COVID-19 Preprocedural Testing: What About the False Positives?

In the COVID-19 era, preprocedural patients are almost uniformly screened for symptoms, asked to quarantine preoperatively, and then undergo a test of uncertain validity with very low pretest probability. A small percentage of these tests return positive. As a result, surgical procedures are delayed and patients are required to quarantine. Are these asymptomatic patients truly positive for COVID-19? What are the impacts of these test results on the patient and the health care system? In the following commentary, we review how the uncertain validity of reverse transcription polymerase chain reaction testing combined with a low-prevalence population predisposes for false-positive results. As a mitigation strategy, we ask that readers refocus on the fundamental principal of diagnostic testing: pretest probability.

Behaviors Interfering with Audiometry Associated with Eventual Diagnosis of Autism.

Children referred for audiology evaluation due to speech and language delays represent a neurodevelopmentally high-risk group. The audiology evaluation is a behaviorally-challenging encounter early in the diagnostic process. We assessed interfering behaviors (IB) that complicated completion of audiometry as predictors of autism spectrum disorder (ASD) diagnosis. This retrospective cohort study using the Military Health System electronic medical record included 296 children aged 18 to 71 months. Children who displayed IB had increased odds of receiving an ASD diagnosis compared to those who did not (OR = 5.6, 95% CI 2.6-12.1). Interfering behaviors had a high specificity (81%) and negative predictive value (94%) for ASD. The audiology evaluation may represent an opportunity early in the diagnostic process to stratify risk for ASD.

Prevalence of Diagnosed Sleep Disorders and Related Diagnostic and Surgical Procedures in Children with Autism Spectrum Disorders.

OBJECTIVE: Sleep disorders are common and important comorbid conditions in children with autism spectrum disorder (ASD) and can contribute to cognitive and behavioral problems. Sleep-disordered breathing (SDB) is a diagnosable and treatable cause of behavioral problems in children. We aimed to quantify the relative risk for children with ASD versus controls of being diagnosed with sleep disorders including SDB and undergoing related diagnostic and surgical procedures. METHOD: This retrospective case-cohort study included 48,762 children with ASD aged 2 to 18 years enrolled in the military health system (MHS) from 2000 to 2013. Children with ASD were matched 1:5 by birthdate, sex, and enrollment time to children without an ASD diagnosis. The MHS database was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for sleep disorders or ICD-9-CM and Current Procedural Terminology codes for diagnostic and surgical procedures. Relative risks (RR) and 95% confidence intervals (CI) were determined with binary Poisson regression conditional on the match and adjusting for confounders. RESULTS: Children with ASD were at higher risk of receiving any sleep disorder diagnosis (RR: 1.97 [95% CI, 1.91-2.02]) including SDB (RR: 1.96 [95% CI, 1.88-2.05]). Children with ASD also were at increased risk of undergoing polysomnography (RR: 3.74 [95% CI, 3.56-3.93]) and sleep disorder-related surgery (RR: 1.50 [95% CI, 1.46-1.54]). CONCLUSION: Children with ASD are more likely to be given a sleep disorder diagnosis including SDB and are more likely to undergo related diagnostic and surgical procedures compared with controls without ASD.

Sleep differences among children with autism spectrum disorders and typically developing peers: a meta-analysis.

OBJECTIVE: Sleep problems such as difficulties in sleep initiation, nighttime awakening, and shortened sleep time are often subjectively reported in children with autism spectrum disorder (ASD). However, results of objective studies have been mixed. Our goal was to evaluate the existing data from objective measures using a systematic approach to identify and describe the differences in sleep parameters by comparing total sleep time (TST), sleep latency (SL), and sleep efficiency (SE) in children with ASD with those of typically developing (TD) peers. METHODS: Studies that used objective measures such as actigraphy or polysomnography (PSG) to describe the sleep parameters of TST, SL, and SE in children with ASD compared with children with TD were identified. A meta-analysis was performed for the 10 studies that met inclusion criteria with evaluation of differences in means using random effects models. A total of 343 children with ASD and 221 children with TD were included. Assessments for sources of heterogeneity and publication bias were undertaken. RESULTS: TST for children with ASD was on average 32.8 minutes less per day (95% confidence interval [CI]: 16.6-49.0 minutes) than their TD peers. Average SL was 10.9 minutes longer (95% CI: 6.7-15.0 minutes), and average SE was 1.9% less (95% CI: 0.7%-3.1%) than their TD peers. Notable heterogeneity was found within studies for TST, and mild heterogeneity was found for SE. Concurrent intellectual disability was a moderator of TST. Children with ASD and normal intelligence had a small and nonsignificant decrease in TST as compared with TD peers, whereas those with ASD and intellectual disability (ID) had a significant decrease in TST as compared with TD peers. The magnitude of the difference in mean SL and SE increased as compared with TD peers as age increased. Studies that used PSG and those that did not include children on medications were more likely to report mean decreases in SE. CONCLUSIONS: Children with ASD have small but measurable objective differences in their sleep parameters that are consistent with subjective reporting. Children with ASD have shorter TST, longer SL periods, and decreased SE as compared with TD peers. Concurrent ID, medication use, method of data collection, and age of subjects significantly moderated these results. The decrease in TST in children with ASD and normal intelligence was not significant as compared with TD peers, suggesting that ID may help explain the shortened TST in children with ASD.