Global Research Letters

The Use of a Smartphone App to Assess Neonatal Jaundice

Oh you a little right everybody sorry I think we’re going to go ahead and start my name is Christine George I am a third year pediatric resident and I’m Erika rescuing and a first-year theatric president and dr. sally Hymas is on her way and she’ll be joining us here shortly today we’re going to be talking about article in pediatrics journals in India about the use of a smartphone app and pediatrics journals in India to assess neonatal jaundice.

I would tell you that’s what I’m about to say is that we have no disclosures pediatric journals India as is also on our first slide okay and with regards to our objective they’re also in front of you but we’re going to be basically going through how do we assess this how to come up with a clinical questions assess it using a critical app and pediatrics journals in Indiaraisal tool and then go over various concepts related to the article in pediatrics journals in India so the first thing that we’re going to talk about is the clinical context here and that’s being neonatal hyperbilirubinemia all right so as many of you already know very common thing that we see in newborns pediatric journals India it’s considered to be clinically significant meaning greater than 17 milligrams per deciliter in app and pediatrics journals in Indiaroximately 10% of term newborns and about 25% of near-term newborns in the United States now that prevalence is actually quite higher in many other countries especially those that have a higher rate of g6pd deficiency and of course why do we care is because there’s really high bilirubin levels there are there’s a risk for various neurological sequelae with that including acute bilirubin encephalopathy doesn’t been progressing to connectors and of course we treat initially with photo therapy in order to help prevent that rise so school standard test for looking for neonatal jaundice fir filter and bilirubin for the blood specimen pediatric journals India he’ll stick little painful sometimes inconvenient at our facility the actual test itself cost about $30 to run and that’s not including actually the cost of the collection of the specimen and any transit typical screening in pediatric journals India that’s done is transcutaneous bilirubin and that’s based off of a concept known as reflectance effect so photometry excuse me and you know it’s nice in that you know it’s kind of a nice point of care tool but it does tend to underestimate pediatric journals India the serum Billy particularly when that sera Billy is higher and there are some other types of costs associated with it the bilirubin meteor itself costs anywhere from five to seven thousand dollars and then you also have to keep up with maintenance pediatric journals India and then each of this calibration tips that you have to use every time you use it is about six dollars each and then of course there is this visual inspection have been used for many years but it is very notoriously unreliable and you know the end up being basically a 50/50 chance as to whether or not you’re actually going to be able to detect clinically significant jaundice versus just normal physiologic jaundice so kind of framing of the article in pediatrics journals in India here so you valuation you nail jaundice is either expensive with transcutaneous or theorem billing or unreliable with the visual estimation and something that is neat concepts thinking about how smart phones which are everywhere all over the world today my offer inexpensive and available option for the diagnosis using various concepts within digital imaging and this leads us to our article in pediatrics journals in India on the use of a smartphone app and pediatrics journals in India to assess neonatal jaundice this was just recently published in the Pediatrics Pediatrics journals in India in September and I run with elite authors coming out of the University of Washington in terms of our peacock questions.

