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Starting with the Yale School of Medicine (YSM) graduating class of 2002, the Cushing/Whitney Medical Library and YSM Office of Student Research have collaborated on the Yale Medicine Thesis Digital Library (YMTDL) project, publishing the digitized full text of medical student theses on the web as a valuable byproduct of Yale student research efforts. The digital thesis deposit has been a graduation requirement since 2006. Starting in 2012, alumni of the Yale School of Medicine were invited to participate in the YMTDL project by granting scanning and hosting permission to the Cushing/Whitney Medical Library, which digitized the Library’s print copy of their thesis or dissertation. A grant from the Arcadia Fund in 2017 provided the means for digitizing over 1,000 additional theses. IF YOU ARE A MEMBER OF THE YALE COMMUNITY AND NEED ACCESS TO A THESIS RESTRICTED TO THE YALE NETWORK, PLEASE MAKE SURE YOUR VPN (VIRTUAL PRIVATE NETWORK) IS ON.

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Diagnostic test evaluation methodology: A systematic review of methods employed to evaluate diagnostic tests in the absence of gold standard – An update

Chinyereugo m. umemneku chikere.

1 Institute of Health & Society, Faculty of Medical Sciences Newcastle University, Newcastle upon Tyne, England, United Kingdom

Kevin Wilson

2 School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, England, United Kingdom

Sara Graziadio

3 National Institute for Health Research, Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals National Health Services Foundation Trust, Newcastle upon Tyne, England, United Kingdom

A. Joy Allen

4 National Institute for Health Research, Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne, England, United Kingdom

Associated Data

All relevant data are within the manuscript and its supporting information files.

To systematically review methods developed and employed to evaluate the diagnostic accuracy of medical test when there is a missing or no gold standard.

Study design and settings

Articles that proposed or applied any methods to evaluate the diagnostic accuracy of medical test(s) in the absence of gold standard were reviewed. The protocol for this review was registered in PROSPERO (CRD42018089349).

Identified methods were classified into four main groups: methods employed when there is a missing gold standard; correction methods (which make adjustment for an imperfect reference standard with known diagnostic accuracy measures); methods employed to evaluate a medical test using multiple imperfect reference standards; and other methods, like agreement studies, and a mixed group of alternative study designs. Fifty-one statistical methods were identified from the review that were developed to evaluate medical test(s) when the true disease status of some participants is unverified with the gold standard. Seven correction methods were identified and four methods were identified to evaluate medical test(s) using multiple imperfect reference standards. Flow-diagrams were developed to guide the selection of appropriate methods.

Various methods have been proposed to evaluate medical test(s) in the absence of a gold standard for some or all participants in a diagnostic accuracy study. These methods depend on the availability of the gold standard, its’ application to the participants in the study and the availability of alternative reference standard(s). The clinical application of some of these methods, especially methods developed when there is missing gold standard is however limited. This may be due to the complexity of these methods and/or a disconnection between the fields of expertise of those who develop (e.g. mathematicians) and those who employ the methods (e.g. clinical researchers). This review aims to help close this gap with our classification and guidance tools.

Introduction

Before a new medical test can be introduced into clinical practice, it should be evaluated for analytical validity (does the test work in the laboratory?), clinical validity (does the test work in the patient population of interest?) and clinical utility (is the test useful–can it lead to improvement in health outcomes?) [ 1 , 2 ]. Clinical validity studies, also called diagnostic accuracy studies, evaluate the test’s accuracy in discriminating between patients with or without the target condition (disease) [ 3 ]. The characteristics of the test (e.g. sensitivity and specificity) may inform what role the index test (the new test under evaluation) plays in the diagnostic pathway; is it a triage, add-on or replacement test? [ 4 ] Sensitivity (the proportion of participants correctly identified by the index test as having the target condition e.g. those with the disease) and specificity (the proportion of participants correctly identified by the index as not having the target condition) [ 5 – 7 ] are basic measures of the diagnostic accuracy of a test. Other common measures are predictive values, likelihood values, overall accuracy [ 8 , 9 ], receiver operating characteristic (ROC) curve, area under the ROC curve (AUROC) [ 10 ], ROC surface, and volume under the ROC surface (VUS) [ 11 – 13 ]. These measures are obtained by comparing the index test results with the results of the best currently available test for diagnosing the same target condition in the same participants; both tests are supposedly applied to all participants of the study [ 14 ]. The test employed as the benchmark to evaluate the index test is called the reference standard [ 15 ]. The reference standard could be a gold standard (GS), with sensitivity and specificity equal to 100%. This means that the gold standard perfectly discriminates between participants with or without the target conditions and provides unbiased estimates of the diagnostic accuracy measure of the index test as describe in Fig 1 . The term “bias” in this review is defined as the difference between the estimated value and the true value of the parameter of interest [ 16 ].

