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Performance of clinical prediction rules for diagnosis of pleural tuberculosis in a high-incidence setting

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Abstract
OBJECTIVES: Diagnosis of pleural tuberculosis (PT) is still a challenge, particularly in resource-constrained settings. Alternative diagnostic tools are needed. We aimed at evaluating the utility of Clinical Prediction Rules (CPRs) for diagnosis of pleural tuberculosis in Peru. METHODS: We identified CPRs for diagnosis of PT through a structured literature search. CPRs using high-complexity tests, as defined by the FDA, were excluded. We applied the identified CPRs to patients with pleural exudates attending two third-level hospitals in Lima, Peru, a setting with high incidence of tuberculosis. Besides pleural fluid analysis, patients underwent closed pleural biopsy for reaching a final diagnosis through combining microbiological and histopathological criteria. We evaluated the performance of the CPRs against this composite reference standard using classic indicators of diagnostic test validity. RESULTS: We found 15 eligible CPRs, of which 12 could be validated. Most included ADA, age, lymphocyte proportion and protein in pleural fluid as predictive findings. A total of 259 patients were included for their validation, of which 176 (67%) had PT and 50 (19%) malignant pleural effusion. The overall accuracy of the CPRs varied from 41% to 86%. Two had a positive likelihood ratio (LR) above 10, but none a negative LR below 0.1. ADA alone at a cut-off of >= 40 IU attained 87% diagnostic accuracy and had a positive LR of 6.6 and a negative LR of 0.2. CONCLUSION: Many CPRs for PT are available. In addition to ADA alone, none of them contributes significantly to diagnosis of PT.
Keywords
ADENOSINE-DEAMINASE, ACTIVATION PRODUCTS, INTERFERON-GAMMA, MTB/RIF, ASSAY, EFFUSIONS, METAANALYSIS, FLUID, THORACOSCOPY, ACCURACY, DISEASE, score, adenosine deaminase activity, pleural tuberculosis, Mycobacterium, tuberculosis

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Chicago
Solari, Lely, Alonso Soto, and Patrick Van Der Stuyft. 2017. “Performance of Clinical Prediction Rules for Diagnosis of Pleural Tuberculosis in a High-incidence Setting.” Tropical Medicine & International Health 22 (10): 1283–1292.
APA
Solari, L., Soto, A., & Van Der Stuyft, P. (2017). Performance of clinical prediction rules for diagnosis of pleural tuberculosis in a high-incidence setting. TROPICAL MEDICINE & INTERNATIONAL HEALTH, 22(10), 1283–1292.
Vancouver
1.
Solari L, Soto A, Van Der Stuyft P. Performance of clinical prediction rules for diagnosis of pleural tuberculosis in a high-incidence setting. TROPICAL MEDICINE & INTERNATIONAL HEALTH. 2017;22(10):1283–92.
MLA
Solari, Lely, Alonso Soto, and Patrick Van Der Stuyft. “Performance of Clinical Prediction Rules for Diagnosis of Pleural Tuberculosis in a High-incidence Setting.” TROPICAL MEDICINE & INTERNATIONAL HEALTH 22.10 (2017): 1283–1292. Print.
@article{8554551,
  abstract     = {OBJECTIVES: Diagnosis of pleural tuberculosis (PT) is still a challenge, particularly in resource-constrained settings. Alternative diagnostic tools are needed. We aimed at evaluating the utility of Clinical Prediction Rules (CPRs) for diagnosis of pleural tuberculosis in Peru. 
METHODS: We identified CPRs for diagnosis of PT through a structured literature search. CPRs using high-complexity tests, as defined by the FDA, were excluded. We applied the identified CPRs to patients with pleural exudates attending two third-level hospitals in Lima, Peru, a setting with high incidence of tuberculosis. Besides pleural fluid analysis, patients underwent closed pleural biopsy for reaching a final diagnosis through combining microbiological and histopathological criteria. We evaluated the performance of the CPRs against this composite reference standard using classic indicators of diagnostic test validity. 
RESULTS: We found 15 eligible CPRs, of which 12 could be validated. Most included ADA, age, lymphocyte proportion and protein in pleural fluid as predictive findings. A total of 259 patients were included for their validation, of which 176 (67\%) had PT and 50 (19\%) malignant pleural effusion. The overall accuracy of the CPRs varied from 41\% to 86\%. Two had a positive likelihood ratio (LR) above 10, but none a negative LR below 0.1. ADA alone at a cut-off of {\textrangle}= 40 IU attained 87\% diagnostic accuracy and had a positive LR of 6.6 and a negative LR of 0.2. 
CONCLUSION: Many CPRs for PT are available. In addition to ADA alone, none of them contributes significantly to diagnosis of PT.},
  author       = {Solari, Lely and Soto, Alonso and Van Der Stuyft, Patrick},
  issn         = {1360-2276},
  journal      = {TROPICAL MEDICINE \& INTERNATIONAL HEALTH},
  language     = {eng},
  number       = {10},
  pages        = {1283--1292},
  title        = {Performance of clinical prediction rules for diagnosis of pleural tuberculosis in a high-incidence setting},
  url          = {http://dx.doi.org/10.1111/tmi.12932},
  volume       = {22},
  year         = {2017},
}

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