An 80-year-old male presents with severe right arm pain after he tripped and fell down 2 steps. Examination shows deformity and swelling to his right upper arm. You obtain AP and lateral humerus x-rays as above.
Adolescent suicide rates in the United States, partly augmented by the COVID-19 pandemic, are steadily increasing [1, 2]. A commonly used screening tool is the 4-question Ask Suicide-Screening Questions (ASQ) instrument, which has a sensitivity and specificity of 60% and 92.7%, respectively, in predicting suicide-related events within 3 months. This was derived from a retrospective study of 15,003 pediatric patients (age 10-18 years) [3]. Given the morbidity and mortality associated with suicide attempts, is there a better screening tool with a higher sensitivity than 60%, while also maintaining adequate specificity? A higher sensitivity rate ensures that we have fewer misses.
In JAMA Psychiatry 2021, the Pediatric Emergency Care Applied Research Network (PECARN) researchers report derivation and external validation data for their suicide screening tool, called the Computerized Adaptive Screen for Suicidal Youth (CASSY) [4]. This publication was actually two studies in one: a derivation of the tool and then an external validation.
This paper assumes that the reader understands certain predictive analytics methodologies and test design concepts. Let’s briefly review some of the foundational terminology used:
A total of 6,536 adolescents (age 12-17 years) from 13 PECARN emergency departments were enrolled and a subset were randomly received follow-up in 3 months to assess for a suicide attempt. These patients responded to 92 questions on a computer tablet. Using a multidimensional item response theory approach, the more correlated questions (72) were used to create the CASSY tool.
A total of 4,050 adolescents from 14 PECARN emergency departments were enrolled, and all received 3-month follow-up assessing for a suicide attempt. These patients completed the CASSY tool, as well as a subset of questions from study 1 for comparison. The frequency of questions used in the adaptive screen are itemized in the paper.
Although there was strong study rigor by deriving and independently validating the tool in separate, multicenter populations, it should be noted that generalizability may be affected.
The CASSY tool accurately serves as a screening predictive tool for adolescents at risk for a suicide attempt in 3 months. Rather than having patients complete exhaustively long (and practically unfeasible) screening questions in the emergency department, this computerized adaptive tool required only a mean of 11 questions, which took a median time of 1.4 minutes (IQR 0.98-2.06 minutes) to complete.
We asked the authors this question, and the answer is in the podcast below.
Listen more with author Dr. Jacqueline Grupp-Phelan talking with ALiEM podcast host, Dr. Dina Wallin, about this landmark paper and behind-the-scenes issues not included on the paper.
This blog post was expert peer-reviewed by Drs. King and Grupp-Phelan, who authored the paper.
A 27-year-old female presents with left knee pain after a low-speed motor vehicle collision in which her knee hit the dashboard. She is tender over the patella without significant effusion and has an intact extensor mechanism. The above x-ray was obtained (Image 1. X-ray left knee. Case courtesy of Dr. M. Mourits, Radiopaedia.org, rID: 14476).
An 18-year-old football player presents to the Emergency Department after an episode of transient numbness, tingling, and inability to move his right upper extremity after making a tackle. He continued playing without recurrence. The above imaging was obtained (Figure 1. Lateral cervical spine x-ray. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 32505).
A 17 year-old female who recently started training for a marathon presents with progressively severe pain over her midfoot, notable for point tenderness over the 2nd metatarsal shaft. The above image was obtained (Image 1. X-ray of the left foot. Image courtesy of Matthew Negaard, MD). (more…)
A 20-year-old male presents with right posterior thigh pain and difficulty walking after he felt a “pop” while sprinting in a race. An ultrasound of the right posterior thigh is performed and the above image is seen on the transverse view without compression (Image 1. ST- semitendinosus; BF – bicep femoris; H – hematoma. Courtesy of Matthew Negaard, MD).
Figure 1: Case Courtesy of Dr. Peter M. Martin