Our population is our healthy term here terms newborn for less than seven days old the diagnostic tests that we’re going to be looking at is the Billy camp smart rent app and pediatrics journals in Indialication they comparing that to a total serum bilirubin which is the gold standard as well as some comparison to the standard screening in pediatric journals India method that’s youth with transcutaneous bilirubin and we’re going to be looking at how likely are we able to predict that the serum bilirubin is going to be in the high-risk zone on the Litani Noora gram pediatric journals India or the serum bilirubin is greater than equal to 17 which is to determine again to be dyed twenty significant threshold the diagnostic question and use diagnostic accuracy studies all right now we’re going to do a little and talk about the index test which is again this Billy cam smartphone app and pediatrics journals in Indialication alright so the main concepts pediatric journals India and you have an example of the cards that were used these color calibration cards used as part of this study you how they app and pediatrics journals in India works is that you basically they take six images using your using the iPhone 5s camera and through the app and pediatrics journals in India there are three photos with flash three photos without flash and this card is centered over the newborns sternum and then that image data is then sent via the internet into a server and then there’s a lot of fancy schmancy background stuff called with machine learning algorithm that ends up being opt out alright so step one you’re going to enter in the date of birth pediatric journals India as well the time of birth of the patient and then next week this is an example of kind of what this app and pediatrics journals in India actually kind of looks like we’re obviously that’s not real ladies but the card is put on the center of the sternum and then the app and pediatrics journals in India opens up and it focuses and automatically takes six different pictures three of them that are with flash three of them that are with out flash again of the sternum the skin that the center on the sternum with the calibration card surrounding it all of that data is then sent to the servers and broken down into several key components though looking at various Conference of the color terms the hue saturation and gamma associated with the light that’s in the light and color that’s reflected off of the jaundice skin and then they’re balancing pediatric journals India that against the known entities that are in the color cards that that are surrounding it then take that and they extract certain of because characteristic features within that data and app and pediatrics journals in Indialy anywhere from seven to twelve different algorithms regression regressions within a larger algorithm that end up allowing us to predict or determine a app and pediatrics journals in Indiaroximate bilirubin estimate okay now I’m going to continue on with you so you designs all right so how do you design here we have our settings all right so this study took place at seven different institutions and across the United States actually have a map here we have institution in Pennsylvania Missouri Utah California Arizona as well as Washington enrollment our inclusion criteria again we’ve kind of got some of this from our Peter question of healthy newborns that were pediatric journals India less than seven days of age and they had to be greater than equal to 35 weeks gestation that’s that term near-term category and the only kind of global exclusion criteria were those that previously received photo therapy now something was interesting about pediatric journals India the study is so they did have additional criteria but that seemed to vary vice right so certain individuals that were enrolled at two institutions they were only enrolled they were enrolled at less than 24 hours of age and then they were been collected billy camp images as well as scare and billy Reuben pediatric journals India was collected at a when they were three to five days old follow-up visits then at two other two institutions it was the data was only collected if they were quote clinically jaundiced and to other institutions it was they did both routine screening in pediatric journals India on newborns that are in their nurseries as well or if they were clinically jaundiced data collection pediatric journals India some key points that were collected in terms of race ethnicity of the infants after the date time of birth we wanted to know okay so what was the collection date and time for the serum Billy as well as the Billy camp Billy and then what was that those two estimated values and then within was tried within the article in pediatrics journals in India if that quote attempts were made to obtain Billy camp images within two hours of the blood draw pediatric journals India there was also some institutions that provided data on also correlating this with transcutaneously Reuben and three institutions notice that they collected for quote virtually all participants at the time of the blood draw for the serum Billy and then at one institution it was collected for selected newborns.

