1. Systematic review: Accuracy of fetal echocardiography Final presentation Introdução à Medicina Anual project 2005/2006 Class 22

2. 1. Introduction Fetal Echocardiography is the only way we can study fetal heart. This technique requires the use of high-resolution ultrasound equipment with M-mode, pulsed and colour Doppler imaging capabilities ( pictures 1, 2, 3 and 4) [1]. Congenital heart disease has been reported to occur in 8/1000 live births. Prenatal diagnosis of congenital heart disease is crucial to optimal obstetric and neonatal care. In utero identification of congenital heart disease allows a variety of treatment options to be considered, including delivery at an appropriate facility, termination of pregnancy and in some cases in utero therapy. Systematic review: accuracy of fetal echocardiography Class 22 Picture 1: M- mode Picture 2: Pulsed Doppler Picture 3: Colour Doppler Picture 4: Power Doppler [1]:Julia A. Drose, “Fetal Echography”, W.B. Saunders Company Lindsey Allan, Lisa K Hornberger, Gurleen Sharland, “Text Book of fetal cardiology”, GMM

3. 1. Introduction (cont.) Sensitivity and specificity are the most widely used statistics to describe a diagnostic test. sensitivity is the probability of a positive test among patients with disease; specificity is the probability of a negative test among patients without disease. OBJECTIVE: Evaluate the accuracy of fetal echocardiography, in prenatal diagnosis of cardiac anomalies. Databases selected: Pubmed SCOPUS Systematic review: accuracy of fetal echocardiography Class 22 Sensitivity and specificity values

4. 2.1 Articles search 2.2 Abstracts analyse 2.3 Full article search 2.4 Quality criteria 2.5 Descriptive statistics 2.6 Homogeneity/Heterogeneity 2.7 Flowchart – planification of the tasks 2.1 Articles search 2.2 Abstracts analyse 2.3 Full article search 2.4 Quality criteria 2.5 Descriptive statistics 2.6 Homogeneity/Heterogeneity 2.7 Flowchart – planification of the tasks 2. Methods Group of tasks that the systematic review includes; Systematic review: accuracy of fetal echocardiography Class 22

5. 2.1 Articles search (Pubmed) Systematic review: accuracy of fetal echocardiography Class 22 #1 ( (((((("sensitivity and specificity"[All Fields] OR "sensitivity and specificity/standards"[All Fields]) OR "specificity"[All Fields]) OR"screening"[All Fields]) OR "false positive"[All Fields]) OR "false negative"[All Fields]) OR "accuracy"[All Fields]) OR ((("predictive value"[All Fields] OR "predictive value of tests"[All Fields]) OR "predictive value of tests/standards"[All Fields]) OR "predictive values"[All Fields]) OR "predictive values of tests"[All Fields]) ) #2 (("reference value"[All Fields] OR "reference values"[All Fields]) OR "reference values/standards"[All Fields]) #3 ((((((((((("roc"[All Fields] OR "roc analyses"[All Fields]) OR "roc analysis"[All Fields]) OR "roc and"[All Fields]) OR "roc area"[All Fields]) OR "roc auc"[All Fields]) OR "roc characteristics"[All Fields]) OR "roc curve"[All Fields]) OR "roc curve method"[All Fields]) OR "roc curves"[All Fields]) OR "roc estimated"[All Fields]) OR "roc evaluation"[All Fields]) ((((( #1 OR #2) OR #3) OR "likelihoodratio"[All Fields]) AND notpubref [sb]) AND "human"[MeSH Terms]) The final sentence will be: (((( #1 OR #2) OR #3) OR "likelihoodratio"[All Fields]) AND notpubref [sb]) This research ensures that we can find all the articles related to tests of sensitivity and specificity. To adapt it to the subject of this work we added: AND ("echocardiography" OR echocardiography[MeSH Terms]) AND (Heart Defects, Congenital[MeSH Terms] OR "cardiac anomalies" Our strategy: We divided in parts the sentence from the article used [2] for the search : We divided in parts the sentence from the article used [2] for the search : [ 2] “BMC Medical Research Methodology”, Conducting systematic reviews of diagnostic studies: didactic guidlines (www.biomedcentral.com/1471-2288/2/9 )www.biomedcentral.com/1471-2288/2/9 1044 articles found

6. We adapted the query used in Pubmed to the SCOPUS software, by making the following changes:  substitute All Fields and Mesh Terms for ALL. Inicial Query: (((((((((((ALL("sensitivity and specificity") OR ALL("sensitivity and specificity/standards")) OR ALL("specificity")) OR ALL("screening")) OR ALL("false positive")) OR ALL("false negative")) OR ALL("accuracy")) OR (((ALL("predictive value") OR ALL("predictive value of tests")) OR ALL("predictive value of tests/standards")) OR ALL("predictive values")) OR ALL("predictive values of tests"))) OR (ALL("reference value") OR ALL("reference values") OR ALL("reference values/standards"))) OR ((((((((((((ALL("roc") OR ALL("roc analyses")) OR ALL("roc analysis")) OR ALL("roc and")) OR ALL("roc area")) OR ALL("roc auc")) OR ALL("roc characteristics")) OR ALL("roc curve")) OR ALL("roc curve method")) OR ALL("roc curves")) OR ALL("roc estimated")) OR ALL("roc evaluation")))) AND (("echocardiography" OR ALL("echocardiography")) AND ALL(congenital heart defects) OR ALL("cardiac anomalies"))) subsequent additions: Systematic review: accuracy of fetal echocardiography Class 22 2.1 Articles search (SCOPUS) AND ( EXCLUDE(PUBYEAR,2006) ) AND (EXCLUDE(SUBJAREA, "VETE")) AND ALL(Fetus OR Fetuses OR fetal OR prenatal OR antenatal OR perinatal OR embryonic OR pregnancy OR pregnant OR pregnancies OR obstetric OR gestation OR utero OR feto OR fetos OR pré-natal OR gravidez OR grávida OR gestação OR útero) 810 articles found

