Methods of investigation in clinical cardiology. X. Studies on the evaluation of diagnostic tests in cardiology

Diagnosis is a complex cognitive process which is characterised by uncertainty. This uncertainty can be managed through specific knowledge in conjunction with probability theory. Studies evaluating diagnostic tests are the best way of building this knowledge. Studies evaluating diagnostic tests have two essential components: the gold standard and the new test. Both components, gold standard and test, are independent measurement process that can be influenced by diverse sources of variability. The comparison between diagnostic and test is essentially a hierarchical procedure. Diagnostic tests are evaluated by their sensitivity, specificity compared to a definitive gold standard. The predictive values and the likelihood ratio test are also used. Sensitivity (the proportion of true positives) and specificity (the proportion of true negatives) are values obtained from a sample and thereby can be considered as the conditional agreement between gold standard and the new test. Kappa coefficients for sensitivity and specificity are useful tools for adjusting both indices. Sensitivity and specificity are non-poblational values, they are estimates of the true values of the study population and can be affected by random error and systematic errors (bias). Confidence intervals are useful for giving an indication of the precision of the point estimates of sensitivity and specificity. A suitable sound design is required to avoiding a biased estimate of sensitivity, likelihood ratio, and predictive values. Finally a list of potential biases is given with methods for minimising these.     

Solitary rectal ulcer syndrome

BACKGROUND: Solitary rectal ulcer syndrome is a rare disorder characterized by erythema or ulceration of the rectal wall, associated with typical histological features, and disturbed defaecatory behaviour with the passage of blood and mucus. METHODS: This is a review based on a literature search using a computer database (Medline) and manual cross-referencing. RESULTS: The pathogenesis is likely to vary in different patients; it includes trauma from straining, direct digital trauma and possibly primary neuromuscular pathology. The histological findings of extension of the muscularis mucosa between crypts and muscularis propria disorganization on full-thickness specimens are characteristic. Biofeedback defaecation retraining, including habit training, can lead to symptom improvement and return to work in a majority of patients. Abdominal rectopexy offers long-term symptom improvement in approximately 50 per cent of patients. Rectal ulceration may persist after any treatment, even if symptoms improve. CONCLUSION: Behavioural therapy and carefully considered operations offer the best treatment results. Further work on psychological factors and neuromuscular and vascular pathology is required.     

The importance of pH in the regulation of ruminal acetate to propionate ratio and methane production in vitro

Grain feeding often causes a decrease in ruminal pH, and experiments were conducted to define the role of pH in regulating the acetate to propionate ratio and production of CH4. Cows that were fed 90% concentrate had lower ruminal pH values (6.22 vs. 6.86), higher VFA concentrations (85 vs. 68 mM), and lower acetate to propionate ratios (2.24 vs. 4.12) than did cows that were fed forage only. When mixed ruminal bacteria from cows that were fed 90% concentrate or 100% forage were incubated (48 h) with hay (10 g/L) or cracked corn (5 g/L) in a medium containing bicarbonate (38 mM) and tricarballylate (50 mM), the final pH values were less than 0.3 units lower than the initial pH. At final pH values less than 5.7, hay fermentation was inhibited, the acetate to propionate ratio and CH4 production declined more than twofold, and the inoculum source was without effect. Small amounts of H2 were detected at pH values less than 5.5. Total VFA production from cracked corn decreased when pH declined, but only if the inoculum was obtained from cows that were fed 90% concentrate. The acetate to propionate ratio of cracked corn incubations declined from 1.2 to 0.6 when final pH was decreased from 6.5 to 5.3, and CH4, as a percentage of total VFA production, also decreased. At pH values less than 5.3, the acetate to propionate ratio of cracked corn increased more than fourfold, and large amounts of H2 could be detected. Over the final pH range of 6.5 to 5.3, CH4 production was highly correlated with acetate to propionate ratio, which was dependent on pH and substrate (CH4 = 0.02 + 0.05 pH; r2 = 0.80). Calculations based on the differences between pH 6.5 and 5.8 indicated that as much as 25% of the decrease in acetate to propionate ratio could be explained by the effect of pH alone.     

Cancer of the breast: the return of lymphoscintigraphy?

Lymphoscintigraphy, after arousing great hope in the past in the field of breast cancer, has now been abandoned. The inability of this examination to predict the metastatic status of the nodes, and progress in therapeutic concepts have led to abandoning this technique. However, certain problems encountered by regional irradiation programmes and the work concerning sentinel node detection may bring this technique back into the spotlight. Lymphoscintigraphy may make it possible to adopt an individual approach, case by case, of the lymphatic drainage basins in breast tumors, thus enabling certain patients to benefit from regional irradiation when it would not have been traditionally recommended for this irradiation. Another aspect concerns the problem of the volumes irradiated. Work carried out with lymphoscintigraphy has enabled internal mammary chain nodes to be precisely located. Theses studies show the necessity of adapting the irradiation field to each individual case, but the clinical impact is limited, in the end, by the low recurrence rate in the internal mammary chain area. However, the new techniques of computer merging of scintigraphic and scanner images could enable the spatial position of the nodes in the upper axillary and supraclavicular regions to be determined. This would have, a priori, much wider clinical impact. Lymphoscintigraphic detection of the sentinel node is another field of major interest, but this technique is in competition with staining techniques. This procedure leads to a large reduction in morbidity of axillary surgery in 70% of patients. The use of techniques for detecting micrometastases in the sentinel node opens prospects in terms of prognosis. The qualities of differents radiotracers and different injection sites possible are also discussed.     

Computer-assisted analysis of sperm motility

The fully automatic method for reconstruction of spermatozoa trajectories was presented. The method is based on computer image analysis. It allow to process pure semen without any treatment like diluting or purifying. Since no human interacting is available, this method lead to objective results. The method was used to analyse semen taken from healthy men (WHO 92 standard). The result shows absence of different populations in single sample.