That’s the only information that were given and some just key stuff about analysis that we’ll get into a little bit more detail later this analysis based loss linear correlation the bland Alvin squat sensitivity and specificity and kind of these two big outcomes that they were looking at symbols either so 10 the Billy cam predict high trip toll serum Billy using two very commonly accepted and use decision rules that we use for the actually transcutaneous Billy Reuben since it’s a similar somewhat similar concept in terms of how the data is extrapolated first of the thing if yes first of those beings if it was greater so if the value that Billy cam produced was plotted on the serum bilirubin chart nomogram and it was greater or than or equal to the 75th percentile which is that high intermediate risk zone or higher that that would predict that the actual serum Billy was in a high-risk zone because again thinking about this in a way that we’re saying that Philly cam is somewhat similar to transit Aeneas it would underestimate the Billy Rubin at when the Billy room is at a higher level and then the other outcome is whether or not if we say that if the Billy cam gets a level that is greater than equal to 13 will that predict that the serum Billy is actually you know greater than or equal to 17 okay so I’m going to continue on with the spendy results so the first graph we have here is a linear correlation graph and it’s looking at the relationship between pair total serum Billy and Billy can Billy values in our 530 newborns so on the y axis we have the total serum Billy and on the x-axis we have the Billy can Billy values each individual red dot is our each newborn and the line going through the red data points is the linear regression line as you can see here the data points are very close together and they’re going in the positive direction so as the Billy can Billy value increases the total serum Billy increases the correlation coefficient is calculated as positive zero point nine one with a 95% confidence interval of zero point eight nine to 0.92 so they also look at the correlation coefficient by ethnic group as you can see here the white population had the highest correlation cold of 0.92 and the asian-american population has the lowest of 0.88 but still very strongly positively correlated to moving on this plot is called the brand Altman’s lot and the brand Altman SWAT looks at identifies or evaluates agreement among two different instruments and in our case it is looking at the total serum Billy and the Billy Chambery and it also identifies any systematic differences that looks at bias so X before we look at the mean difference on a y-axis we have the difference between the Billy campaign and the total serum Billy and on the x axis we have the average of the Billy kam Billy and the total serum Billy the horizontal solid line here is the mean difference which is 0.01 plus or minus 1.8 milligrams per deciliter and the – horizontal line is called the limits of agreement or the 95 percent confidence interval or two standard deviations from the mean and that is minus 3.6 to positive three point six milligrams per deciliter they calculated at 92 percent of the Billy can Billy eval use we’re within three milligrams per deciliter of the total serum Billy and 73 percent of the building can Billy values are within on two milligrams per deciliter of the total scam billing so this table here looks at the utility of the Billy can Billy and also they included the transcutaneous Billy a screening in pediatric journals India tools to identify newborns with i total durham billion values so this table can be kind of confusing because it as it looks like sensitivity specificity positive predictive value and negative predictive value and they were looking at two different outcomes the first outcome is the Billy kam Billy or transcutaneous Billy greater than or equal to the 75th percentile on the Buchanan our total film nomogram to predict a total sham Billy in the high-risk zone and the second outcome is looking at Billy kam Billy or transcutaneous Billy level greater than or equal to 13 to catch up to predict total theorem Billy and greater than or equal to 70 milligrams per deciliter so looking at the sensitivity in the first outcome between the Billy kam billion a transcutaneous billionaire they’re pretty much equal 80-85 verse 81 percent and it’s not a very good sensitivity some only really age 85 and 81 percent looking at to the second second outcome sensitivity 100% for both Billy Kim and transcutaneous Billy so the specificity is the first outcome Billy cam has slightly less specificity but again not very good compared to the transcutaneous filling 82 and for the specificity for the second outcome they both are very similar but again not very good specificities positive predictive value there they have low positive predictive value Billy can have slightly higher 32 percent versus 19% and for the second outcome again is very low positive predictive values Billy kamek slightly higher 20% versus 13% negative predictive values for for both the outcomes but is high is 97 and 98 and for the second outcome so although we’re going to make our own conclusion about the results at the very end I just wanted to include what the author’s mentioned they stated that the Billy camp provided accurate estimates of total serum Billy values demonstrating that an inexpensive technology that uses commodity smart phones could be used to effectively screen newborns for jaundice so now we’re going to move on to critical app and pediatrics journals in Indiaraisal so we’re going to talk about are the results of the trial valid and we’re going to talk about the internal validity so the first question is was a diagnostic test evaluated in a representative spectrum of patients so this diagnostic tool in the silly camp app and pediatrics journals in Indialication diagnosing all spectrum of disease is it looking at normal babies isn’t looking at big news with smile of Diamonds marjan measure severe jaundice so Nords way to do that is to look at um the age and also the total serum daily sorry looking at not just finding the first day’s life or the second day of life and so they reported a mean of age of 75 plus or minus 29 hours with a range of 12 to 163 hours old and they also reported a total serum daily of 10 plus or minus 4 with the range of 0.6 to 29 milligrams furgus milligrams per deciliter of the total serum belly of 12 and a half percent were in the high-risk zone on the toilet belly nomogram and 15% were had a total serum daily greater than or equal to 15 milligrams per deciliter the only reported mean for these for age and total serum Billy they didn’t report the median or the interquartile ranges and that would have been useful to have those up to better understand the distribution we just mean to be more affected by by outliers and it can be it can use me can be skewed so it would have been useful to have median and interquartile ranges also looking at another way to answer this question is is to see if they looked at various ethnic group and they looked at as much as you saw on the other table they looked at various ethnic groups as you can see on this table here and although they had a higher percentage of white population at 55% they still had a very good representation from the other ethnic groups the African American and Asian American at 2021 percents and Hispanics at 26% so continuing on with the internal validity through that authors include information about those who satisfy the inclusion criteria but didn’t receive the diagnostic index or reference standard test so those who didn’t receive the Billy Kim app and pediatrics journals in India or the total serum Billy and so this is yes and no so they didn’t tell us about those who did identify inclusion criteria but weren’t app and pediatrics journals in Indiaroached to either partake in the study or those who declined to partake in the study didn’t include information about that also as Christine mentioned there were site-specific inclusion criteria of its vague but in the 580 newborns who were who receive daily camp images they included that eighth and missing matching total serum daily levels or had no no matching total serum bilirubin levels were obtained to high live issues to parents decline blood draws three had issues with the consent process so if you subtract all those you get 569 participants or less so the authors include how indeterminate results misuk results and outliers if the index tests were handled and so they stated that of the 569 participants 39 newborns didn’t receive complete.