It is also expected that when evaluating the diagnostic accuracy of a medical test, the participants undertake both the index and reference tests within a short time-period if not simultaneously. This is to avoid biases caused by changes in their true disease status, which can also affect the diagnostic accuracy of the index test.

In addition to the common aforementioned diagnostic accuracy measures, there are other ways to evaluate the test performance of an index test. These include studies of agreement or concordance [ 17 ] between the index test and the reference standard and test positivity (or negativity) rate; that is the proportion of diagnostic tests that are positive (or negative) to the target condition [ 18 ].

In practice, there are deviations from the classical method ( Fig 1 ). These deviations are:

• Scenarios where the gold standard is not applied to all participants in the study (i.e. there is a missing gold standard) because it is expensive, or invasive, or patients do not consent to it, or the clinicians decided not to give the gold test to some patients for medical reasons [ 19 , 20 ]. Evaluating the new test using data only from participants whose disease status was confirmed with the gold standard can produce work-up or verification bias [ 21 ].
• Scenarios where the reference standard is not a gold standard (i.e. it is an imperfect reference standard) because it has a misclassification error or because there is no generally accepted reference standard for the target condition. Using an imperfect reference standard produces reference standard bias [ 22 , 23 ].

Several methods have been developed and used to evaluate the test performance of a medical test in these two scenarios.

Reviews of some of these methods have been undertaken previously. The reviews by Zhou [ 24 ], Alonzo [ 25 ] and the report by Naaktgeboren et al [ 26 ] focused on methods when the gold standard or reference standard is not applied to all participants in the study; Van Smeden et al [ 27 ] and Collins and Huynh [ 28 ] focused on the latent class models (LCMs); and Hui and Zhou [ 29 ], Trikalinos and Balion [ 30 ] and Enoe et al [ 31 ] focused on methods employed when the reference standard is imperfect. Zaki et al [ 32 ] focused on the agreement between medical tests whose results are reported as a continuous response. Branscum et al [ 33 ] focused on Bayesian approaches; and the reviews by Walsh [ 23 ], Rutjes et al [ 14 ] and Reitsma et al [ 34 ] focused around methods for evaluating diagnostic tests when there is a missing or imperfect reference standard.

The existing comprehensive reviews on this topic were published about 11 years ago [ 14 , 34 ]; knowledge, ideas, and research in this field has evolved significantly since then. Several new methods have been proposed and some existing methods have been modified. It is also possible that some previously identified methods may now be obsolete. Therefore, one of the aims of this systematic review is to review new and existing methods employed to evaluate the test performance of medical test(s) in the absence of gold standard for all or some of the participants in the study. It also aims to provide easy to use tools (flow-diagrams) for the selection of methods to consider when evaluating medical tests when sub-sample of the participants do not undergo the gold standard. The review builds upon the earlier reviews by Rutjes et al and Reitsma et al [ 14 , 34 ]. This review sought to identify methods developed to evaluate a medical test with continuous results in the presence of verification bias and when the diagnostic outcome (disease status) is classified into three or more groups (e.g. diseased, intermediate and non-diseased). This is a gap identified in the review conducted by Alonzo [ 25 ] in 2014.

