Ruling a diagnosis in or out with “SpPIn” and “SnNOut”: a note of caution

Pewsner, Daniel; Battaglia, Milva; Minder, Christoph E.; Marx, Arthur; Bucher, Heiner C.; Egger, Matthias

doi:10.1136/bmj.329.7459.209

Cited by 154 publications

(129 citation statements)

References 20 publications

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“…First, the study population consisted of new presenters with symptoms of pain and/or stiffness of the hip/and or knee. Therefore, the results of the present study can only be extrapolated to comparable populations with early symptomatic hip and/or knee OA (4,20). The ACR classification criteria for hip OA (1) and the EULAR recommendations for the diagnosis of knee OA (7) are intended to identify patients with OA and to separate them from patients with other diseases.…”

Section: Discussionmentioning

confidence: 99%

“…Test sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio for a positive test (LRϩ), likelihood ratio for a negative test (LRϪ), pretest probability, posttest probability of a positive test, posttest probability of a negative test, and the area under the receiver operating characteristic curve (AUC) were calculated (19,20) (Table 2). The AUC was nonparametrically estimated (21).…”

Section: Holla Et Almentioning

confidence: 99%

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Diagnostic accuracy of range of motion measurements in early symptomatic hip and/or knee osteoarthritis

Holla¹,

Leeden²,

Roorda³

et al. 2011

Arthritis Care & Research

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Objective. To examine the diagnostic accuracy of hip internal rotation, hip flexion, and knee flexion measurements for the presence of osteophytosis and joint space narrowing (JSN) in early symptomatic osteoarthritis (OA). Methods. The baseline data for 598 participants of the Cohort Hip & Cohort Knee study were used. Participants underwent a standardized physical and radiographic examination. The active range of motion (ROM) was assessed using a goniometer. The ROM cutoff with the highest discriminative ability for radiographic features of OA was defined by maximizing the sum of the sensitivity and specificity. Several diagnostic measures were calculated to establish the diagnostic accuracy of ROM measurements for the presence of radiographic features. Results. In patients with hip symptoms, hip internal rotation <24°and flexion <114°were found to be the cutoffs with the highest discriminative ability to distinguish between patients with and without radiographic features. In patients with knee symptoms, knee flexion <132°was the cutoff with the highest discriminative ability. The American College of Rheumatology (ACR) criterion of hip internal rotation <15°increased the probability of the presence of osteophytosis or JSN from 25% to 58%. The diagnostic accuracy of hip and knee flexion measurements was low. Conclusion. To reduce the number of patients that are not identified by the ACR criterion of hip internal rotation <15°, it is recommended to change the cutoff to internal rotation <24°in patients with early symptomatic OA. Individual hip and knee flexion measurements seem to be of little diagnostic value in early symptomatic OA.

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Section: Discussionmentioning

confidence: 99%

Section: Holla Et Almentioning

confidence: 99%

Diagnostic accuracy of range of motion measurements in early symptomatic hip and/or knee osteoarthritis

Holla¹,

Leeden²,

Roorda³

et al. 2011

Arthritis Care & Research

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“…Other than some of the technical issues that have been discussed, there remain several issues that can alter the sensitivity and specificity of prediction tools. The effect of the spectrum of the disease tested can have a significant effect on the characteristics of the performance of a diagnostic test (19)(20)(21).…”

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confidence: 99%

Angina pectoris: Has the cornerstone of symptomatic coronary artery disease been moved?

Hessian

2007

Canadian Journal of Cardiology

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But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned more at length. The seat of it and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pectoris. They who are afflicted with it are seized while they are walking (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still this uneasiness vanishes.William Heberden 1768 (1-3)A classical history of angina pectoris has long been considered to be a symptom of myocardial ischemia and, as such, a predictor of the presence of significant coronary artery disease. The work by Høilund-Carlsen et al (pages 641-647 of the current issue of the Journal) challenges this cornerstone of care.This work provides an interesting window into the correlation of clinical history with the presence of angiographic disease. This study was a substudy of a larger prospective study that looked at myocardial perfusion scintigraphy (MPS) as a gatekeeper for coronary angiography (CA) in patients referred for angiography with angina pectoris and possible coronary artery disease.The data collected for this study are unique. At the time of the study, MPS was not a routine part of the work-up of patients with suspected coronary artery disease in Denmark. The patients were isolated on the island of Funen. Patients were sent directly for angiography from local general practitioners or through local hospitals. Before angiography, they received MPS, and only after the angiogram were the results available to the investigator or clinician. This local practice variation enabled a comparison of MPS with CA in a group of patients who would not normally be selected for angiography based on the results of the MPS study, thus eliminating the effect of 'referral' or 'work-up' bias on the correlation of MPS and CA. Work-up bias has been examined in the literature, and the overall effect is that a greater number of angiograms are performed in patients with abnormal scans. This increases the sensitivity and reduces the specificity of the test being evaluated -in this case, the MPS (4,5).This study has a number of companion publications (6-8); the purpose of the original study was to compare patient findings on MPS with those found on CA. In this population, the overall sensitivity of MPS was found to be 75% and the specificity was 79% (8). At publication, these results were attributed to the absence of a referral or work-up bias.The focus of the current publication was the correlation of clinical features to the angiogram. Three clinical assessment scales were used to classify patients undergoing angiography. The subgroups of patients who were thought to have a high probability of disease were then segregated, and the correlation to significant angiographic cor...