Billy can images and you don’t know they don’t explain why these 39 newborns didn’t get the complete set of images this could have been an issue with the technology and issues lighting the positioning was wrong they didn’t go into detail as soon as Internet connectivity we don’t really know they don’t go into detail so if you subtract it from 39 newborns who didn’t get the complete images you have 530 newborns who got both the belly cams Billy and the total serum filling so was the reference standard clearly defined independent invalid it was clearly defined it was defined as the total of serum bilirubin it was independent so every the total serum Billy was done independent of the result of the Billy cam Billy but in some sites on the patients got total serum Billy and Billy can vary based on visible jaundice so that was it was dependent on visible jaundice they received the total fare Billy and so again based on jaundice but the total serum Billy and and Billy cam Billy was done independently of each other and the reference standard which is the total serum Billy is balanced because it’s the gold standard of how to no hyperbole Romania was the reference standard app and pediatrics journals in Indialied regardless of the index diagnostic test and vice versa and this answer is yes so the total serum Billy was app and pediatrics journals in Indialied regardless of the ability and billing and vice versa what’s their flying comparison of the reference and index cash and this is no and this authors didn’t mention that the total serum Billy and the Billy cam Billy were blinded to each other and this decreases the validity of the study because a nurse or physician could get to the results of the total serum Billy and could repeat the Billy cam again to try to match the total share ability so that wasn’t they weren’t blinded to each other they didn’t mention that we and we also don’t know if the Billy cam was collected before or after the total serum Billy they did mention that 92 percent of the total serum Billy and Billy cam Billy were collected two hours apart and 3% of the total jaren Billy and Billy Camberley were collected between two and three hours the last question under internal validity is was the test validated in a second independent group of patients this is know so they make like the data Christine mentioned from the 17 different sites around the country and it was combined into winos fooled into one dataset it wasn’t it was analyzed by subgroup but it was not they do not perform a separate did not perform study in a second independent group so it still needs to be validated.

I’m in a separate population we’ve never done I just planned alright okay guys yeah sometimes so now we’re on to there were some more detailed stuff about the results and I know sometimes this can be a little bit Drive we’ll try to make this as dynamic as scissors here we’ll try so how accurate and precise were these results all right nice and easy and that there’s only really one question in terms of well what’s kind of tested they even prevent in terms of what results do they prevent all right and so we’re going to kind of we’re going to go through each of these or do a little quick review though make sure everybody’s on the same page of understanding these concepts so first is we have a linear correlation coefficient and as dr. Brazilians already kind of showed in talked about we have this very nice correlation graph here and within this study looking at comparing the serum bilirubin versus the Billy cam values there’s a pretty strong positive correlation here between the two again correlation looking at strengths and directions of correlation so in terms of whether you can be positive or negative or it can be strong the greater it is strong the higher is away from zero and down here we have examples those kind of different positives the person’s negative relation and how that would look on the graph over here we have this high positive correlation around point nine being very similar to the correlation net with a paint for values within this study however as you all know correlation does not equal you know it is just one piece in several thing that we have to look at looking at a diagnostic test all right so next we will look at this called a bland ultimate plot.

