7% (95% CI 38.0,57.5) and a positive likelihood ratio of 6.6 (95% CI 4.8,9.0), with 13.5% of all women presumed to be at risk. Other combinations resulted in inferior prediction. Conclusion, The combination of the maternal height with the transverse diagonal of the Michaelis sacral rhomboid area could identify, before labour, more than half of the cases of dystocia in nulliparous women. [source] Combination of cervical interleukin-6 and -8, phosphorylated insulin-like growth factor-binding protein-1 and transvaginal cervical ultrasonography in assessment of the risk of preterm birthBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 8 2001Merja Kurkinen-Räty Objective To determine the value of combinations of cervical interleukin-6 (IL-6), cervical interleukin-8 (IL-8), the phosphorylated isoform of insulin-like growth-factor binding protein-1 (IGFBP-1), and cervical ultrasonography in the prediction of preterm birth. Design Prospective follow up. Setting Oulu University Hospital maternity clinic from February 1997 to July 1998. Population Women with singleton pregnancies (n= 77), referred from outpatient clinics at 22,32 weeks of gestation with symptoms (uterine contractions) or signs (cervical change) of threatened preterm birth. Symptomless women (n= 78) matched for gestational age, parity and maternal age at recruitment were studied as a reference group. Methods A urine sample for bacterial culture was collected, and cervical swab samples for assays of interleukin-6 and -8 and phoshorylated IGFBP-1 were taken before digital cervical examination. A Pap smear for analysis of bacterial vaginosis and samples for analysis of chlamydia and streptococci were also obtained. Cervical measurements were made by transvaginal ultrasonography. The same sampling and cervical measurement were repeated twice at two-week intervals. The cutoff values of the markers were determined by receiver-operating characteristic curve analysis. Main outcome measure Preterm birth (<37 weeks). Results The preterm birth (<37 weeks) rate for women in the study group was 16% (12/77). The cervical interleukin-6 cutoff value (61 ng/L) at first visit had a sensitivity of 73% and a specificity of 61% in predicting preterm birth, with a positive likelihood ratio (LR+) of 1.9 (95% CI 1.2,3.0). An ultrasonographically measured cervical index value of > 0.36 at recruitment predicted preterm birth in 25% (5/20) of the study group compared with 9% (5/54); LR+ 2.2 (95% CI 1.03,4.7). Cervical phosphorylated IGFBP-1 > 6.4,g/L [LR+ 1.8 (95% CI 0.7,2.9)], interleukin-8 > 3739 ng/L [LR+ 1.4 (95% CI 0.9,2.4)], and ultrasonograpic cervical length < 29.3 mm [LR+ 2.7 (95% CI 0.8,9.7)] increased the risk of preterm birth. According to the logistic regression model, a combination of IL-6, and IL-8 and cervical index increased the specificity to 97%, but the sensitivity fell to 30% in detecting preterm birth. There was a significantly increased incidence of puerperal infections if phosphorylated IGFBP-1 concentrations were elevated (> 21.0 ,g/L), 36% (4/11) compared with 4.6% (3/65), LR+ 6.7 (95% CI 2.7,17), the sensitivity being 67% (4/6) and the specificity 90% (63/70). Elevated phosphorylated IGFBP-1 concentrations (> 21.6,g/L) were also associated with an increased risk of neonatal infections; LR+ 8.0 (95% CI 3.5,18). Conclusions An increase in cervical IL-6 concentration and the ultrasonographically measured cervical index appear to be associated with preterm birth. A combination of these markers with measurement of cervical IL-8 appears to be the best predictor of preterm birth. Neither the sensitivity nor specificity of the tests used in this study are good enough to predict preterm birth for clinical decision making. Cervical phosphorylated IGFBP-1 seems to be a marker of puerperal and neonatal infectious morbidity in cases of threatened preterm delivery, suggesting early tissue degradation at the choriodecidual interface. [source] Free Fluid in Morison's Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic PregnancyACADEMIC EMERGENCY MEDICINE, Issue 8 2007Chris Moore MD BackgroundEctopic pregnancies are frequently present in women who present to the emergency department