Methodologic Standards for the Development of Clinical Decision Rules in Emergency Medicine

Stiell, Ian G.; Wells, George A.

doi:10.1016/s0196-0644(99)70309-4

Cited by 515 publications

(511 citation statements)

References 70 publications

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“…We believe that having as an outcome the presence of or recently healed ulcer (without definition) could introduce selection as well as information bias, due to the absence of blinding to presence of the condition. In addition, there are concerns about adequacy of sample size (taking in consideration the reported appropriated number of subjects for each predictive variable's detection) [27]. This study assessed, in univariate analysis, the association between 27 different variables and ulceration in a sample of 213 participants [18].…”

Section: Discussionmentioning

confidence: 99%

Risk stratification systems for diabetic foot ulcers: a systematic review

et al. 2011

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Aims/hypothesis Several risk stratification systems have been proposed for predicting development of diabetic foot ulcer. However, little has been published that assesses their similarities and disparities, diagnostic accuracy and evidence level. Consequently, we conducted a systematic review of the existing stratification systems. Methods We searched the MEDLINE database for studies (published until April 2010) describing the creation and validation of risk stratification systems for prediction of diabetic foot ulcer development. Results We included 13 studies describing or evaluating the following different risk degree stratification systems: University of Texas; International Working Group on Diabetic Foot; Scottish Intercollegiate Guideline Network (SIGN); American Diabetes Association; and Boyko and colleagues. We confirmed that five variables were included in almost all the systems: diabetic neuropathy, peripheral vascular disease, foot deformity, and previous foot ulcer and amputation. The number of variables included ranged from four to eight and the number of risk groups from two to six. Only four studies reported or allowed the calculation of diagnostic accuracy measures. The SIGN system showed some higher diagnostic accuracy values, particularly positive likelihood ratio, while predictive ability was confirmed through external validation only in the system of Boyko et al. Conclusions/interpretation Foot ulcer risk stratification systems are a much needed tool for screening patients with diabetes. The core variables of various systems are very similar, but the number of included variables in each model and risk groups varied greatly. Overall, the quality of evidence for these systems is low, as little validation of their predictive ability has been done.

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Section: Discussionmentioning

confidence: 99%

Risk stratification systems for diabetic foot ulcers: a systematic review

et al. 2011

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“…Sin embargo, el desarrollo de reglas de decisión clínica a partir de estos resultados requiere validarlos en una nueva población de pacientes, determinando su reproducibilidad y evaluando su aceptación por parte de los profesionales de la salud y el potencial efecto de esta escala de puntuación sobre la práctica médica (21,29).…”

Section: Discussionunclassified

Criterios clínicos para diagnosticar el dengue en los primeros días de enfermedad.

Díaz¹,

Martínez²,

Villar³

2006

biomedica

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Introducción. La definición de caso de dengue de la Organización Mundial de la Salud (OMS) tiene alta sensibilidad, pero es muy inespecífica. Objetivo. Formular una escala diagnóstica de mayor exactitud que la definición de la OMS para la identificación clínica temprana del dengue en áreas endémicas. Materiales y métodos. En una cohorte de adultos (>12 años) con síndrome febril agudo sin causa aparente en Bucaramanga, Colombia, compuesta por 125 casos de dengue (confirmados serológica o virológicamente) y 126 de síndrome febril de otra etiología, se determinaron las manifestaciones clínicas tempranas (en los primeros cuatro días de la enfermedad) asociadas al dengue y con ellas se formularon y evaluaron diversas combinaciones diagnósticas. Resultados. La escala compuesta por exantema, prueba de torniquete positiva, ausencia de rinorrea, artralgias, ausencia de diarrea (1 punto por cada hallazgo), recuentos de leucocitos <4.000/mm 3 (3 puntos) y plaquetas <180.000/mm 3 (2 puntos) exhibió un área bajo la curva de características operador-receptor de 81,04%, superior a la observada con los criterios de la OMS de 69,96% (p=0,0003). Con ≥3 puntos se obtuvo una sensibilidad de 95,2%; una especificidad de 27,8%; un valor diagnóstico positivo de 56,7%; un valor diagnóstico negativo de 85,4%. Con ≥6 puntos se obtuvo una sensibilidad de 70,4%; una especificidad de 78,6%; un valor diagnóstico positivo de 76,5%; un valor diagnóstico negativo de 72,8%. Con ≥8 puntos se obtuvo una sensibilidad de 42,4%; una especificidad de 96%; un valor diagnóstico positivo de 91,4%; un valor diagnóstico negativo de 62,7%. Con 9 o 10 puntos, la especificidad y el valor diagnóstico positivo fueron de 100%. Conclusión. La escala descrita puede ser útil para el diagnóstico clínico temprano del dengue en áreas endémicas.Palabras clave: dengue, diagnóstico clínico, Organización Mundial de la Salud, recuento de leucocitos, recuento de plaquetas. Clinical criteria to diagnose dengue in its early stagesIntroduction. Clinical differentiation of dengue from other diseases with similar symptoms is difficult. The case definition of the World Health Organization (WHO) has high sensitivity but its specificity is very low. Objective. A diagnostic scale was formulated for early clinical diagnosis of dengue that provided greater accuracy than that of the WHO definition. Materials and methods. A cohort of 251 adults (>12 years of age) with unspecific acute febrile syndrome was selected from clinics located in Bucaramanga, Colombia. They consisted of 125 cases of dengue (serologically and/or virologically confirmed) and 126 with other febrile diseases. Clinical manifestations encountered during the first four days of dengue disease were determined, along with the diverse diagnostic combinations that were presented. Results: The scale consisted of the following criteria: presence of rash, positive tourniquet test, absence of nasal discharge, arthralgias, absence of diarrhea (1 point for each finding), leukocyte count < 4,000/mm3 (3 points) and platelet count <1...

