The global rise in deaths caused by pulmonary tuberculosis (TB) has placed increased pressure on overburdened healthcare systems to provide TB diagnostic services. Artificial intelligence-based computer-aided diagnosis (AI-based CAD) promises to be a powerful tool in responding to this health challenge by providing actionable outputs which support the diagnostic accuracy and efficiency of clinicians. However, these technologies must first be extensively evaluated to understand their impact and risks before pursuing wide-scale deployment. Yet, health technology assessments for them in real world settings have been limited. Comprehensive evaluation demands consideration of technical safety, human factors, and health impacts to generate robust evidence and understand what is needed for long-term sustainable benefit realisation. This work-in progress study presents a three-stage methodological approach that will be used to guide the data collection and analysis process for evaluating the impact of implementing a commercial AI-based CAD system for TB diagnosis in a real-world radiological setting.

Authors' objectives: Objective The aim of this health technology assessment (HTA) is to evaluate the safety, effectiveness and economic impact of folate testing in an asymptomatic general population and in patients with suspected folate deficiency due to the presence of symptoms, underlying medical disorders or external factors. In addition, ethical, legal, social and organisational issues related to folate testing are investigated.

BACKGROUND: People forced to leave their homes, such as refugees and internally displaced persons, are exposed to various stressors during their forced displacement, putting them at risk for mental disorders. OBJECTIVE: To summarize evidence on the efficacy of psychosocial interventions aiming to promote mental health and/or to prevent mental symptoms by fostering transdiagnostic skills in forcibly displaced persons of all ages. METHOD: Four databases and reference lists were searched for randomized controlled trials on interventions in this population on 11 March 2022. Thirty-six studies were eligible, 32 studies (comprising 5299 participants) were included in random-effects multilevel meta-analyses examining the effects of interventions on mental symptoms and positive mental health (e.g. wellbeing) as well as moderators to account for heterogeneity. OSF Preregistration-ID: 10.17605/OSF.IO/XPMU3 RESULTS: Our search resulted in 32 eligible studies, with 10 reporting on children/adolescents and 27 on adult populations. There was no evidence for favourable intervention effects in children/adolescents, with 44.4% of the effect sizes pointing to potentially negative effects yet remaining non-significant. For adult populations, our meta-analyses showed a close-to-significant favourable effect for mental symptoms, M(SMD) = 0.33, 95% CI [-0.03, 0.69], which was significant when analyses were limited to high-quality studies and larger for clinical compared to non-clinical populations. No effects emerged for positive mental health. Heterogeneity was considerable and could not be explained by various moderators (e.g. type of control, duration, setting, theoretical basis). Certainty of evidence was very low across all outcomes limiting the generalizability of our findings. CONCLUSION: The present review provides at most weak evidence for an effect favouring transdiagnostic psychosocial interventions over control conditions for adult populations but not for children and adolescents. Future research should combine the imperative of humanitarian aid in face of major crises with studying the diverse needs of forcibly displaced persons to improve and tailor future interventions.

Introduction: Despite common, serious, costly, and often fatal conditions affecting up to 50 % of older patients, delirium is often unrecognized and overlooked. We examine the accuracy of the 4AT for detecting older patients with delirium.Methods: We performed a systematic search of PubMed, Web of Science, PsycINFO, and EMBASE databases from inception to April 2020 and updated to January 2022. Four independently reviewers extracted study data and assessed the methodological quality using the revised quality assessment of diagnostic accuracy studies tool (QUADAS-2). Pooled estimates of sensitivity and specificity were generated using a bivariate random effects model. All statistical analyses were performed with STATA version 15.1 and Meta-DiSc version 1.4 software. Results: Eleven studies with 2789 participants were included. The pooled sensitivity and specificity were 0.87 (95 % CI: 0.81-0.91) and 0.87 (95 % CI: 0.79-0.92), respectively, and the positive and negative likelihood ratios were 6.66 (95 % CI: 4.12-10.74) and 0.15 (95 % CI: 0.10-0.23), respectively. Deeks' test indicated no significant publication bias (t = 0.83, P = 0.43). Univariable meta-regression showed that patient selection and flow and timing significantly influenced the pooled sensitivity (P < 0.05), settings significantly influenced the pooled specificity (P < 0.05).Conclusion: Our meta-analysis demonstrates that 4AT is a sensitive and specific screening tool for delirium in older patients. Its brevity and simplicity support its use in routine clinical practice, particularly in time-poor settings. Clinicians should come to a conclusion based largely on the 4AT findings in conjunction with clinical judgment.