7. SEARCH RESULTS Each article was submitted to analyses, to evaluate how it can be relevant to our study Systematic review: accuracy of fetal echocardiography Class 22 Pubmed 1044 articles SCOPUS 810 articles 1854 articles 2.1 Articles search (cont) We used the program EndNote to compare the articles from Pubmed with the articles from SCOPUS. We had removed 158 articles that were repeated. 1854 – 158 = 1696 1696 articles TOTAL

8. INCLUSION/EXCLUSION CRITERIA: We selected articles which fullfil the following criteria:  To be applied to humans, fethus, in particular;  Refer the echocardiography as the only diagnostic test used;  Cardiac anomalies as subject of study;  Articles with their abstracts available;  Sensitivity and specificity studies;  Language: english or portuguese. Each article was reviewed by two students; in cases of discordance prevailed the decision of a third reviewer; Systematic review: accuracy of fetal echocardiography Class 22 2.2 Abstract’s analyse 157 (Pubmed) + 91 (SCOPUS) articles included

9. 2.3 Full article search The full articles were searched, according to the following order: Systematic review: accuracy of fetal echocardiography Class 22 1st: Through Web:  Pubmed;  SCOPUS;  Google; 2nd: Faculty Library; which indicated us in which department was the article available. 3rd: Contact autor(s) by e-mail; 14 articles included

10. 2.4 Quality criteria STARD checklist [3]: –It is a 25 item document that classifies articles quality, based on the total items fulfiled: –If an article has a caracteristic we atribute 1 point, if not we atribute 0 points. Finally, we added up all the points and verificate the result obtained. Systematic review: accuracy of fetal echocardiography Class 22 [3] “Towards complete and Accurate Reporting of Studies of diagnostic Accuracy: The STARD Initiative” – Patrick M. Bossuyt et al; available on http/www.annals.org.

11. Metadisc was the statistical software selected; We analysed the following information: True Positives True Negatives False Positives False Negatives Positive predicted value Negative predicted value Likelihood ratio The software designed a Forest Plot, indicating the sensitivity and specificity values of the diagnostic test in study. 2.5 Descriptive statistics Systematic review: accuracy of fetal echocardiography Class 22

12. 2.6 Homogeneity vs Heterogeneity It is important to know if the variance found is or is not the result of the variability of the sample. STRATEGY: a) evaluate the heterogeneity’s degree; b) find and explore the causes c) interpret these results in the context of the problem; Chi-square test Chi-square test : a statistical software which analyses the degree of homogeneity/heterogeneity, by calculating the p value: Systematic review: accuracy of fetal echocardiography Class 22 If p > 0,05 Homogeneous study If p < 0,05 Heterogeneous study (95% confidence interval)

13. 2.7 Flowchart This flowchart is a resume of our methods. Systematic review: accuracy of fetal echocardiography Class 22

14. 3. Results Systematic review: accuracy of fetal echocardiography Class 22 QUALITY RESULTS PMIDTOTAL 1212469414 1625030714 1210041316 882681115 1532055216 157164818 159588217 1223571919 1032581113 777862717 157163810 1223571919 368536415 1223159818 Tab1: quality’s degree of the articles included in our study. This result refers to a scale from 0 to 25 as already seen in Methods

15. SENSITIVITY RESULTS Graph1: studies with high sensitivity Graph2: studies with low sensitivity

16. Systematic review: accuracy of fetal echocardiography Class 22 SPECIFICITY RESULTS Graph 3: Specificity

17. 4. Conclusion/Discussion Systematic review: accuracy of fetal echocardiography Class 22 There was a great variance of quality among the articles found. The quality mean – 15,8 (out of 25) – reveal that these articles have a reasonable classification in terms of quality. Different values of sensitivity Different populations Different methods Four-chamber view Extended Echocardiography High risk population Low risk population Low sensitivity values High sensitivity values All the articles had a very high specificity value

18. 4. Conclusion/Discussion Systematic review: accuracy of fetal echocardiography Class 22 Nowadays… … four-chamber view in low risk population … extended echocardiography in high risk population However… … most neonates with congenital heart disease are born in women without any previous known risk factors … four-chamber less expensive less human resources … high risk population the sensitivity tends to be higher with both techniques

19. 4. Conclusion/Discussion Systematic review: accuracy of fetal echocardiography Class 22 We are able to conclude… … the four-chamber view may be enough to detect cardiac anomalies in high risk population … the four-chamber view appears to be ineffective in low risk population as a screening method … the screening technique to be used should be the extended echocardiography. In the future, it would be useful to investigate a way to make the extended echocardiography affordable so it can be used as a screening method

20. Sofia Pina Tânia Abreu Tânia Afonso Tiago Rito Systematic review: accuracy of fetal echocardiography Class 22 Class 22: Tiago Cardoso Telma Santos Teresa Bastos Vítor Ferreira Zoe Costa

21. Systematic review: accuracy of fetal echocardiography Class 22