with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention. ObjectivesTo prospectively determine if emergency physician (EP)-performed transabdominal pelvic ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the need for operative intervention. MethodsPatients who were suspected to have an ectopic pregnancy were prospectively enrolled over a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the hepatorenal space (Morison's pouch) for free fluid. The EP US was classified as intrauterine pregnancy (IUP) or no definitive IUP, with Morison's pouch classified as positive or negative. The majority of patients had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients were followed up for radiology results, need for operative intervention, and ultimate outcome of the pregnancy. ResultsThere were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27 seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative intervention. Free fluid in Morison's pouch was identified in ten patients, nine of whom underwent operative intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for patients with suspected ectopic pregnancy who required operative intervention. ConclusionsFree intraperitoneal fluid found in Morison's pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by EP-performed US and predicts the need for operative intervention. [source] Utility of diagnostic tests in the follow-up of egg-allergic childrenCLINICAL & EXPERIMENTAL ALLERGY, Issue 10 2009Ma C. Diéguez Summary Background Better knowledge of the accuracy of a skin prick test (SPT) and specific IgE (sIgE) levels to egg allergens would help to identify persistent egg-allergic children, avoiding unnecessary risky challenges. This study was designed to assess the accuracy of a SPT and sIgE levels to egg allergens in order to determine persistent egg allergy in IgE-mediated allergic children after an egg-free diet. Methods Children below 16 years were prospectively and consecutively recruited. Inclusion criteria were: allergy to egg proteins (children with a positive clinical case of IgE-mediated egg allergy and a positive SPT to egg allergens and/or positive sIgE levels), and strict egg avoidance diet followed for at least 6 months. Clinical histories were recorded and all patients underwent SPTs, sIgE levels to egg allergens and the gold standard -a double-blind placebo-controlled egg challenge (DBPCFG). DBPCFG was interpreted without knowledge of the results of the other tests and vice-versa. A SPT and sIgE levels' ROC curves analysis was performed to compare the diagnostic performance of the different tests. Results Finally, 157 children were included in the study. One hundred out of these 157 children (63.7%) had a positive oral challenge. Ninety-six were male (61%), and the median age was 2.5 years. One hundred and three (66.9%) had atopic dermatitis. A 7 mm egg white prick test had a positive likelihood ratio (+LR) of 6.7, and a level of 1.3 KU/L egg white-sIgE had a +LR of 5.1. A 7 mm egg white SPT had a positive predictive value of 92.3% (95% CI 85.1,99.5), and for a 9 mm egg white SPT this value was 95.6% (95% CI 87.3,100.0). For egg white-sIgE, 1.5 KU/L had a positive predictive value of 90.4% (95% CI 82.4,98.4) and for 25 KU/L it was 100.0% (95% CI 100.0,100.0). SPTs with ovotransferrin and lysozyme showed the lowest accuracy, followed by yolk and ovalbumin SPTs. Conclusion This study is the first to evaluate both tests (SPT and sIgE levels) and all egg allergens to determine the persistence of egg allergy in IgE-mediated allergic children. Measuring the SPT and sIgE levels is useful to predict persistent allergy in these children, especially with the egg white complete extract. An oral challenge should not be performed in egg allergic paediatric patients with either an egg white prick test above 7 mm or a white egg-sIgE determination above 1.3 KU/L, because there is a 90% probability of remaining allergic. [source] Comparison of simple tests for the non-invasive diagnosis of clinically silent cirrhosis in chronic hepatitis CALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 5 2006G. BORRONI Summary Background Biopsy is the gold standard for assessing cirrhosis in patients with chronic hepatitis