The subsequent sections discuss the method employed to undertake the review, the results, the discussion of the findings and guidance to researchers involved in test accuracy studies.

Methodology

A protocol for this systematic review was developed, peer-reviewed and registered on PROSPERO (CRD42018089349).

Eligibility criteria

The review includes methodological articles (that is papers that proposed or developed a method) and application articles (that is papers where any of the proposed methods) were applied.

• Articles published in English language in a peer-reviewed journal.
• Articles that focus on evaluating the diagnostic accuracy of new (index) test when there is a missing gold standard, no gold standard or imperfect reference standard.
• Articles that assumed that the reference standard was a gold standard and the gold standard was applied to all participants in the study.
• Books, dissertations, thesis, conference abstracts, and articles not published in a peer reviewed journal.
• Systematic reviews and meta-analyses of the diagnostic accuracy of medical test(s) for a target condition (disease) in the absence of gold standard for some or all of the participants. However, individual articles included in these reviews that met the inclusion criteria were included.

Search strategies and selection of articles

The PRISMA statement [ 35 ] was used as a guideline when conducting this systematic review. The PRISMA checklist for this review, S1 Checklist , is included as one of the supplementary materials. The following bibliographic databases were searched: EMBASE, MEDLINE, SCOPUS, WILEY online library (which includes Cochrane library, EBM), PSYCINFO, Web of Science, and CINAHL. The details of the search strategies at reported in the S1 Appendix . The search dates were from January 2005 –February 2019. This is because, this review is an update of a review by Rutjes et al and Reitsma et al whose searched up to 2005. However, original methodological articles that proposed and described a method to evaluate medical test(s) when there is a missing or no gold standard published before 2005 were also included in the review. These original articles were identified by "snowballing" [ 36 ] from the references of some articles. All articles obtained from the electronic databases were imported to Endnote X8.0.2. The selection of articles to be included in this review were done by three people (CU, AJA, and KW). The sifting process was in two-stages: by title and abstract and then by full text against the inclusion and exclusion criteria. Any discrepancies between reviewers were resolved in a group meeting.

Data synthesis

A data collection form was developed for this review ( S1 Data ), which was piloted on seven studies and remodified to fit the purpose of this review. Information extracted from the included articles were synthesized narratively.

A total of 6127 articles were identified; 5472 articles were left after removing the duplicated articles; 5071 articles were excluded after sifting by title and abstract; 401 articles went forward to full text assessment; and a total of 209 articles were included in the review. The search and selection procedure are depicted using the PRISMA [ 35 ] flow-diagram ( Fig 2 ).

The articles included in this review used a wide variety of different study designs, like cross-sectional studies, retrospective studies, cohort studies, prospective studies and simulation studies.

The identified methods were categorized into four groups based on the availability and/or application of the gold standard to the participants in the study. These group are:

• Group 1: Methods employed when there is a missing gold standard.
• Group 2: Correction methods which adjust for using an imperfect reference standard whose diagnostic accuracy is known.
• Group 3: Methods employed when using multiple imperfect reference standards.
• Group 4: “other methods” . This group includes methods like study of agreement, test positivity rate, and considering alternative study design like validation.

Methods in groups 2, 3 and 4 are employed when there is no gold standard to evaluate the diagnostic accuracy of the index test; while methods in group 1 are employed when there is a gold standard to evaluate the diagnostic accuracy of the index test(s). However, the gold standard is applied to only a sub-sample of the participants.

A summary of all methods identified in the review, their key references and the clinical applications of these methods are reported on Table 1 .