INTRODUCTION: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. METHODS: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. RESULTS: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). CONCLUSIONS: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy.

Background: EarlyCDT Lung (Oncimmune Holdings plc, Nottingham, UK) is a blood test to assess malignancy risk in people with solid pulmonary nodules. It measures the presence of seven lung cancer-associated autoantibodies. Elevated levels of these autoantibodies may indicate malignant disease. The results of the test might be used to modify the risk of malignancy estimated by existing risk calculators, including the Brock and Herder models. Objectives: The objectives were to determine the diagnostic accuracy, clinical effectiveness and cost-effectiveness of EarlyCDT Lung; and to develop a conceptual model and identify evidence requirements for a robust cost-effectiveness analysis. Data sources: MEDLINE (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE), EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, EconLit, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database (NHS EED) and the international Health Technology Assessment database were searched on 8 March 2021. Review methods: A systematic review was performed of evidence on EarlyCDT Lung, including diagnostic accuracy, clinical effectiveness and cost-effectiveness. Study quality was assessed with the quality assessment of diagnostic accuracy studies-2 tool. Evidence on other components of the pulmonary nodule diagnostic pathway (computerised tomography surveillance, Brock risk, Herder risk, positron emission tomography-computerised tomography and biopsy) was also reviewed. When feasible, bivariate meta-analyses of diagnostic accuracy were performed. Clinical outcomes were synthesised narratively. A simulation study investigated the clinical impact of using EarlyCDT Lung. Additional reviews of cost-effectiveness studies evaluated (1) other diagnostic strategies for lung cancer and (2) screening approaches for lung cancer. A conceptual model was developed. Results: A total of 47 clinical publications on EarlyCDT Lung were identified, but only five cohorts (695 patients) reported diagnostic accuracy data on patients with pulmonary nodules. All cohorts were small or at high risk of bias. EarlyCDT Lung on its own was found to have poor diagnostic accuracy, with a summary sensitivity of 20.2% (95% confidence interval 10.5% to 35.5%) and specificity of 92.2% (95% confidence interval 86.2% to 95.8%). This sensitivity was substantially lower than that estimated by the manufacturer (41.3%). No evidence on the clinical impact of EarlyCDT Lung was identified. The simulation study suggested that EarlyCDT Lung might potentially have some benefit when considering intermediate risk nodules (10-70% risk) after Herder risk analysis. Two cost-effectiveness studies on EarlyCDT Lung for pulmonary nodules were identified; none was considered suitable to inform the current decision problem. The conceptualisation process identified three core components for a future cost-effectiveness assessment of EarlyCDT Lung: (1) the features of the subpopulations and relevant heterogeneity, (2) the way EarlyCDT Lung test results affect subsequent clinical management decisions and (3) how changes in these decisions can affect outcomes. All reviewed studies linked earlier diagnosis to stage progression and stage shift to final outcomes, but evidence on these components was sparse. Limitations: The evidence on EarlyCDT Lung among patients with pulmonary nodules was very limited, preventing meta-analyses and economic analyses. Conclusions: The evidence on EarlyCDT Lung among patients with pulmonary nodules is insufficient to draw any firm conclusions as to its diagnostic accuracy or clinical or economic value.

BACKGROUND: The number of people with chronic diseases and the subsequent pressure on health care is increasing. eHealth technology for diagnostic testing can contribute to more efficient health care and lower workload. OBJECTIVE: This systematic review examines the available methods for direct web-based access for patients to diagnostic testing and results in the absence of a health care professional in primary care. METHODS: We searched the PubMed, Embase, Web of Sciences, Cochrane Library, Emcare, and Academic Search Premier databases in August 2019 and updated in July 2021. The included studies focused on direct patient access to web-based triage leading to diagnostic testing, self-sampling or testing, or web-based communication of test results. A total of 45 studies were included. The quality was assessed using the Mixed Methods Appraisal Tool. RESULTS: Most studies had a quantitative descriptive design and discussed a combination of services. Diagnostic test services mainly focused on sexually transmitted infections. Overall, the use was high for web-based triage (3046/5000, >50%, who used a triage booked a test), for self-sampling or self-testing kits (83%), and the result service (85%). The acceptability of the test services was high, with 81% preferring home-based testing over clinic-based testing. There was a high rate of follow-up testing or treatment after a positive test (93%). CONCLUSIONS: The results show that direct access to testing and result services had high use rates, was positively evaluated, and led to high rates of follow-up treatment. More research on cost-effectiveness is needed to determine the potential for other diseases. Direct access to diagnostic testing can lower the threshold for testing in users, potentially increase efficiency, and lower the workload in primary care.