Ulpan plot excusing and subsequent analysis we talked about this a little bit but again we’re looking at big thing is mean different limits of agreement all right so it’s another way to plot this data out and to look at it and compare okay what am I is are there tons of outliers on either side and then in addition something else they can tell you is another type of bias help team looking yet so you can see there’s a little bit of a slope down here so this aligns with kind of the thought that the Billie cam Phillies do something that’s somewhat similar to what transcutaneous Billy Reubens do meaning they tend to underestimate the serum ability at the higher levels versus oh but can essentially overestimate them at the at lower levels sensitivity and specificity all right again all right went through these generally our sensitivities were better than the specificities all right guys remember this note and spin all right so our sensitivity high sensitivity and you have a negative results then you can feel pretty good that they don’t have the diagnosis or the condition that is concerning and then the specificity if you have high specificity and you have a positive result you can feel pretty confident that they do have that diagnosis and here’s the student kind of graphical depictions of so high sensitivity being a low false negative rate and that’s very good for screening in pediatric journals India test in particular because you really don’t want to miss you’re pulling a big group of people you just and you don’t want to miss you know somebody who has the condition because you plan on doing something else that will kind of filter them out even more then we have our positive and negative predictive values all right again here are your like both okay so our positive values are kind of lowering our negative six values are are high but what the heck does that mean so cute again positive predictive values proportion of people that are positive and have the condition and the negative predictive value being this proportion of people with a negative test you don’t have a condition the end so very similar but in the end it’s related to prevalence so predictive values are dependent on prevalence or that pretest probability is what we’ll often use for then there’s two kind of equations of how prevalence that it kind of gets incorporated into some of the calculations sit here are listed on this slide there’s a graph also kind of showing basically as the prevalence of a certain condition increases that actually tends to increase your positive predictive value and decrease your negative predictive value and in general we’re talking about so I said they’re looking at term newborns 10% of them which are is a decent amount but it’s still not extremely high prevalence end up having the disease and so you just it’s not mean it’s physically possible for you to get very high positive predictive values and you’re pretty much you should be almost guaranteed negative bit negative predictive value all right and the culmination question how okay great now what the heck I do with all this information and how does this house is actually really going to help me and my patient in and where I work so the external validity and app and pediatrics journals in Indialicability couple more concepts I need to throw at you guys just to make sure that we understand pretest probability again it’s used oftentimes synonymously with prevalence but it is not the exact same thing as prevalence pretest probability actually is looking just at a smaller level you’re looking at the more individual level of how suspicious is the clinician that this a certain patient has a disorder so it could potentially be higher than the prevalence if there are other factors that come into play you know for that particular patient but in general if you’re just kind of dealing with a very broad group you like using the be known prevalence is the way to go protest probability is in the revision of that after you’ve done your test or your physical exam finding to that then can should move you along your diagnostic path and then connected to all that is your likelihood ratios those houses that’s and this is where we bring in that so stiffening specificity and those become important terms how likely is it you know is it that this test is going to tell me that this patient has a disease or does not have a disease and then we have this nomogram.