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“…A negative result from a highly sensitive screening test will rule out COPD because the test produces very few false-negatives (a commonly used mnemonic is "SNout": a test with high SN, when negative, rules disease out). 8 On the other hand, a positive result from a highly specific screening test will rule in COPD because the test produces very few false-positives ("SPin": SP, when positives, rules in). 8 For COPD screening, high SN is probably more important than high SP.…”

mentioning

confidence: 99%

“…8 On the other hand, a positive result from a highly specific screening test will rule in COPD because the test produces very few false-positives ("SPin": SP, when positives, rules in). 8 For COPD screening, high SN is probably more important than high SP. We want to miss as few patients with COPD as possible, at the expense of diagnosing more patients "at risk" of COPD who in fact are healthy.…”

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confidence: 99%

Interpreting the diagnostic accuracy of tools for early detection of COPD

Kotz

Schayck

2011

Primary Care Respiratory Journal

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There has been increasing interest in recent years in developing and testing strategies for early detection of chronic obstructive pulmonary disease (COPD) in primary care. Proponents of early detection argue that COPD is underdiagnosed and should be detected early because of its irreversible and progressive nature.1 Opponents, on the other hand, argue that early detection primarily yields subjects with mild to moderate airflow limitation and that medical services do not have the capacity to provide care for patients with borderline abnormal spirometry.2 In this issue of the PCRJ, two studies present findings on a potential new tool for early detection of COPD -the PiKo-6 ® expiratory flow meter (or 'mini-spirometer') -and compare this with an existing strategy -a COPD diagnostic questionnaire. 3,4The PiKo-6 ® (nSpire Health Inc.) is a relatively new and simple screening device that measures the forced expiratory volume in one and six seconds (FEV1 and FEV6, respectively) and the FEV1/FEV6 ratio. The device provides audio-visual feedback on the duration and quality of the exhalation manoeuvre and shows results immediately on a small display. Subjects below a certain threshold of FEV1/FEV6 (e.g., <0.70 pre-or post-bronchodilator) are considered "at risk" of COPD.An international group of primary care specialists developed a COPD diagnostic questionnaire which has been implemented by the International Primary Care Airways Group (this questionnaire is further referred to as the "IPAG questionnaire" throughout this text). 5,6 The questionnaire comprises eight items and its scoring system permits the calculation of an overall COPD risk score ranging from 0 -38 points. Subjects with more than 16.5 points are considered "at risk" of COPD. 6In the two studies from Sichletidis et al. 3 and Frith et al. 4 , the diagnostic accuracy of the IPAG questionnaire and the PiKo-6 ® were tested against the "gold standard" -i.e., spirometry according to ATS/ERS guidelines, with post-bronchodilator FEV1/forced vital capacity (FVC) <0.70 defining COPD. 7In the first study, Sichletidis et al. screened 1,078 current, former and never-smoking patients aged older than 40 years without prior diagnosis of COPD, 49% of whom were current smokers. 3 The prevalence of COPD was 10% (of which 84% was mild-to-moderate disease). For patients with PiKo-6 ® post-bronchodilator FEV1/FEV6< 0.70, sensitivity (SN) and specificity (SP) were SN=80% and SP=95%. For patients with IPAG >16.5 points, these measures were SN=91% and SP=49%.In the second study, Frith et al. screened 204 current and former smoking patients aged 50 or older without prior diagnosis of COPD, 45% of whom were current smokers. 4 The prevalence of COPD was 28% (of which 95% was mild-to-moderate COPD). For patients with PiKo-6 ® pre-bronchodilator FEV1/FEV6< 0.75, the diagnostic accuracy measures were SN=81% and SP=71%. For patients with IPAG > 16.5 points, these measures were SN=91% and SP=37%.How can we interpret these different measures of diagnostic accuracy? Most diagnostic tes...

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Ruling a diagnosis in or out with “SpPIn” and “SnNOut”: a note of caution

Cited by 154 publications

References 20 publications

Diagnostic accuracy of range of motion measurements in early symptomatic hip and/or knee osteoarthritis

Diagnostic accuracy of range of motion measurements in early symptomatic hip and/or knee osteoarthritis

Angina pectoris: Has the cornerstone of symptomatic coronary artery disease been moved?

Interpreting the diagnostic accuracy of tools for early detection of COPD

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