Numerous factors contribute to the low adherence to lung cancer screening (LCS) programs. A theory-informed approach to identifying the obstacles and facilitators to LCS uptake is required. This study aimed to identify, assess, and synthesize the available literature at the individual and healthcare provider (HCP) levels based on a social-ecological model and identify gaps to improve practice and policy decision-making. Systematic searches were conducted in nine electronic databases from inception to December 31, 2020. We also searched Google Scholar and manually examined the reference lists of systematic reviews to include relevant articles. Primary studies were scored for quality assessment. Among 3938 potentially relevant articles, 36 studies, including 25 quantitative and 11 qualitative studies, were identified for inclusion in the review. Fifteen common factors were extracted from 34 studies, including nine barriers and six facilitators. The barriers included individual factors (n = 5), health system factors (n = 3), and social/environmental factors (n = 1). The facilitators included only individual factors (n = 6). However, two factors, age and screening harm, remain mixed. This systematic review identified and combined barriers and facilitators to LCS uptake at the individual and HCP levels. The interaction mechanisms among these factors should be further explored, which will allow the construction of tailored LCS recommendations or interventions for the Chinese context.

PURPOSE: Depression is a symptom commonly encountered in primary care; however, it is often not detected by doctors. Recently, disease diagnosis and treatment approaches have been attempted using smart devices. In this study, instrumental effectiveness was confirmed with the diagnostic meta-analysis of studies that demonstrated the diagnostic effectiveness of PHQ-9 for depression using mobile devices. PATIENTS AND METHODS: We found all published and unpublished studies through EMBASE, MEDLINE, MEDLINE In-Process, and PsychINFO up to March 26, 2021. We performed a meta-analysis by including 1099 subjects in four studies. We performed a diagnostic meta-analysis according to the PHQ-9 cut-off score and machine learning algorithm techniques. Quality assessment was conducted using the QUADAS-2 tool. Data on the sensitivity and specificity of the studies included in the meta-analysis were extracted in a standardized format. Bivariate and summary receiver operating characteristic (SROC) curve were constructed using the metandi, midas, metabias, and metareg functions of the Stata algorithm meta-analysis words. RESULTS: Using four studies out of the 5476 papers searched, a diagnostic meta-analysis of the PHQ-9 scores of 1099 people diagnosed with depression was performed. The pooled sensitivity and specificity were 0.797 (95% CI = 0.642-0.895) and 0.85 (95% CI = 0.780-0.900), respectively. The diagnostic odds ratio was 22.16 (95% CI = 7.273-67.499). Overall, a good balance was maintained, and no heterogeneity or publication bias was presented. CONCLUSION: Through various machine learning algorithm techniques, it was possible to confirm that PHQ-9 depression screening in mobiles is an effective diagnostic tool when integrated into a diagnostic meta-analysis.

BACKGROUND: Point of care testing (POCT) for infectious diseases is testing conducted near the patient. It allows clinicians to offer the most appropriate treatment more quickly. As POCT devices have increased in accuracy and become more cost-effective, their use has grown, but a systematic assessment of their use for clinical and public health management of infectious diseases in EU/EEA countries has not been previously undertaken. METHODS: A scoping review of the literature on POCT in EU/ EEA countries as at November 2019, and a survey of key stakeholders. RESULTS: 350 relevant articles were identified and 54 survey responses from 26 EU/EEA countries were analysed. POCT is available for a range of infectious diseases and in all countries responding to the survey (for at least one disease). POCT is commonly available for influenza, HIV/AIDS, Legionnaires' disease and malaria, where it is used in at least half of EU/EEA countries. While POCT has the potential to support many improvements to clinical care of infectious diseases (e.g., faster diagnosis, more appropriate use of antimicrobials), the results suggest POCT is infrequently used to support public health functions (e.g., disease surveillance and reporting). CONCLUSION: Although POCT is in use to some extent in all EU/EEA countries, the full benefits of POCT in wider public health functions have yet to be realised. Further research on barriers and facilitators to implementation is warranted.

