Kline Jeffrey A, Neumann Dawn, Hall Cassandra L, Capito Jacob
Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Emerg Med J. 2017 Feb;34(2):82-88. doi: 10.1136/emermed-2016-205874. Epub 2016 Aug 2.
Many clinicians use a global visual interpretation of patient appearance to decide if a patient looks sick or not. For patients with suspected acute pulmonary embolism (PE), we tested the relationship between visual appearance of a happy patient facial affect and probability of PE+ on CT pulmonary angiography (CTPA).
Eligible patients were selected by usual care to undergo CTPA, the criterion standard for PE+ or PE-. Prior to CTPA result, trained study personnel obtained physician pretest probability using the gestalt method (visual analogue scale, 0%-100%), the Wells score (0-12) and physicians' impression of whether the patient smiled during the initial examination (smile+). Patients' faces were also video recorded and analysed with an automated neural network-based algorithm (Noldus FaceReader) for happy affect.
Of the 208 patients enrolled, 27 were PE+ and smile+ was more frequent in patients with PE+ than PE-, a finding confirmed by the Noldus. The diagnostic sensitivity and specificity of smile was low, and physicians overestimated presence of an alternative diagnosis more likely to PE with smile+ than smile- patients in patients with true PE. As a result, the area under the receiver operating characteristic curve (AUROC) was lower for the Wells score in smile+ patients. However, the physicians' mean gestalt estimate of PE did not differ with smile status, nor did smile status affect the AUROC for gestalt.
In patients with suspected PE, physician recollection of patients' smile+ was more common in PE+ patients, and was associated with a less accurate Wells score, primarily because physicians overestimated probability of alternative diagnosis. However, the overall diagnostic accuracy of physicians' gestalt did not differ with perceived smile status. These data suggest that the patients' smile had less effect on the numeric gestalt pretest probability assessment than on the binary decision about an alternative diagnosis.
许多临床医生通过对患者外观的整体视觉判断来确定患者是否看起来病情严重。对于疑似急性肺栓塞（PE）的患者，我们测试了患者愉悦面部表情的视觉外观与CT肺血管造影（CTPA）上PE阳性概率之间的关系。
通过常规护理选择符合条件的患者进行CTPA检查，这是判断PE阳性或阴性的标准方法。在CTPA结果出来之前，经过培训的研究人员使用整体法（视觉模拟量表，0%-100%）、Wells评分（0-12）以及医生对患者在初次检查时是否微笑的印象（微笑阳性）来获得医生的预测试概率。还对患者的面部进行了视频录制，并使用基于神经网络的自动算法（Noldus面部识别软件）分析其愉悦表情。
在纳入的208例患者中，27例为PE阳性，PE阳性患者中微笑阳性的情况比PE阴性患者更常见，这一结果得到了Noldus软件的证实。微笑的诊断敏感性和特异性较低，在真正患有PE的患者中，医生高估了微笑阳性患者比微笑阴性患者更可能存在替代诊断的情况。因此，微笑阳性患者的Wells评分的受试者工作特征曲线下面积（AUROC）较低。然而，医生对PE的平均整体估计与微笑状态无关，微笑状态也不影响整体法的AUROC。
在疑似PE的患者中，PE阳性患者中医生回忆起患者微笑阳性的情况更为常见，且与Wells评分准确性较低有关，主要原因是医生高估了替代诊断的概率。然而，医生整体判断的总体诊断准确性与感知到的微笑状态无关。这些数据表明，患者的微笑对数字整体预测试概率评估的影响小于对替代诊断二元决策的影响。