I know a lot of its kind of we see them a lot of books and then you just kind of go oh I don’t know that that thing was complicated and crazy and I don’t think it’s funny to use that like why why would I need to know how to do that was on the boards is the first one but it’s also a lot easier than you would think in terms of trying to help allow this use this tool to help determine whether or not a test is good for particular patients sorry a couple more things about the likelihood ratios larger number in terms of likelihood ratio that’s closer to something like 10 steps that means it’s there’s a big change that this test really really helps you in terms of saying that yes they have a certain disease versus a negative within the negative likelihood ratio and then we’re closer to zero that’s what tells you that has a larger magnitude in terms of that jump from your pretest probability into a post-test probability one way or another in terms of whether ruling in a ruling out disease so will they change my management now we get to do a little bit of math and a little bit of drawing so with our first outcome again this so if our Billy cam Billy ends up plotting at that high intermediate risk or higher on that grip on the nomogram will that predict a high-risk zone and we’ve already talked about the sensitivity and specificity of 85 and 75% all right so this probability again we’re dealing we’re just going to go with the prevalence and ever likely then we’re able to calculate our likelihood ratios based off of sensitivity specificity now these were not presented in the paper in pediatrics journals in India itself so this is something that you do have to do on your own as part of your critical analysis of this type of baby and you do that and coming up at the likely positive likelihood ratio is three point four so ends up being connect the dots start off say 10% then you connect it in as the Elector bridge in the middle here at this at brown 3.4 and you just didn’t keep drawing a straight line and see where it lands and this ends up being at about 27% so small increase in terms of that your help trying to rule in that diagnosis and then your negative likelihood ratio is 0.2 same kind of joke where you end up start at 10 see where intersects that point too can you go down so you actually do make some better gains here in terms of helping to rule out that diagnosis by utilizing this rule within this app and pediatrics journals in Indialication and then we get even actually some better results here with the second outcome in terms of looking at saying alright it’s if our billy cam is greater than equal to 13 is that going to predict it hi Billy a total serum Billy again we have this higher sensitivity so we would predict that we would get definitely have it would help us in terms of ruling out that diagnosis our likelihood ratio ends up being 4.2 your little lines there and we get oh you know a little higher gain say to 32% from 10% and then but our negative likelihood ratio again we have a hundred percent sensitivity now I would just like to weren’t a caution of this you know whenever they anything of a hundred percent or anything is zero you like sets yoga be just a little bit where iam and wonder right was my population size big enough that I really that this truly is a sensitive you know as as what this is saying but this is reassuring it in that regard based off of the population side because basically they were just like I can’t even really make it it’s just it’s all the way down there if you say zero in terms of that language ratio so this you’re really they didn’t miss a single Billy total serum Billy that was higher than seventeen by using this rule so will they be better off well then some one thing with the transcutaneous Billy Rubin that uses you know should decrease the number of unnecessary blood drop and then you talk about possible cost savings going to Billy Rubin meter for twenty seven thousand dollars and then you know it can break and then you know you’re waiting on maintenance so then take care of it and then you’re all set the cost of each of those calibration tips and oftentimes you’re still been stuck actually poking them and having to get a total fear and Billy and they’re also they’re the interesting thought about using use a resource limited areas as many people who I think who have done work internationally can say cell phones are everywhere I mean I personally spent three months in Mali and while we didn’t have electricity running water for most of that time there was an hour every day where they would turn on the generator and everybody cell phones would be charging during that time but I still had to go through able to get my water to bathe in this was just fit this is kind of the reality of what of a lot of places that are you know in kind of use resource limited resource poor areas so you see ready case to have a smartphone and have be able to access data in some way shape or form and not have to buy an expensive machine that would require upkeep alright and then the last question here is who are these methods described in sufficient detail to permit replication.

I mean they’re good to be fair there’s a lot of back-end stuff there’s a lot of very computer science e algorithm back in where even if you were to have gone through all of it it would have been a dissertation and a lot of algorithm that we would have been honestly not I think really would not have app and pediatrics journals in Indiareciated they have submitted their this happ and pediatrics journals in Indiaen double bagger process in for a patent which is still under review so you are able to get something information if you’re kind of thinking they’re just googling a lot out of this which obviously I did and there is a little bit more information though available and they did do a proof-of-concept article in pediatrics journals in India in 2014 and it does give a little bit more information but again it’s not sure if that they have mentioned help things this is kind of an evolving process and changing as as they figure out a better way to kind of attack this problem our conclusions so I mean it’s promising but you’ve got to do a better study is enough there’s a lot of website there’s a lot of things where we said like no not really we’re going to expect critical or critical analysis tool you know but again that I think there is a lot of potential here which makes it very interesting in terms of something that’s more easily accessible and potentially less expensive again but more studies required some key outstanding issues so again needs to be validated in this like an independent blinded group okay got it tell us when are you like that okay you collect the Billy kam Billy’s just prior to her these acting time is your total serum because you can get that back within an hour and again you’re going to you could potentially you know cause significant bias and stuff to your to your study if you don’t take that into account now doing other stuff like okay what about HIPAA compliance with the data transmission of these pictures that are being taken of a patient and then being sent identifying March other other things the security of that and the overarching plan that this group that did make this app and pediatrics journals in Indialication is commercialization and they’re right now they’re in the process of designing a second study and also having this they’re wanting this to be one of the first mobile app and pediatrics journals in Indialications that are that’s app and pediatrics journals in Indiaroved by the FDA for as a true medical device that providers could use in their offices but a couple of things need to be taken before that can actually be finalized including all right well what if you don’t have internet you know we’d be able to compete is it possible to make an offline option and not everybody has an iPhone let’s I mean that’s very biased kind of group so and every different smartphones cameras are a little bit different and they need to then adapter algorithm to be able to be used in all this and then to make it even more complicated the company that was made that kind of ended up producing this was actually just thought bought by Google so I will so you will not find this app and pediatrics journals in India on the App and pediatrics journals in India Store just say I know everybody is what many people have already looked and trying to find it it does not exist the asset was used in these studies was actually manually downloaded on each of their own individual.

