Diagnostic accuracy of X-ray versus CT in COVID-19: a propensity-matched database study

Objectives: To identify the diagnostic accuracy of common imaging modalities, chest X-ray (CXR) and CT, for diagnosis of COVID-19 in the general emergency population in the UK and to find the association between imaging features and outcomes in these patients. Design: Retrospective analysis of electronic patient records. Setting Tertiary: academic health science centre and designated centre for high consequence infectious diseases in London, UK. Participants 1198 patients who attended the emergency department with paired reverse transcriptase PCR (RT-PCR) swabs for SARS-CoV-2 and CXR between 16 March and 16 April 2020. Main outcome measures: Sensitivity and specificity of CXR and CT for diagnosis of COVID-19 using the British Society of Thoracic Imaging reporting templates. Reference standard was any RT-PCR positive naso-oropharyngeal swab within 30 days of attendance. ORs of CXR in association with vital signs, laboratory values and 30-day outcomes were calculated. Results: Sensitivity and specificity of CXR for COVID-19 diagnosis were 0.56 (95% CI 0.51 to 0.60) and 0.60 (95% CI 0.54 to 0.65), respectively. For CT scans, these were 0.85 (95% CI 0.79 to 0.90) and 0.50 (95% CI 0.41 to 0.60), respectively. This gave a statistically significant mean increase in sensitivity with CT of 29% (95% CI 19% to 38%, p<0.0001) compared with CXR. Specificity was not significantly different between the two modalities. CXR findings: were not statistically significantly or clinically meaningfully associated with vital signs, laboratory parameters or 30-day outcomes. Conclusions: Computed tomography has substantially improved diagnostic performance over CXR in COVID-19. CT should be considered in the initial assessment for suspected COVID-19 instead of CXR if capacity allows and balanced against radiation exposure risk

Patterns of comorbidity and psychopharmacology in adults with intellectual disability and attention deficit hyperactivity disorder: an UK national cross-sectional audit.

Background: Attention-deficit hyperactivity disorder (ADHD) is higher in people with intellectual disability (ID) compared to the general population. Available limited evidence suggests this population has increased psychological problems, diagnostic overshadowing and psychotropic prescribing. This audit Identifies and analyzes real-world characteristics, diagnostic practices, treatment, and management of ADHD in adults with ID.Research Design and Methods: Pooled retrospective case note data for people with ID and ADHD, collected from 30 organizations across the UK, were analyzed. Patients were classified into mild and moderate-profound ID groups. Associated mental health and neurodevelopmental co-morbidity, Demographics, concomitant psychotropics, and mental and behavioral concerns were collected. Group differences were reported using logistic regression models.Results: Of 445 participants, 73% had co-occurring autism spectrum disorder (ASD) and 65% were prescribed ADHD medications. Those on ADHD medication were less likely to be prescribed antipsychotics (p < 0.001) and antidepressants (p < 0.001). Multiple significant differences were found in ADHD medication response between ID groups and those with/without co-morbid ASD but not associated with challenging behavior reduction.Conclusions: High levels of neurodevelopmental and psychiatric comorbidity were found. ID severity and the presence of ASD appear to influence the use of certain psychotropic medications. Appropriate use of ADHD medication appears to reduce psychotropic polypharmacy

Diagnosis of Attention Deficit Hyperactivity Disorder in Intellectual Disability:Diagnostic and Statistical Manual of Mental Disorder V versus clinical impression

BACKGROUND: Diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in people with intellectual disability (ID) remains challenging. The Diagnostic and Statistical Manual of Mental Disorder V (DSM V) classification system is often used to diagnose ADHD in the general population; however, the presence of ID and other associated conditions such as autism and communication difficulties can make it difficult to apply the DSM V criteria in people with ID. Therefore, diagnosing ADHD in people with ID is often made using clinical judgement and/or the application of diagnostic criteria. There are no studies comparing the diagnostic accuracy of clinical judgement and the use of DSM V criteria in people with ID and ADHD. METHOD: The aims of the study were to compare the accuracy of the diagnosis of ADHD in people with ID according to the DSM V criteria versus clinical judgement and to determine which criteria are more reliable. A questionnaire was developed using five fictional case scenarios of people with ID. Questionnaires were presented to practising psychiatrists chosen as a convenience sample in the United Kingdom over a period of 12 months. Case scenarios were developed and agreed to be positive or negative for ADHD by the study authors prior to rating by clinicians. The clinicians were asked to read the scenarios and to make a judgement on the cases regarding the symptoms of ADHD. They were then presented with the 18 DSM V criteria of ADHD and asked to select the criteria they considered were present in each scenario. Sensitivity, specificity, likelihood ratios and predictive values for both the DSM V criteria and clinical opinions were calculated for correctly identifying the exemplar cases. RESULTS: The data showed strong sensitivity [0.82 95% confidence interval (CI) 0.74-0.89] and high specificity (1.00 95% CI 0.95-1.00) for the raters' clinical opinion. In contrast, the DSM V criteria alone, as assessed by the raters, did not reliably provide ADHD diagnoses, with a sensitivity of only 0.23 (95% CI 0.15-0.31). This difference in sensitivity between the two was statistically significant at P < 0.001. CONCLUSION: The study results suggest that clinical opinion is the 'gold standard' at present in diagnosing ADHD in adults with ID in the absence of a validated diagnostic tool in this group. Further studies are needed to understand how symptoms of ADHD can be presented differently in people with ID. DSM V criteria for ADHD may need to be adapted according to the severity of ID and other neurodevelopmental disorders