C virus infection, but it is expensive and at risk of complications. Alternative non-invasive methods have been developed but their usefulness remains uncertain. Aim To compare the accuracy of five non-invasive scores in detecting cirrhosis. Methods We reviewed the charts and liver biopsies of 228 consecutive, treatment-naïve, hepatitis C virus-positive patients, 13.2% of whom with histological diagnosis of cirrhosis. The five alternative scores were age-platelet index, cirrhosis discriminant score, aspartate transaminases to platelet ratio index, Pohl's index, and aspartate transaminases/alanine transaminases ratio. Results The specificities of the scores were good (87,100%), but not so their sensitivities (17,67%). Accordingly positive likelihood ratios were generally good but negative likelihood ratios were suboptimal. Combinations of the scores independently related to cirrhosis only slightly change this diagnostic accuracy. Using double cut-offs to exclude/diagnoses cirrhosis, cirrhosis discriminant score classified 21% of patients without misdiagnoses and aspartate transaminases to platelet ratio index classified 85% of case with 9% of misdiagnoses. Conclusions The five scores showed variable sensitivities and specificities in detecting liver cirrhosis, both individually and in combination. The use of double cut-off points may make the cirrhosis discriminant score and aspartate transaminases to platelet ratio index useful to reduce the number of patients submitted to liver biopsy. [source] Incremental Benefit of 80-Lead Electrocardiogram Body Surface Mapping Over the 12-Lead Electrocardiogram in the Detection of Acute Coronary Syndromes in Patients Without ST-elevation Myocardial Infarction: Results from the Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT MI) TrialACADEMIC EMERGENCY MEDICINE, Issue 9 2010Brian J. O'Neil MD ACADEMIC EMERGENCY MEDICINE 2010; 17:932,939 © 2010 by the Society for Academic Emergency Medicine Abstract Background:, The initial 12-lead (12L) electrocardiogram (ECG) has low sensitivity to detect myocardial infarction (MI) and acute coronary syndromes (ACS) in the emergency department (ED). Yet, early therapies in these patients have been shown to improve outcomes. Objectives:, The Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT-MI) trial was a multicenter trial comparing a novel 80-lead mapping system (80L) to standard 12L ECG in patients with chest pain and presumed ACS. This secondary analysis analyzed the incremental value of the 80L over the 12L in the detection of high-risk ECG abnormalities (ST-segment elevation or ST depression) in patients with MI and ACS, after eliminating all patients diagnosed with ST-elevation MI (STEMI) by 12L ECG. Methods:, Chest pain patients presenting to one of 12 academic EDs were diagnosed and treated according to the standard care of that site and its clinicians; the clinicians were blinded to 80L results. MI was defined by discharge diagnosis of non,ST-elevation MI (NSTEMI) or unstable angina (UA) with an elevated troponin. ACS was defined as discharge diagnosis of NSTEMI or UA with at least one positive test result (troponin, stress test, angiogram) or revascularization procedure. Results:, Of the 1,830 patients enrolled in the trial, 91 patients with physician-diagnosed STEMI and 225 patients with missing 80L or 12L data were eliminated from the analysis; no discharge diagnosis was available for one additional patient. Of the remaining 1,513 patients, 408 had ACS, 206 had MI, and one had missing status. The sensitivity of the 80L was significantly higher than that of the 12L for detecting MI (19.4% vs. 10.4%, p = 0.0014) and ACS (12.3% vs. 7.1%, p = 0.0025). Specificities remained high for both tests, but were somewhat lower for 80L than for 12L for detecting both MI and ACS. Negative and positive likelihood ratios (LR) were not statistically different between groups. In patients with severe disease (defined by stenosis > 70% at catheterization, percutaneous coronary intervention, coronary artery bypass graft, or death from any cause), the 80L had significantly higher sensitivity for detecting MI (with equivalent specificity), but not ACS. Conclusions: Among patients