Background: This systematic review aimed to investigate the reliability of ultrasound method compared with digital vaginal examinations in detecting cervical dilation. Methods: We searched Cochrane (CENTRAL), MEDLINE, EMBASE, CINAHL, ISI Web of Science Core Collection, Trip Database, PubMed, DARE and NHS EED, HTA, and PROSPERO. Ten observational studies with a total sample size of 856 were included in the meta-analysis. Results: The intraclass correlation coefficient (ICC) values ranged between 0.21 and 0.69. The fixed-effect models for the ultrasound test showed an average of ICC (r = 0.32 (95% CI 0.26-0.38). Correlation between two methods was poor (r = 0.359, 95% CI 0.26-0.44). In nulliparous and multigravida participants the correlation between ultrasound measurements and digital examinations was (r = 0.349, 95% CI 0.25-0.43) and ICC (r = 0.676, 95% CI 0.419-0.833), respectively. Conclusion: Trans-perineal ultrasonography seems to be a reliable method for assessing labor progression in multigravida women, but its usage in nulliparous women needs further studies.

Background: Standard diagnostic and monitoring methods for glycemic status involve invasive sample collection through venous puncture or fingerstick. Recent attention has been focused on exploring noninvasive methods through oral biofluids. Specifically, serum fructosamine has been established as a short-term (2- to 3-wk) marker of disease status in patients with diabetes. Fructosamine measured through noninvasive means such as saliva has shown promise, but its clinical applicability is unknown. Objective: Evaluate the available evidence on using salivary fructosamine as a reliable noninvasive marker to screen and diagnose patients with diabetes mellitus in the clinical setting. A comparative analysis of the correlative accuracy of salivary fructosamine measurements with established blood glycemic biomarkers such as serum fructosamine, blood glucose, and HbA1c will be conducted. Methods: Six electronic databases (PubMed, PubMed Central, MEDLINE, EMBASE, Scopus, Cochrane Library) were searched for original research papers (clinical and animal studies) that were relevant to the objective of this systematic review. The search was initiated on May 28, 2020. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Bias risk assessment, overall quality, and level of evidence were based on the Oxford Centre for Evidence-Based Medicine, Appraisal Tool for Cross-Sectional Studies, and Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies tool. Heterogeneity was assessed using the National Institutes of Health quality assessment tool for cross-sectional studies. Results: A total of 174 records were identified. Full-text articles screened for eligibility ( = 21) identified only 6 original research articles relevant to the research question and were thus included in the systematic review. The types of studies identified were cross-sectional and in vivo studies. Three studies (3/6) showed positive correlation of salivary fructosamine with blood glucose levels, while 1 study (1/6) demonstrated a positive correlation with glycated hemoglobin (HbA1c). Limitations related to sample size and selection were identified along with a fair level of interstudy heterogeneity. Conclusion: Based on the evidence evaluated, the utility of salivary fructosamine as a noninvasive marker to screen and diagnose patients with diabetes is doubtful. The overall level of evidence was low (IIIB) and the risk of bias was determined to be high. Knowledge transfer statement: Further evidence in the form of large-scale well-controlled studies is needed prior to recommending salivary fructosamine as a noninvasive diagnostic tool for glycemic status in patients with diabetes mellitus.

BACKGROUND: To evaluate the effectiveness of audit and communication strategies to reduce diagnostic errors made by clinicians. METHODS: MEDLINE complete, CINHAL complete, EMBASE, PSNet and Google Advanced. Electronic and manual search of articles on audit systems and communication strategies or interventions, searched for papers published between January 1990 and April 2017. We included studies with interventions implemented by clinicians in a clinical environment with real patients. RESULTS: A total of 2431 articles were screened of which 26 studies met inclusion criteria. Data extraction was conducted by two groups, each group comprising two independent reviewers. Articles were classified by communication (6) or audit strategies (20) to reduce diagnostic error in clinical settings. The most common interventions were delivered as technology-based systems n = 16 (62%) and within an acute care setting n = 15 (57%). Nine studies reported randomised controlled trials. Three RCT studies on communication interventions and 3 RCTs on audit strategies found the interventions to be effective in reducing diagnostic errors. CONCLUSION: Despite numerous studies on interventions targeting diagnostic errors, our analyses revealed limited evidence on interventions being practically used in clinical settings and a bias of studies originating from the US (n = 19, 73% of included studies). There is some evidence that trigger algorithms, including computer based and alert systems, may reduce delayed diagnosis and improve diagnostic accuracy. In trauma settings, strategies such as additional patient review (e.g. trauma teams) reduced missed diagnosis and in radiology departments review strategies such as team meetings and error documentation may reduce diagnostic error rates over time.