IPhones because again this is they did not want this then to be used by parents and saying like oh look I can you know and when this was definitely still an ADA says study process and has not have been validated alright good so this is really quick leveling summary of teaching points of some of more dry stuff that I excited have to go through now spin alright since its high sensitivity and a negative results rule out the diagnosis high specificity positive result role in the diagnosis likelihood ratios dependence on test sensitivity and specificity alright but those that is independent of the prevalence unlike positive and negative predictive values post-test probabilities that’s like where the big bang for your buck gives in terms of looking at an individual patient and you know and kind of trying to say how much is this really going to help me in the rule in or rule out this disease in this patient by using this test and you need to have enough information to be able to determine their pretest probabilities or at least the prevalence in that population as well as then the likelihood ratios and then you can easily use that cool immigrants in the back of your here at Lane that you thought you wouldn’t have to use ever then four things just to remember about diagnostic accuracy studies is it a representative spectrum other patients that they’ve used that they’ve app and pediatrics journals in Indialied this to was the reference standard app and pediatrics journals in Indialied for barred list of index test results so everybody got an independent and blind which study did not have comparison between that index in that reference standard and then did they tell us enough so that we could actually replicate this because that’s key part of scientific methods in terms of actually proving that this is it’s able to be done independently alright little throwback here from my very first pediatrics journals in India Club sorry let’s move anyway I was they were a little fuzzy about how they select patients study and although it seems that a lot of actually a fair portion of the study is unbiased that really patient selection should have been worked really dying resetting I was you know screw doctors yes there was a lot of definite we were underwhelmed dramatically by the lack of information like there was just there’s so many things any questions were like but what about what what about this whether this is like I mean we know things happ and pediatrics journals in Indiaen things go wrong but just we just want that transparency and we were not provided with that unfortunately residents have heard me say this before when article in pediatrics journals in India for publication in pediatrics journals in India they’re supposed to have peer review and is the opportunity of the reviewers critic image created to article in pediatrics journals in India and had their comments before it’s published as those other reviewers have a better job of asking y’all to clarify these parts before things they app and pediatrics journals in Indiaroved for publication in pediatrics journals in India 100% agreed and it’s some this is one of those where that initial titles I think I got it gets people’s attention and you’re not like oh look at that cool and you maybe you read the abstracts and you say oh maybe they don’t look so bad like actually that sounds actually maybe it could be pretty cool but again this is that emphasizing the importance of going through this process and actually really reading and saying well mmm not definitely not as good as it initially app and pediatrics journals in Indiaeared question any other questions yes this is for depression for survivors disasters in negative so when we do train to any ancillary this sweet garner in comes the hospital for doing that engineers Weaver’s that problem is part of anymore package taken temperature giving this up and flashcards yeah by Chris medicated for concerns that I don’t know but I know we spend $40,000 a year on the PCB tax each cap is $6 yeah I guess I’m doing money so this if this is smart phone in a card that’s were useful on patients you lose that revenue we’re spending however for paper in pediatrics journals in India and I had our vendors out every year but I just wasn’t sure that my ferb outpatient clinics because our revenue stream porosity not try to get that information and various territories or we’re not making much kind of the cost of the television scripts yeah well we’re going to get the tab are the miss art doesn’t have that automatic lastima situation but the one I thought about where they have their have that it’s not beautiful for each test I can see that hospital building would not be transparent but actually doctor tension with your son is generating revenues from the PPP.