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“…22,23 Data analysis was performed using SAS, version 9.3, and a webbased statistical program for creating decision rules (www.wessa.net). Initial univariate and multivariate analysis of the data was performed on the entire data set (n = 605).…”

Section: Resultsmentioning

confidence: 99%

The Massachusetts Abscess Rule: A Clinical Decision Rule Using Ultrasound to Identify Methicillin-resistantStaphylococcus aureusin Skin Abscesses

et al. 2014

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Objectives: Treatment failure rates for incision and drainage (I&D) of skin abscesses have increased in recent years and may be attributable to an increased prevalence of community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA). Previous authors have described sonographic features of abscesses, such as the presence of interstitial fluid, characteristics of abscess debris, and depth of abscess cavity. It is possible that the sonographic features are associated with MRSA and can be used to predict the presence of MRSA. The authors describe a potential clinical decision rule (CDR) using sonographic images to predict the presence of CA-MRSA.Methods: This was a pilot CDR derivation study using databases from two emergency departments (EDs) of patients presenting to the ED with uncomplicated skin abscesses who underwent I&D and culture of the abscess contents. Patients underwent ultrasound (US) imaging of the abscesses prior to I&D. Abscess contents were sent for culture and sensitivity. Two independent physicians experienced in soft tissue US blinded to the culture results and clinical data reviewed the images in a standardized fashion for the presence or absence of the predetermined image characteristics. In the instance of a disagreement between the initial two investigators, a third reviewer adjudicated the findings prior to analysis. The association between the primary outcome (presence of MRSA) and each sonographic feature was assessed using univariate and multivariate analysis. The reliability of each sonographic feature was measured by calculating the kappa (j) coefficient of interobserver agreement. The decision tree model for the CDR was created with recursive partitioning using variables that were both reliable and strongly associated with MRSA.Results: Of the total of 2,167 patients who presented with skin and soft tissue infections during the study period, 605 patients met inclusion criteria with US imaging and culture and sensitivity of purulence. Among the pathogenic organisms, MRSA was the most frequently isolated, representing 50.1% of all patients. Six of the sonographic features were associated with the presence of MRSA, but only four of these features were reliable using the kappa analysis. Recursive partitioning identified three independent variables that were both associated with MRSA and reliable: 1) the lack of a well-defined edge, 2) small volume, and 3) irregular or indistinct shape. This decision rule demonstrates a sensitivity of 89.2% (95% confidence interval [CI] = 84.7% to 92.7%), a specificity of 44.7% (95% CI = 40.9% to 47.8%), a positive predictive value of 57.9 (95% CI = 55.0 to 60.2), a negative predictive value of 82.9 (95% CI = 75.9 to 88.5), and an odds ratio (OR) of 7.0 (95% CI = 4.0 to 12.2).Conclusions: According to our putative CDR, patients with skin abscesses that are small, irregularly shaped, or indistinct, with ill-defined edges, are seven times more likely to demonstrate MRSA on culture.ACADEMIC EMERGENCY MEDICINE 2014;21:558-567

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Methodologic Standards for the Development of Clinical Decision Rules in Emergency Medicine

Cited by 515 publications

References 70 publications

Risk stratification systems for diabetic foot ulcers: a systematic review

Risk stratification systems for diabetic foot ulcers: a systematic review

Criterios clínicos para diagnosticar el dengue en los primeros días de enfermedad.

The Massachusetts Abscess Rule: A Clinical Decision Rule Using Ultrasound to Identify Methicillin-resistantStaphylococcus aureusin Skin Abscesses

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