Background: Artificial intelligence (AI) has been extensively used in a range of medical fields to promote therapeutic development. The development of diverse AI techniques has also contributed to early detections, disease diagnoses, and referral management. However, concerns about the value of advanced AI in disease diagnosis have been raised by health care professionals, medical service providers, and health policy decision makers. Objective: This review aimed to systematically examine the literature, in particular, focusing on the performance comparison between advanced AI and human clinicians to provide an up-to-date summary regarding the extent of the application of AI to disease diagnoses. By doing so, this review discussed the relationship between the current advanced AI development and clinicians with respect to disease diagnosis and thus therapeutic development in the long run. Methods: We systematically searched articles published between January 2000 and March 2019 following the Preferred Reporting Items for Systematic reviews and Meta-Analysis in the following databases: Scopus, PubMed, CINAHL, Web of Science, and the Cochrane Library. According to the preset inclusion and exclusion criteria, only articles comparing the medical performance between advanced AI and human experts were considered. Results: A total of 9 articles were identified. A convolutional neural network was the commonly applied advanced AI technology. Owing to the variation in medical fields, there is a distinction between individual studies in terms of classification, labeling, training process, dataset size, and algorithm validation of AI. Performance indices reported in articles included diagnostic accuracy, weighted errors, false-positive rate, sensitivity, specificity, and the area under the receiver operating characteristic curve. The results showed that the performance of AI was at par with that of clinicians and exceeded that of clinicians with less experience. Conclusions: Current AI development has a diagnostic performance that is comparable with medical experts, especially in image recognition-related fields. Further studies can be extended to other types of medical imaging such as magnetic resonance imaging and other medical practices unrelated to images. With the continued development of AI-assisted technologies, the clinical implications underpinned by clinicians' experience and guided by patient-centered health care principle should be constantly considered in future AI-related and other technology-based medical research.

BACKGROUND: One-stop clinics provide comprehensive diagnostic testing in one outpatient appointment. They could benefit patients with conditions, such as cancer, whose outcomes are improved by early diagnosis, and bring efficiency savings for health systems. OBJECTIVE: To assess the use and outcomes of one-stop clinics for symptoms where cancer is a possible diagnosis. DESIGN AND SETTING: Systematic review of studies reporting use and outcomes of one-stop clinics in primary care patients. METHOD: We searched MEDLINE, Embase, and Cochrane Library for studies assessing one-stop clinics for adults referred after presenting to primary care with any symptom that could be indicative of cancer. Study selection was carried out independently in duplicate with disagreements resolved through discussion. RESULTS: Twenty-nine studies were identified, most were conducted in the UK and observational in design. Few included a comparison arm. A pooled comparison of the cancer conversion rate of one-stop and multi-stop clinics was only possible for breast symptoms, and we found no significant difference. One-stop clinics were associated with significant reductions in the interval from referral to testing (15 versus 75 days) and more patients diagnosed on the same day (79% versus 25%) compared to multi-stop pathways. The majority of patients and GPs found one-stop clinics to be acceptable. CONCLUSION: This review found one-stop clinics were associated with reduced time from referral to testing, increased same day diagnoses, and were acceptable to patients and GPs. Our conclusions are limited by high levels of heterogeneity, scarcity of comparator groups, and the overwhelmingly observational nature of included studies.

BACKGROUND: The acute respiratory distress syndrome (ARDS) results in substantial mortality but remains underdiagnosed in clinical practice. Automated ARDS "sniffer" systems, tools that can automatically analyze electronic medical record data, have been developed to improve recognition of ARDS in clinical practice. OBJECTIVE: To perform a systematic review examining the evidence underlying automated sniffer systems for ARDS detection. DATA SOURCES: MEDLINE and Scopus databases through October 2018 to identify studies of tools using routinely available clinical data to detect patients with ARDS. DATA EXTRACTION: Study design, tool description, and diagnostic performance were extracted by two reviewers. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate each study for risk of bias in 4 domains: patient selection, index test, reference standard, and study flow and timing. SYNTHESIS: Among 480 studies identified, nine met inclusion criteria, evaluating six unique ARDS sniffer tools. Eight studies were derivation and/or temporal validation designs, with one also evaluating the effect of implementing a tool in clinical practice. A single study performed an external validation of previously published ARDS sniffer tools. Studies reported a wide range of sensitivities (43% to 98%) and positive predictive values (26% to 90%) for detection of ARDS. Most studies had potential for high risks of bias identified in their study design, including patient selection (5 of 9), reference standard (4 of 9), and flow and timing (3 of 9). In the single external validation without any perceived risks of biases, performance of ARDS sniffer tools were worse. CONCLUSIONS: Sniffer systems developed to detect ARDS had moderate to high predictive value in their derivation cohorts, although most studies had potential for high risks of bias in study design. Methodological issues may explain some of the variability in tool performance. There remains an ongoing need for robust evaluations of ARDS sniffer systems and their impact on clinical practice.