LCA: latent class analysis; CRS is composite reference standard. ROC is receiver operating characteristics; NGS is no gold standard

Methods employed when gold standard is missing

Fifty-one statistical methods were identified from the review that were developed to evaluate the diagnostic accuracy of index test(s) when the true disease status of some participants is not verified with the gold standard. These methods are divided into two subgroups:

• Differential verification approach : Participants whose disease status was not verified with the gold standard could undergo another reference standard (that is imperfect or less invasive than the gold standard [ 84 ]) to ascertain their disease status. This is known as differential verification [ 200 ]. Differential verification has been explored Alonzo et al, De Groot et al and Naaktgeboren et al [ 200 – 202 ]. They discussed the bias associated with differential verification, and how results using this approach could be presented. There are three identified statistical methods in this group. They are: a Bayesian latent class approach proposed by De Groot et al [ 82 ], a Bayesian method proposed by Lu et al [ 203 ] and a ROC approach proposed by Glueck et al [ 16 ]. These three methods aim to simultaneously adjust for differential verification bias and reference standard bias that arises from using an alternative reference standard (i.e. imperfect reference standard) for participants whose true disease status was not verified with the gold standard.

Correction methods

This group includes algebraic methods developed to correct the estimated sensitivity and specificity of the index test when the sensitivity and specificity of the imperfect reference standard is known. There are seven statistical methods in this group described in five different articles [ 91 – 95 ]. The methods by Emerson et al [ 95 ] does not estimate a single value for sensitivity or specificity, unlike the other correction methods [ 91 – 94 ] but produces an upper bound value and a lower bound value for the sensitivity and specificity of the index test. These bounded values are used to explain the uncertainty around the estimated sensitivity and specificity of the index test.

Methods with multiple imperfect reference standards

A gold standard or accurate information about the diagnostic accuracy of the imperfect reference standard are often not available to evaluate the index test. In these situations, multiple imperfect reference standards can be employed to evaluate the index test. Methods in this group include:

• Discrepancy analysis : this compares the index test with an imperfect reference standard. Participants with discordant results undergo another imperfect test, called the resolver test, to ascertain their disease status. Discrepancy analysis is typically not recommended because it produces biased estimates [ 100 , 204 ]. Modifications of this approach have been proposed [ 18 , 101 , 136 ]. In these, some of the participants with concordant responses (true positives and true negatives) are sampled to undertake the resolver test alongside participants with discordant responses (false negative–FN and false positive–FP). However, further research is needed to explore if these modified approaches are adequate to remove or reduce the potential bias.
• Latent class analysis (LCA) : The test performance of all the tests employed in the study are evaluated simultaneously using probabilistic models with the basic assumption that the disease status is latent or unobserved. There are frequentist LCAs and Bayesian LCAs. The frequentist LCAs use only the data from the participants in the study to estimate the diagnostic accuracy measures of the tests; while the Bayesian LCAs employ external information (e.g. expert opinion or estimates from previous research study) on the diagnostic accuracy measures of the tests evaluated in additional to the empirical data obtained from participants within the study. The LCAs assume that the tests (new test and reference standards) are either conditionally independent given the true disease status or the tests are conditionally dependent. To model the conditional dependence among the tests, various latent class model (LCM) with different dependence structure have been developed such as the Log-linear LCM [ 102 ], Probit LCM [ 103 ], extended log-linear and Probit LCM [ 108 ], Gaussian Random Effect LCM [ 105 ] and two-crossed random effect LCM [ 107 ] among others. However, some studies [ 205 ],[ 206 ] have shown that latent class models with different conditional dependence structures produce different estimates of sensitivities and specificities and each model still has a good fit. Thus, further research could be carried out to explore if each of the conditional dependence LCM are case specific.
• Construct composite reference standard : this method combines results from multiple imperfect tests (excluding the index test) with a predetermined rule to construct a reference standard that is used to evaluate the index test. By excluding the index test as part of the composite reference standard, incorporation bias can be avoided [ 131 ]. A novel method identified under the composite reference standard is the “dual composite reference standard” proposed by Tang et al [ 134 ].
• Panel or consensus diagnosis : this method uses the decision from a panel of experts to ascertain the disease status of each participant, which is then used to evaluate the index test.

