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The results of the combination of these characteristics generated a score in which each corresponds to a point, as shown in Table 3. Table 2 Open in a separate window Table 3 Score and performance of clinical score, consisting of absence of rhinorrhea, oropharyngeal erythema, and exudate for the clinical diagnosis of streptococcal pharyngotonsillitis.
Open in a separate window As expected, it can be observed that the higher the score, the greater the specificity and the lower the sensitivity of the clinical picture. Thus, a score of 3 points, or the presence of the three characteristics absence of rhinorrhea, oropharyngeal exudate, and oropharyngeal erythema corresponds to a sensitivity of Several studies have been published aiming to elucidate the clinical picture accuracy for the etiological diagnosis of APT in children, with variable results.
Therefore, the importance of the present study is emphasized, conducted in a country where RF and its complications are a major public health problem. However, none of these characteristics is unique to streptococcal or viral APT.
Moreover, none of them show, concomitantly, high sensitivity and specificity for the diagnosis of streptococcal APT. Furthermore, the characteristics statistically associated with the presence of GAS in this study, namely, the absence of rhinorrhea, absence of conjunctivitis, oropharyngeal erythema, oropharyngeal exudate, and tonsillar hypertrophy, were different from those obtained in other studies performed in Brazil.
None of the characteristics analyzed in this study showed a high likelihood ratio. It was observed, however, that both exanthema and palatal petechiae showed wide confidence intervals that include 1, which makes the results inaccurate and of little significance.
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In an attempt to increase the diagnostic usefulness of the clinical picture, some authors have proposed the use of clinical prediction scores. Thus, McIsaac et al 6 obtained a score with a sensitivity and specificity of However, the sample used by these authors consists mostly of adult patients, although their score is corrected for age.
Smeesters et al 8 and Joachim, Campos and Smeesters 9 developed their scores aiming to diagnose cases of non-streptococcal APT. Nonetheless, the aim of these scores is to provide an alternative to microbiological tests for the correct management of the APTs, that is, to provide adequate antibiotic therapy when required and avoid its use when unnecessary, especially given the current concern with bacterial resistance development.
This also corresponds to a likelihood ratio of 1. As the score has low sensitivity, it does not allow ruling out the diagnosis of streptococcal APT only by this criterion. Despite the moderate specificity, the score of 3 points has a likelihood ratio that is considered low. Considering the important impact of APT, especially RF and RC, particularly in less developed countries, it is necessary to consider and define what would be the best strategy for the diagnosis and management of APTs, taking into account individual and collective risks, availability of laboratory tests for the diagnosis, the limitations of these tests, and the costs of each strategy, without losing sight of the possible complications of each one.
Thus, some authors have made efforts to define which strategy would be the most appropriate for APT management. Nevertheless, this extrapolation is only a theoretical exercise, as the information used by these researchers may not apply to Brazil, in the context of the abovementioned considerations on the variability of APT between different regions.
Moreover, the clinical criteria used by the Spanish authors differ from those found in this study. The literature review showed only one study that, as the present, used the combination of culture and rapid antigen detection test as the reference standard.
In the present, all patients were submitted to the two tests. Considering that, in practice, the positive result of both the culture and the RADT should be seen as positive, it is considered that the methodology applied in this study is closer to the reality.
Furthermore, the use of two highly specific tests reduces the possibility of false negative results, by increasing the standard sensitivity. This study has some limitations. First, due to the incapacity of reference standards, LPAT, culture, or a combination of both, to differentiate patients with GAS, one may have underestimated the actual accuracy of the clinical picture for the diagnosis for APT.
Moreover, as the study had a cross-sectional design, the impact that subsequent assessments might have on clinical picture accuracy could not be assessed. That would be important, as a frequent conduct in APT cases is to wait for the evolution within 24 to 48 hours to reassess children and define the therapeutic strategy.
No studies in the literature that used such approach were found. Thus, it would be important, given the information already available and the contribution of this work, to perform longitudinal studies to sequentially evaluate patients and assess whether such a measure would increase the diagnostic accuracy of the clinical picture.
The present results show that the clinical picture should not be used alone to confirm the episode of streptococcal APT. Even when some clinical features are combined, the resulting positive likelihood ratio does not allow increasing the post-test likelihood to a sufficiently high value to confirm the diagnosis of streptococcal APT.
It is necessary to increase the availability of confirmatory laboratory tests, especially RADT, which allows a rapid and accurate diagnosis of the streptococcal APT episode. In view of the Brazilian reality, where there is scarce availability and request for confirmatory laboratory tests in a continuous feedback, it would be important that medical societies, such as the Brazilian Society of Pediatrics, the Brazilian Society of Infectious Diseases, and the Brazilian Society of Cardiology, as well as the Ministry of Health, issue a recommendation for the correct diagnosis and management of APT.Acta Med Port.
A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Em que momento percebi que estava sozinha, fiz uma retrospectiva da minha vida. Ceus e terra, clamai, aonde? Considering that, in practice, the positive result of both the culture and the RADT should be seen as positive, it is considered that the methodology applied in this study is closer to the reality.
In the second half of the 20th century, the development of more sophisticated analytical techniques, such as gas chromatography, has allowed the separation and identification of volatile compounds from complex biological matrices, such as exhaled breath. Veja maisProblemas na algar oral:
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