Zhang Ludi, Rojas-Carabali William, Choo Shannon Sheriel, Thng Zheng Xian, Lim Yuan Heng, Lee Bernett, Jun Song Wen, Patnaik Gazal, Biswas Jyotirmay, Agarwal Aniruddha, Testi Ilaria, Mahajan Sarakshi, Kempen John H, Smith Justine R, McCluskey Peter, Kon Onn Min, Nguyen Quan Dong, Pavesio Carlos, Gupta Vishali, Agrawal Rupesh
Lee Kong Chian School of Medicine, Nanyang Technological University of Singapore.
National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore.
JAMA Ophthalmol. 2024 Dec 1;142(12):1140-1148. doi: 10.1001/jamaophthalmol.2024.4567.
This was the first study, to the authors' knowledge, to statistically evaluate the predictive accuracy of Collaborative Ocular Tuberculosis Study (COTS) calculator in guiding initiation of antitubercular therapy (ATT) in patients with clinically suspicious tubercular uveitis (TBU) in an international cohort.
To evaluate the accuracy of a score of 4 or greater on the online COTS calculator in recommending ATT initiation.
DESIGN, SETTING, AND PARTICIPANTS: This study was an evaluation of a diagnostic test or technology. Data input required for the COTS calculator were extracted from the COTS-1 study dataset, which comprised retrospective, observational records of patients with TBU who were monitored for 12 months after treatment. Patients were recruited from international ophthalmic centers. In the absence of a traditional criterion standard, the 12-month treatment response to ATT was used to classify patients as disease positive or negative. The accuracy of clinicians at the ATT decision-making stage in the COTS-1 study was set against COTS calculator scores of 4 or greater. Diagnostic accuracy metrics, including sensitivity, specificity, positive predictive value (PPV), precision, recall, and F1 score, were computed. Data collected from January 2004 to December 2014 were analyzed.
COTS calculator to guide initiation of ATT in patients with TBU.
Comparison of accuracy between clinician judgment and the COTS calculator, analyzed at varying scores and further stratified by tuberculosis endemicity.
Of the 492 participants (mean [SD] age, 42.3 [19.0] years; 233 male [47.3%]), application of the COTS calculator identified 225 (45.7%) with high or very high probability to start ATT (score = 4 or 5) and 111 (22.5%) with very high probability alone (score = 5). COTS-5 exhibited the highest specificity (88.7%; 95% CI, 81.4%-93.8%) compared with clinician judgment (29.6%; 95% CI, 21.4%-38.8%), and clinician judgment led in sensitivity (95.5%; 95% CI, 92.9%-97.4%) compared with COTS-5 (26%; 95% CI, 21.6%-30.7%). COTS-4 and COTS-5 balanced specificity (64.3%; 95% CI, 54.9%-73.1%) and sensitivity (48.8%; 95% CI, 43.7%-54%). PPV and sensitivity were consistently higher in the endemic group for all 3 tests.
Results of this diagnostic study suggest that the COTS calculator (score ≥4) was more specific than clinician judgment for ATT initiation. Although clinician judgment is a good first step to identify all potential true positives (with high sensitivity), a second consultation with COTS-5 (with high PPV) may lead to less false positives. This tool, apt for high-prevalence, low-resource settings, recommends ATT more selectively for genuine TBU cases. Large prospective studies are essential to explore potential improvements in the calculator's sensitivity.
据作者所知，这是第一项对协作性眼部结核病研究（COTS）计算器在国际队列中指导临床疑似结核性葡萄膜炎（TBU）患者开始抗结核治疗（ATT）的预测准确性进行统计学评估的研究。
评估在线COTS计算器上4分或更高的分数在推荐开始ATT方面的准确性。
设计、设置和参与者：本研究是对一种诊断测试或技术的评估。COTS计算器所需的数据输入是从COTS-1研究数据集提取的，该数据集包括TBU患者的回顾性观察记录，这些患者在治疗后被监测了12个月。患者是从国际眼科中心招募的。在没有传统标准参照的情况下，对ATT的12个月治疗反应被用于将患者分类为疾病阳性或阴性。将COTS-1研究中临床医生在ATT决策阶段的准确性与COTS计算器4分或更高的分数进行对比。计算了诊断准确性指标，包括敏感性、特异性、阳性预测值（PPV）、精确率、召回率和F1分数。对2004年1月至2014年12月收集的数据进行了分析。
COTS计算器用于指导TBU患者开始ATT。
比较临床医生判断与COTS计算器之间的准确性，按不同分数进行分析，并进一步按结核病流行情况分层。
在492名参与者中（平均[标准差]年龄，42.3[19.0]岁；233名男性[47.3%]），应用COTS计算器确定225名（45.7%）开始ATT的概率高或非常高（分数=4或5），111名（22.5%）单独概率非常高（分数=5）。与临床医生判断（29.6%；95%CI，21.4%-38.8%）相比，COTS-5表现出最高的特异性（88.7%；95%CI，81.4%-93.8%），而临床医生判断在敏感性方面领先（95.5%；95%CI，92.9%-97.4%），相比之下COTS-5为（26%；95%CI，21.6%-30.7%）。COTS-4和COTS-5在特异性（64.3%；95%CI，54.9%-73.1%）和敏感性（48.8%；95%CI，43.7%-54%）之间取得了平衡。在所有3项测试中，流行组的PPV和敏感性始终更高。
这项诊断研究的结果表明，COTS计算器（分数≥4）在开始ATT方面比临床医生判断更具特异性。虽然临床医生判断是识别所有潜在真阳性（敏感性高）的良好第一步，但与COTS-5（PPV高）进行二次会诊可能会减少假阳性。这个适用于高流行、资源匮乏环境的工具，能更有选择性地为真正的TBU病例推荐ATT。大型前瞻性研究对于探索提高计算器敏感性的潜在改进至关重要。