Other methods

This group includes methods that fit the inclusion criteria but could not be placed into the other three groups. They include study of agreement, test positivity rate and the use of an alternative study design such as analytical validation. Study of agreement and test positivity rate are best used as exploratory tools alongside other methods [ 152 , 178 ] because they are not robust enough to assess the diagnostic ability of the medical test. Validation of a medical test cut across different disciplines in medicine such as psychology, laboratory or experimental medicine. With this approach, the medical test is assessed based on what it is designed to do [ 191 ]. Other designs include case-control designs (where the participants are known to have or not have the target condition) [ 207 , 208 ], laboratory based studies or experimental studies which are undertaken with the aim to evaluate the analytical sensitivity and specificity of the index test [ 190 , 209 , 210 ].

Guidance to researchers

The guidance flowchart ( Fig 5 ) is a modification and extension of the guidance for researchers flow-diagram developed by Reitsma et al [ 34 ].

Since, evaluating the accuracy measures of the index test is the focus of any diagnostic accuracy study, the flowchart starts with asking the first question “Is there a gold standard to evaluate the index test?” Following the responses from each question box (not bold); methods are suggested (bold boxes at the bottom of the flowchart) to guide clinical researchers, test evaluators, and researchers as to the different methods to consider.

Although, this review aims to provide up-to-date approaches that have been proposed or employed to evaluate the diagnostic accuracy of an index test in the absence of a gold standard for some or all of the participants in the accuracy study; some things researchers can consider when designing an accuracy study aside from the aim of their studies, are outlined in Box 1 ([ 26 , 211 – 218 ]).

Box 1: Suggestions when designing a diagnostic accuracy study.

• Design a protocol : The protocol describes every step of the study. It states the problem and how it will be addressed.
• Selection of participants from target population : The target population determines the criteria for including participants in the study. Also, the population is important in selecting the appropriate setting for the study.
• Selection of appropriate reference standard: The reference standard should diagnose same target condition as the index test. The choice of reference standard (gold or non-gold) determines the methods to apply when evaluating the index test (see Fig 5 ).
• Sample size : Having adequate sample size is necessary to make precise inference from the statistical analysis that will be carried out. Studies that discuss the appropriate sample size to consider when planning test accuracy are [ 211 – 215 ].
• Selection of accuracy measure to estimate : The researchers need to decide which accuracy measures they wish to estimate, and this is often determined by the test’s response (binary or continuous).
• Anticipate and eliminate possible bias : multiple forms of bias may exist [ 26 , 216 – 218 ]. Exploring how to avoid or adjust for these bias (if they are unavoidable) is important.
• Validation of results : Is validation of the results from the study on an independent sample feasible? Validation ensures an understanding of the reproducibility, strengths, and limitations of the study.

Some guidelines and tools have been developed to assist in designing, conducting and reporting diagnostic accuracy studies such as the STARD [ 219 – 223 ] guidelines, GATE [ 224 ] framework, QUADAS [ 225 ] tools; which can aid the design of a robust test accuracy study.

This review sought to identify and review new and existing methods employed to evaluate the diagnostic accuracy of a medical test in the absence of gold standard. The identified methods are classified into four main groups based on the availability and/or the application of the gold standard on the participants in the study. The four groups are: methods employed when only a sub-sample of the participants have their disease status verified with the gold standard (group 1); correction methods (group 2); methods using multiple imperfect reference standards (group 3) and other methods (group 4) such as study of agreement, test positivity rate and alternative study designs like validation.

In this review additional statistical methods have been identified that were not included in the earlier reviews on this topic by Reitsma et al [ 34 ] and Alonzo [ 25 ]. A list of all the methods identified in this review are presented in the supplementary material ( S1 Supplementary Information ). This includes a brief description of the methods and a discussion of their strengths and weaknesses and any identified case studies where the methods have been clinically applied. Only a small number of the methods we have identified have applied clinically and published [ 38 , 63 ]. This may be due to the complexity of these methods (in terms of application and interpretation of results), and/or a disconnection between the fields of expertise of those who develop (e.g. mathematicians or statisticians) and those who employ the methods (e.g. clinical researchers). For example, the publication of such method in specialist statistical journals may not be readily accessible to clinical researchers designing the study. In order to close this gap, two flow-diagrams (Figs ​ (Figs3 3 and ​ and4) 4 ) were constructed in addition to the modified guidance flowchart, ( Fig 5 ) as guidance tools to aid clinical researchers and test evaluators in the choice of methods to consider when evaluating medical test in the absence of gold standard. Also, an R package ( bcROCsurface ) and an interactive web application (Shiny app) that estimates the ROC surface and VUS in the presence of verification bias have been developed by To Duc [ 78 ] to help bridge the gap.