PURPOSE: Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners. METHODS: We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS: We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting. CONCLUSIONS: POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.

BACKGROUND: The incidence of oral cancer is increasing. Guidance for oral cancer from the National Institute for Health and Care Excellence (NICE) is unique in recommending cross-primary care referral from GPs to dentists. AIM: This review investigates knowledge about delays in the diagnosis of symptomatic oral squamous cell carcinoma (OSCC) in primary care. DESIGN AND SETTING: An independent multi-investigator literature search strategy and an analysis of study methodologies using a modified data extraction tool based on Aarhus checklist criteria relevant to primary care. METHOD: The authors conducted a focused systematic review involving document retrieval from five databases up to March 2018. Included were studies looking at OSCC diagnosis from when patients first accessed primary care up to referral, including length of delay and stage of disease at time of definitive diagnosis. RESULTS: From 538 records, 16 articles were eligible for full-text review. In the UK, more than 55% of patients with OSCC were referred by their GP, and 44% by their dentist. Rates of prescribing between dentists and GPs were similar, and both had similar delays in referral, though one study found greater delays attributed to dentists as they had undertaken dental procedures. On average, patients had two to three consultations before referral. Less than 50% of studies described the primary care aspect of referral in detail. There was no information on inter-GP-dentist referrals. CONCLUSION: There is a need for primary care studies on OSCC diagnosis. There was no evidence that GPs performed less well than dentists, which calls into question the NICE cancer option to refer to dentists, particularly in the absence of robust auditable pathways.

OBJECTIVE: The number of mobile applications addressing health topics is increasing. Whether these apps underwent scientific evaluation is unclear. We comprehensively assessed papers investigating the diagnostic value of available diagnostic health applications using inbuilt smartphone sensors. METHODS: Systematic Review-MEDLINE, Scopus, Web of Science inclusive Medical Informatics and Business Source Premier (by citation of reference) were searched from inception until 15 December 2016. Checking of reference lists of review articles and of included articles complemented electronic searches. We included all studies investigating a health application that used inbuilt sensors of a smartphone for diagnosis of disease. The methodological quality of 11 studies used in an exploratory meta-analysis was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool and the reporting quality with the 'STAndards for the Reporting of Diagnostic accuracy studies' (STARD) statement. Sensitivity and specificity of studies reporting two-by-two tables were calculated and summarised. RESULTS: We screened 3296 references for eligibility. Eleven studies, most of them assessing melanoma screening apps, reported 17 two-by-two tables. Quality assessment revealed high risk of bias in all studies. Included papers studied 1048 subjects (758 with the target conditions and 290 healthy volunteers). Overall, the summary estimate for sensitivity was 0.82 (95 % CI 0.56 to 0.94) and 0.89 (95 %CI 0.70 to 0.97) for specificity. CONCLUSIONS: The diagnostic evidence of available health apps on Apple's and Google's app stores is scarce. Consumers and healthcare professionals should be aware of this when using or recommending them.

BACKGROUND: Health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations, has been promoted to improve the efficiency, cost-effectiveness, quality, and safety of health care delivery. OBJECTIVE: To systematically review the available research on HIE outcomes and analyze future research needs. METHODS: Data sources included citations from selected databases from January 1990 to February 2015. We included English-language studies of HIE in clinical or public health settings in any country. Data were extracted using dual review with adjudication of disagreements. RESULTS: We identified 34 studies on outcomes of HIE. No studies reported on clinical outcomes (eg, mortality and morbidity) or identified harms. Low-quality evidence generally finds that HIE reduces duplicative laboratory and radiology testing, emergency department costs, hospital admissions (less so for readmissions), and improves public health reporting, ambulatory quality of care, and disability claims processing. Most clinicians attributed positive changes in care coordination, communication, and knowledge about patients to HIE. CONCLUSIONS: Although the evidence supports benefits of HIE in reducing the use of specific resources and improving the quality of care, the full impact of HIE on clinical outcomes and potential harms are inadequately studied. Future studies must address comprehensive questions, use more rigorous designs, and employ a standard for describing types of HIE. TRIAL REGISTRATION: PROSPERO Registry No CRD42014013285; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42014013285 (Archived by WebCite at http://www.webcitation.org/6dZhqDM8t)