Professional Documents
Culture Documents
Diagnosis of Helicobacter
pylori infection
Clinical Scenario
The patient is a middle aged male with
symptoms of dyspepsia. Your first concern in
managing this patient is to determine if the
dyspepsia is related to peptic ulcer disease.
This generally requires endoscopy, which is a
minimally invasive, but a relatively expensive
diagnostic test. To decrease the use of
endoscopy, you have been considering the
strategy of testing for H. pylori, treating those
that are positive, and then doing an
endoscopy on those that remain symptomatic.
Clinical Scenario
The standard laboratory ELISA has been the
favored screening test for H. pylori but this
test can take days to accomplish. Recently you
have read about more convenient in-office or
"near patient" whole-blood tests (such as
FlexSure) that can show results within hours.
Before you consider a change in practice, you
want to find out if the these "near patient"
tests, such as FlexSure, are as sensitive as the
"gold standard" ELISA test for detecting H.
pylori.
Steps in Practicing
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Interventi
on
Comparis Outcome
on
Adults with
suspected
H. pylori
The "near
patient"
wholeblood tests
such as
FlexSure
Gold
standard:
the ELISA
assay
Diagnosis
of
Helicobact
er pylori
infection
Steps in Practicing
EBM
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The Evidence
Duggan AE, Elliott, C. Logan
RF.Testing for Helicobacter pylori
infection: validation and diagnostic
yield of a near patient test in primary
care. BMJ. 319(7219):1236-9,1999
Nov 6.
Testing for Helicobacter pylori infecti
on - validation and diagnostic yield o
f a near patient test in primary
care.pdf
Steps in Practicing
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2 x 2 Table
Disease
Totals
Presen Absent
t
Diagnosti Positive
a
b
a+b
c
Negativ
c
d
c+d
Test
e
Totals
a+c
b+d a+b+c
Sensitvity = a/(a+c).
+d
Specificity = d/(b+d).
Positive Predictive Value = a/(a+b).
Negative Predictive Value = d/(c+d).
But,
The prevalence of MD is 1 in 5000 (0.02%)
HARM!
Another Example:
Mammography
Mammography in women between 4050 yrs
If 100,000 women are screened:
6,034 mammograms will be abnormal
5,998 (99.4%) will be false-positive
36 will actually have breast cancer
Why? Prevalence = 0.036%
Hamm RM. J Fam Pract 1998;47:44-52.
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Technical precision
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Technical precision
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Clinical precision
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Clinical precision
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Technical Precision
Specificity: Remember SpPin
When a test has a high Specificity, a
Positive test rules IN the disorder.
Sensitivity: Remember SnNout
When a test has a high Sensitivity, a
Negative result rules OUT the disorder.
Yes
Yes
Yes
Test-Treatment Thresholds
Do not
test
Do not
test
.10
Get on
with
treatment
Do not
treat
.20
.30
.40
.50
.60
.70
.80
.90
Clinical Probability
Clinical features
of presentation
including
characteristics of
patient, history,
Test (can
and exam.
include
Pre-Test
Probability
distinct
features of
presentation
in history or
examination).
High PostTest
Probability
Knowing
likelihood ratio
allows you to
calculate posttest
probability
Low Post-Test
Probability
Likelihood ratio
FlexSure Positive
FlexSure negative
Totals
H. pylori ELISA
Positiv Negati
e
ve
90
5
44
236
134
241
Totals
95
280
375
Probably yes
Steps in Practicing
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Steps in Practicing
EBM
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Questions?