Nigrovic Lise E, Bennett Jonathan E, Balamuth Fran, Levas Michael N, Chenard Rachel L, Maulden Alexandra B, Garro Aris C
Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;
Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.
Pediatrics. 2017 Dec;140(6). doi: 10.1542/peds.2017-1975.
To make initial management decisions, clinicians must estimate the probability of Lyme disease before diagnostic test results are available. Our objective was to examine the accuracy of clinician suspicion for Lyme disease in children undergoing evaluation for Lyme disease.
We assembled a prospective cohort of children aged 1 to 21 years who were evaluated for Lyme disease at 1 of the 5 participating emergency departments. Treating physicians were asked to estimate the probability of Lyme disease (on a 10-point scale). We defined a Lyme disease case as a patient with an erythema migrans lesion or positive 2-tiered serology results in a patient with compatible symptoms. We calculated the area under the curve for the receiver operating curve as a measure of the ability of clinician suspicion to diagnose Lyme disease.
We enrolled 1021 children with a median age of 9 years (interquartile range, 5-13 years). Of these, 238 (23%) had Lyme disease. Clinician suspicion had a minimal ability to discriminate between children with and without Lyme disease: area under the curve, 0.75 (95% confidence interval, 0.71-0.79). Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease (score 1-3), 65 (12%) had Lyme disease, and of the 127 children who the treating clinicians thought were very likely to have Lyme disease (score 8-10), 39 (31%) did not have Lyme disease.
Because clinician suspicion had only minimal accuracy for the diagnosis of Lyme disease, laboratory confirmation is required to avoid both under- and overdiagnosis.
为做出初步管理决策，临床医生必须在诊断检测结果出来之前估计莱姆病的患病概率。我们的目的是检验临床医生对接受莱姆病评估的儿童患莱姆病的怀疑准确性。
我们组建了一个前瞻性队列，纳入年龄在1至21岁之间、在5个参与研究的急诊科之一接受莱姆病评估的儿童。要求主治医生估计莱姆病的患病概率（采用10分制）。我们将莱姆病病例定义为患有游走性红斑病变的患者，或症状符合的患者二级血清学检测结果呈阳性。我们计算了受试者工作特征曲线下面积，以此作为临床医生怀疑诊断莱姆病能力的一项指标。
我们纳入了1021名儿童，中位年龄为9岁（四分位间距为5至13岁）。其中，238名（23%）患有莱姆病。临床医生的怀疑对区分患莱姆病和未患莱姆病的儿童能力极小：曲线下面积为0.75（95%置信区间为0.71至0.79）。在主治医生认为不太可能患莱姆病（评分在1至3分）的554名儿童中，65名（12%）患有莱姆病；在主治医生认为很可能患莱姆病（评分在8至10分）的127名儿童中，39名（31%）未患莱姆病。
由于临床医生的怀疑对莱姆病诊断仅有极小的准确性，因此需要实验室确诊以避免漏诊和过度诊断。