One of the issues not addressed in this current review was on methods that evaluate the differences in diagnostic accuracy of two or more tests in the presence of verification bias. Some published articles that consider this issue are Nofuentes and Del Castillo [ 226 – 230 ], Marin-Jimenez and Nofuentes [ 231 ], Harel and Zhou [ 232 ] and Zhou and Castelluccio [ 233 ]. This review also did not consider methods employed to estimate the time-variant sensitivity and specificity of diagnostic test in absence of a gold standard. This issue has recently been addressed by Wang et al [ 234 ].

In terms of the methodology, a limitation of this review is the exclusion of books, dissertations, thesis, conference abstract and articles not published in English language (such as the review by Masaebi et al [ 235 ] which was published in 2019), which could imply that there could still be some methods not identified by this review.

Regarding the methods identified in this review, further research could be carried to explore the different modification to the discrepancy analysis approaches to understand if these modifications reduce or remove the potential bias. In addition, further research is needed to determine if the different methods developed to evaluate an index test in the presence of verification bias are robust methods. Given the large numbers of statistical methods that have been developed especially to evaluate medical tests when there is a missing gold standard and the complexity of some of these methods; more interactive web application (e.g. Shiny package in R [ 236 ]) could be developed to implement these methods in addition to the Shiny app developed by To Duc [ 78 ] and Lim et al [ 237 ]. The development of such interactive web tools will expedite the clinical applications of these developed methods and help bridge the gap between the method developers and the clinical researchers or tests evaluators who are the end users of these methods.

Various methods have been proposed and applied in the evaluation of medical tests when there is a missing gold standard result for some participants, or no gold standard at all. These methods depend on the availability of the gold standard, its application to all or subsample of participants in the study, the availability of alternative reference standard(s), and underlying assumption(s) made with respect to the index test(s) and / or participants in the study.

Knowing the appropriate method to employ when analysing the data from participants of a diagnostic accuracy studies in the absence of gold standard, help to make statistically robust inference on the accuracy of the index test. This, in addition to data on cost-effectiveness, utility and usability of the test will support clinicians, policy makers and stake holders to decide the adoption of the new test in practice or not.

Supporting information

S1 checklist, s1 appendix, s1 supplementary information, acknowledgments.

The authors will like to acknowledge Professor Patrick Bossuyt from the Department of Clinical Epidemiology and Biostatistics, Academic Medical centre, University of Amsterdam, the Netherlands, for giving the consent to update his review, reviewing the protocol and his continued advice throughout this work. Also we will like to acknowledge the authors of the previous review, Dr Anne Rutjes in University of Bern, Switzerland; Professor Johannes Reitsma in the Department of Epidemiology, Julius Center Research Program Methodology UMC Utrecht, The Netherlands; Professor Arri Coomarasamy in the College of Medical and Dental Sciences, University of Birmingham, UK; and Professor Khalid Saeed Khan in Queen Mary, University of London for the guidance flowchart which was modified and extended. AJA, SG, and LV are supported by the National Institute for Health Research (NIHR) Newcastle In Vitro Diagnostics Co-operative. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Funding Statement

This work is supported by the Newcastle University Research Excellence; the School of Mathematics, Statistics and Physics Newcastle University; the Institute of Health & Society Newcastle University; and the National Institute for Health Research (NIHR) [NIHR Newcastle In Vitro Diagnostics Co-operative]. The view and opinions expressed are those of the authors and do not necessary reflect those of the NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University and Newcastle upon Tyne NHS Foundation Trust, the NHS or Newcastle Research Academy. The views expressed are those of the authors and not necessarily those of the NIHR, the NHS or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Kasturba Medical College, Mangalore Theses and Dissertations

Theses/dissertations from 2021 2021.