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Background: Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods: All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results: A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion: Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions

The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by CT imaging : a systematic review and meta-analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Recognising contributions to work in research collaboratives: Guidelines for standardising reporting of authorship in collaborative research

Background Trainee research collaboratives (TRCs) have been revolutionary changes to the delivery of high-quality, multicentre research. The aim of this study was to define common roles in the conduct of collaborative research, and map these to academic competencies as set out by General Medical Council (GMC) in the United Kingdom. This will support trainers and assessors when judging academic achievements of those involved in TRC projects, and supports trainees by providing guidance on how to fulfil their role in these studies. Methods A modified Delphi process was followed. Electronic discussion with key stakeholders was undertaken to identify and describe common roles. These were refined and mapped to GMC educational domains and International Committee of Medical Journal Editors authorship (ICJME) guidelines. The resulting roles and descriptions were presented to a face-to-face consensus meeting for voting. The agreed roles were then presented back to the electronic discussion group for approval. Results Electronic discussion generated six common roles. All of these were agreed in face-to-face meetings, where two further roles identified and described. All eight roles required skills that map to part of the academic requirements for surgical training in the UK. Discussion This paper presents a standardised framework for reporting authorship in collaborative group authored research publications. Linkage of collaborator roles to the ICMJE guidelines and GMC academic competency guidelines will facilitate incorporation into relevant training curricular and journal publication policies

Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study

The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri-operative period. This study aimed to investigate if withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers peri-operatively reduces the risk of acute kidney injury following major non-cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi-level models were used to account for centre-level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republic of Ireland. From this population, 573 (60.4%) patients had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers withheld during the peri-operative period. One hundred and seventy-five (18.4%) patients developed acute kidney injury; there was no difference in the incidence of acute kidney injury between patients who had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers continued or withheld (107 (18.7%) vs. 68 (18.1%), respectively; p = 0.914). Following propensity matching, withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers did not demonstrate a protective effect against the development of postoperative acute kidney injury (OR (95%CI) 0.89 (0.58–1.34); p = 0.567)

4 The risk of deterioration in CT identified mild traumatic brain injury: a systematic review and meta-analysis

© 2017, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. BACKGROUND: The optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13-15 patients with traumatic brain (TBI) injury identified by CT imaging. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED).OBJECTIVE: To estimate the risk of death, neurosurgery and clinical deterioration minor head injured patients with TBI identified by CT imaging, and assess which factors affect the risk of these outcomes.emermed;34/12/A862-a/F1F1F1Figure 1Risk of neurosurgery stratified by the initial GCS of the study population METHODS: A systematic review and meta-analysis adhering to PRISMA standards of reporting. Four electronic data bases and a range of additional literature were searched using a highly sensitive search strategy. Study selection was performed by 2 independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks of: clinical deterioration, neurosurgery and death. Meta-regression was used to explore between study variation in outcome estimates using study characteristics. Factors assessed by individual studies as affecting the outcomes of interest were recorded and pooled within study risk factor effects were estimated where possible.RESULTS: 4431 studies were identified by the search strategy, of which 123 studies were fully retrieved and 49 primary studies and 5 reviews met the inclusion criteria. The estimated pooled risk of the outcomes of interest were: clinical deterioration 11.7% (95% CI:11.7 to 15.8; neurosurgery 3.5% (95% CI:2.2% to 4.9%); death 1.4% (95% CI:0.8% to 2.2%). A large degree of between study variation in the estimates of the outcomes was identified. Multivariable meta-regression of study characteristics identified that mean age of the study population and mean initial GCS accounted for up to half of the variation in reported study outcomes. Within studies the following factors were found to affect the risk for these adverse outcomes: age; severity of injury; type of injury; initial GCS; anti-coagulation; anti-platelet medication; and injury severity scoring. When univariable within study risk factor effect estimates were pooled patients with isolated subarachnoid haemorrhage had an odds ratio of 0.19 for deterioration compared to other injury types.emermed;34/12/A862-a/F2F2F2Figure 2Meta-regression of study factors predictive of neurosurgery CONCLUSION: Minor head injured patients with brain injury identified by CT imaging have a clinically important risk of serious adverse outcomes. Research has identified the possible factors that affect this risk. However, these factors need to be incorporated into a validated multivariable prognostic model before low-risk patients can be reliably identified clinically and triaged to lower levels of care.emermed;34/12/A862-a/F3F3F3Figure 3PRISMA flow-diagram showing selection of studies for inclusion in the systematic review