Search

Bell J.M.1, Shields M.1, Angus A.2, Dunlop K.3, Bourke T.1, Kee F.1, Lynn F.A.1 1Queen’s University Belfast, Belfast, UK, 2Belfast Health & Social Care Trust, Belfast, UK, 3South Eastern Health and Social Care Trust, Belfast, UK OBJECTIVES: To establish if the procalcitonin (PCT) test’s diagnostic performance is more clinically and cost-effective than C reactive protein (CRP) and White Cell Count (WCC) tests for suspicion of prodomal stage Meningococcal disease (MD) in children presenting at emergency department (ED) with a fever without source. METHODS: A decision analytic model was designed to reflect realistic clinical pathways for a child presenting with non-specific fever to ED. Test accuracy was evaluated using data from independent studies carried out in developed countries identified through a systematic literature search. Studies were combined to determine the optimal cut-off value for the PCT, CRP and WCC tests, each as an indicator of MD. Summary Receiver Operator Curve (SROC) analysis was used to determine the inter-study and overall diagnostic performance of each test from the areas under the curve (AUC), with 95% confidence intervals (CIs). Components of each clinical pathway were costed in UK sterling using the National Schedule of Reference Costs 2010-2011. Hospital stays were costed using the appropriate Health Resource Group code. RESULTS: Seven studies involving 881 children with non-specific fever provided data for inclusion. The PCT test was more accurate (sensitivity= 89%, 95%CI= 75-96; specificity= 71%, 95%CI= 37-91) for early MD compared to CRP (sensitivity= 84%, 95%CI= 74-90; specificity= 60%, 95%CI= 44-74) and WCC (sensitivity= 50%, 95%CI= 39-60; specificity= 68%, 95%CI= 54-79). PCT had the best PLR (3.0, 95%CI= 1.8-7.8) to be viable as a rule-in test for MD and a borderline NLR as a rule-out test, making it a better option to either CRP (2.1, 95%CI= 1.4-3.1) or WCC (1.5, 95%CI= 1.0-2.3). Outcomes from the decision analytic model indicated that the PCT test was the most cost-effective (£2547 per patient treated), followed by the combined CRP and WCC test (£3069 per patient treated). CONCLUSIONS: The improved sensitivity and specificity of the PCT test provides a more cost-effective test than the currently recommended CRP and WCC tests.

The writer discusses the patronage of Ambrogio Lorenzetti's frescoes at San Galgano in Montesiepi, Tuscany. She argues that the fresco cycle may have been commissioned by Ristoro da Selvatella, a member of Cistercian San Galgano, in around 1334–36, as it presents scenes from the legend of Saint Galgano according to the Cistercian Order's own ideals of piety and devotion.

Why do some societies appear to experience little or no racial conflict? Scotland, for example, is perceived as having no race relations problem but, argue Miles and Dunlop, this does not mean an absence of racism. What distinguishes Scotland, they believe, is the absence of a ‘racialization of the political process’.