without ST elevation on the 12L ECG, the 80L body surface mapping technology detects more patients with MI or ACS than the 12L, while maintaining a high degree of specificity. [source] Clinical Predictors of Occult Pneumonia in the Febrile ChildACADEMIC EMERGENCY MEDICINE, Issue 3 2007Charles G. Murphy MD Background: The utility of chest radiographs (CXRs) for detecting occult pneumonia (OP) among pediatric patients without lower respiratory tract signs has been previously studied, but no predictors other than white blood cell count (WBC) and height of fever have been investigated. Objectives: To identify predictors of OP in pediatric patients in the postconjugate pneumococcal vaccination era. Methods: This was a retrospective cross sectional study that was conducted in a large urban pediatric hospital. Physician records of emergency department (ED) patients of age 10 years or less who presented with fever (,38°C) and had a CXR obtained for suspected pneumonia were reviewed. Patients were classified into two groups: "signs of pneumonia" and "no signs of pneumonia" on the basis of the presence or absence of respiratory distress, tachypnea, or lower respiratory tract findings. Occult pneumonia was defined as radiographic pneumonia in a patient without signs of pneumonia. Results: Two thousand one hundred twenty-eight patients were studied. Among patients categorized as having no signs of pneumonia (n = 1,084), 5.3% (95% CI = 4.0% to 6.8%) had OP. Presence of cough and longer duration of cough (greater than 10 days) had positive likelihood ratios (LR+) of 1.24 (95% CI = 1.15 to 1.33) and 2.25 (95% CI = 1.21 to 4.20), respectively. Absence of cough had a negative likelihood ratio (LR,) of 0.19 (95% CI = 0.05 to 0.75). The likelihood of OP increased with increasing duration of fever (LR+ for more than three days and more than five days of fever, respectively: 1.62; 95% CI = 1.13 to 2.31 and 2.24; 95% CI = 1.35 to 3.71). When obtained (56% of patients), WBC was a predictor of OP, with a LR+ of 1.76 (95% CI = 1.40 to 2.22) and 2.17 (95% CI = 1.58 to 2.96) for WBC of >15,000/mm3 and >20,000/mm3, respectively. Conclusions: Occult pneumonia was found in 5.3% of patients with fever and no lower respiratory tract findings, tachypnea, or respiratory distress. There is limited utility in obtaining a CXR in febrile children without cough. The likelihood of pneumonia increased with longer duration of cough or fever or in the presence of leukocytosis. [source] Rose Bengal test: diagnostic yield and use for the rapid diagnosis of human brucellosis in emergency departments in endemic areasCLINICAL MICROBIOLOGY AND INFECTION, Issue 3 2005J. D. Ruiz-Mesa Abstract The aim of the present study was to analyse the diagnostic yield of the rose Bengal test for the rapid diagnosis of human brucellosis in an emergency department in an area where the disease is endemic. The study included 711 patients diagnosed initially with brucellosis and 270 controls. Brucellosis patients were divided into three groups: group I, individuals with no regular exposure to or history of brucellosis; group II, individuals exposed repeatedly to Brucella infection; and group III, individuals infected with Brucella who had received appropriate treatment during the previous 12 months. Blood cultures were positive for 445 (62.6%) brucellosis patients, while the remaining 266 (37.4%) patients were diagnosed according to clinical and serological criteria. The overall sensitivity of the rose Bengal test was 92.9%. The specificities for groups I, II and III were 94.3%, 91.7% and 76.9%, respectively, with positive likelihood ratios of 16.5, 10.4 and 4.2, respectively. The diagnostic gain after the performance of the rose Bengal test was good or very good in patients with no previous exposure to Brucella or history of brucellosis, but poor in patients who were exposed repeatedly to Brucella or had a history of brucellosis and a low pre-test probability. Use of the rose Bengal test as the sole technique for the diagnosis of brucellosis in endemic areas should be considered very carefully in the context of patients who are exposed repeatedly to Brucella or have a history of brucellosis. [source] | ||||||||||