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JOURNAL APPRAISAL

Andrea Isabel T. Contreras


CASE SCENARIO
 GO 24/F
 CC: difficulty of breathing
 1 week history of easy fatigability, weakness, palpitations, restlessness, increased sweating,
dysphagia; 2 day history of cough
 No heat/cold intolerance, bowel movement changes, weight changes
 Soft, nontender mass 3x3x1 cm R anterolateral neck
 Slight rib hump R on forward bend test
CASE SCENARIO
Primary working impression
• Anterior neck mass t/c diffuse toxic goiter
• Musculoskeletal strain, back r/o dextroscoliosis
• Upper respiratory tract infection, probably viral
CLINICAL QUESTION
Among adult patients presenting with an anterior neck mass and thyroid
symptoms, what is the accuracy of clinical evaluation compared to hormonal
assays in making a diagnosis of hyperthyroidism?
CLINICAL QUESTION
P Adult patient with anterior neck mass and
thyroid symptoms
I Clinical evaluation (history, physical exam)

C Hormonal assays (FT4, TSH)

O Diagnosis of hyperthyroidism

M Cross-sectional study
DECISION ANALYSIS
80%
Pretest
probability

10%
90%
Diagnostic
Treatment
threshold
threshold
LITERATURE SEARCH
LITERATURE SEARCH
LITERATURE SEARCH
LITERATURE SEARCH
1. Is it relevant?
1. Relevance Yes

Case Study

Adult patients with


Adult patients with
Population anterior neck mass and
thyroid symptoms
thyroid symptoms

Intervention Clinical evaluation UST Thyroid Index

Hormonal assays
Comparison FT4, TSH
(FT4, TSH)
Diagnosis of
Diagnosis of
Outcome hyperthyroidism &
hyperthyroidism
hypothyroidism

Methodology Cross-sectional Cross-sectional


II. Is it valid?
1. Was there an independent comparison with a
reference standard? Yes
2. Did the patient sample include an appropriate spectrum
of patients to whom the test will be done? Yes
Table 1. Profile of subjects
3. Was the reference standard done regardless of the
result of the of the diagnostic test being evaluated? Yes
UST Thyroid Scoring Index
4. Were the methods for performing the test described in
sufficient detail to permit replication? Yes
4. Were the methods for performing the test described in sufficient
detail to permit replication?
Yes
III. What are the results?
RESULTS

Sensitivity = True Positive/ True Positive + False Negative


Specificity = True Negative/True Negative + False Positive
Likelihood Ratio
Sensitivity 67.4% LR (+) LR (-)
Specificity 84.3% Hyperthyroidism 4.29 0.39

LR (+) = Sensitivity/1-Specificity
LR (-) = 1-Sensitivity/Specificity
Will the likelihood
ratio shift the
pretest
probability?

Yes
IV. Can the results help me in caring
for my patients?
1. Will the reproducibility of the test result and
its interpretation be satisfactory in my setting? Yes
2. Are the results applicable to my patient? Yes

Age
Female
Clinical Score – 11
(± fine finger tremor, exophthalmos,
moist skin, hyperkinetic movement)
3. Will the results change my management? Yes
80% 95%
Pretest Post test
probability probability

10%
90%
Diagnostic
Treatment
threshold
threshold
Summary
Using the UST Thyroid index (Sn 67.4, Sp 84.3), physicians in low
resource settings may readily diagnose hyperthyroidism and start
treatment even in the absence of FT4 and TSH levels.