You should see that clearly actually event we have been working with our doing I wanted to like it is a lot of money to run this machine and outpatient providers clinic of that you know I really just any as I said it has potential so that’s the question are they going to charge you or they have my coming in the career you gathering the data beautiful the questions that save us enough and that certainly not would be reasonable participation because it’s unless you can sterilize and so gas goes on photo paper in pediatrics journals in India right being you’re looking in our city in certify me wonder and yeah and I we had to read that honestly many many times before perfectly like I don’t understand then what would have going on and that goes back to so again they do that’s done based off of the transcutaneous lots of things that we’ve seen with transcutaneous Billy Rubin that we need to understood it because we’re we’re not going to it’s in order to make sure that we are really catching all of these cases that we’re not missing anybody because it’s not the battery they choose the thirteen to represent because that’s what a study has been done that showed us that that number is a pretty good number and that’s one of three different things that are detailed in the 2009 updates to the hyperbilirubinemia practice guidelines that the AAP has put out their ethnicity skin color was so tight yet for always yes and that is another good point because there I’ve been several studies that have come out showing how transcutaneous silly Ruben oftentimes will overestimate values in african-american the african-american population in particular and even in some of the Latino population and which is one of the limitations of using connect to genius and so yes I do think that that I was surprised and I was I mean I was glad that they at least gave us that subgroup analysis but again but for now for questioning what is how people were chosen it to be in the study if it makes you kind of question okay well again we need more more data I think is your racism up standard station and lights on linked off app and pediatrics journals in Indialy shell collection six inches three inches all these issues are critically important interview validated clearly the political trick that the data almost contribute to tight I mean is this is a great case where you’ve contaminated before hits contest I agree heads off buzz but it makes work with something left off definitely all right Wiccans of listening to ours oh yeah that yeah we attended yeah I was good yes and what it was knowledgeable about like other the rise of really and in would soon hours I don’t know right it I mean I would say clinically speaking I think that this so might you might get a slightly different answer depending on on who you ask I mean greater we are we’re not talking about Nicki babies here so where things can train just extremely dramatically you spend very quickly if I would say I mean for especially if we’re dealing more with thinking more outpatient two hours seems reasonable but that’s again we just think they could be good also in terms of the they excluded possible I think this would be for the next study with the ideal to you really want to point those tips and see how these came out right as a sucker I agree oh yeah because they’re testing on sick radiation really thanks we need for therapy now and and you see the highest serum billion that was in that group of patients was twenty four point eight I believe and we really talked about this significant risk for kernicterus and again when we talked about this again why why do we do all this stuff is that greater than equal to 25 like so we’ve we got close but we didn’t even really surpass that so what is that what are the limitations there and it has not been tested in that ultimate at six and that’s what limitations in the spectrum of population that they looked at okay.

I have one prep question really quick you guess we get to use anybody’s go go ha literally this was a prep question for this year so really quickly two month old male presents to the emergency department late winter with a 2-day history of coughs rhinorrhea decrease feeding and progressive difficulty breathing based on the infant’s clinical picture and the case mix you have seen recently you estimate app and pediatrics journals in Indiaroximately 50% chance that he’s infected with RSV please send a rapid RF e antigen test which is positive is known that patients with RSV because of course but you just know this are five times more likely to have a positive test damn patients who do not have a disease app and pediatrics journals in Indialying the nomogram shown the post-test probability that he has RSV is what a next so well I will let you think about it a little bit miss Hart it’s hard to do it yeah because you don’t have it in front of you but go next to more quote of the scoop this is more about let’s work this through a little bit together to show you what we’re meaning is your next step they’re real cool little animations here so two key things app and pediatrics journals in Indiaroximately 50% chance that he’s infected so what what is what did that tell what is the pretest probability five times more likely have a positive test the positive likelihood ratio ounces so next okay 8% cancer cc 50% actually people have gotten this wrong on prep which is actually really high which again so but this was actually incredibly easy just utilizing these very basic principles okay next thank you for your patience.

I ran late you.

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