“The Impact of Self-Stigma of Seeking Help and Perceived Social Support on Burnout among Clinical Psychologists” , Aavrita A

The impact of self-stigma of seeking help &percieved social support on burnout among clinical psychologists. , Aavrita .

Immediate Effects of Novel Hand Rehabilitation Board on Fine Motor Skills in Children with Cerebral Palsy. , Romita Fernandes. Abraham

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Comparative predictive validity of Alberta Infant Motor Scale and Infant Neurological International Battery in Low Birth Weight Infants- A Prospective Longitudinal Study. , Polisetti Siva Sai Anand

Antagonistic Asynchrony in Muscle Recruitment Pattern of Forward Reach Movement In Children With Cerebral Palsy. , Sanya Anklesaria

Muscle fatigue response of rotator cuff muscles in sitting and standing postures , Lisanne Aranha

Effectiveness of static weight bearing versus modified constraint induced movement therapy on improving hand function in hemiplegic cerebral palsy- A Randomized Clinical Trial. , Ruth Bavighar

How informed are our patients about generic medicines? – A study from coastal South India , Darshan BB

Morphological variants of the human spleen, a cadaveric study , Murlimanju BV

Association between cervical breast cancer and Diabtetes mellitus among women seeking health care in tertiary hospitals od south India: A cross sectional study , Pratik Kumar Chatterjee

Carcinoma Breast in among Women with Diabetes Mellitus: A Case Control Study , Pratik Kumar Chatterjee

Perception of Empathy among medical students: A cross sectional study , Pratik Kumar Chatterjee

CLINICOMYCOLOGICAL PROFILE OF DERMATOPHYTOSIS IN A TERTIARY CARE HOSPITAL IN SOUTH INDIA , Adyashree Dalai

Study of outcome of Ponseti technique of management for idiopathic clubfoot in a tertiary center in south India , Lulu Damsas

Comparative study of emotional labour &burnout on life satisfaction among school teachers across different educational settings , Meghana Dharampalan

“Comparative Study of Emotional Labor and Burnout on Life Satisfaction Among School Teachers Across Different Educational Settings” , Meghana V. Dharmapalan

“Relationship Between Sexual Fantasy, Sexual Communication, Personality Traits and Sexual Satisfaction in Married Individuals” , Rhea Dhir

Comparing the efficacy of USG guided supraclavicular brachial plexus block with or without intercostobrachial nerve block for forearm surgeries – an observational study , DIKSHA D’MELLO

Does Quality of Sitting influence Functional Mobility in Cerebral Palsy? A cross-sectional study , Kaiorisa N. Doctor

Factors effecting gait velocity in osteoarthritis knee-An observational study. , Lisha Gretal D’silva

Effect of Inspiratory Muscle Training on Pulmonary Function, Functional Capacity, Quality Of Life And Length Of Stay in individuals undergoing Cardiac Surgery , Fiona Verdine Dsouza

Relationship of Academic Resilience with Self-Efficacy, and Perceived Social Support; Among Civil Service Aspirants , Neha Eldho

EFFICACY, FEASIBILITY, AND SAFETY OF PERCUTANEOUS IMAGE-GUIDED CATHETER DRAINAGE OF THORACIC, ABDOMINAL, AND PELVIC FLUID COLLECTION , Aishwarya Gadwal

Comparison of efficacy of two different bolus doses of norepinephrine as prophylac-tic to prevent post-spinal hypotension during elective caesarean section , PRANATHI GARAPATI

Trends in Frailty and its Associated factors in Community Dwelling Elderly Indian Population during COVID-19 Pandemic- A Prospective Analytical Study , Karan Gautam

Speech Sound acquisition in some south Indian Dravidian languages: A systematic review , Jesica George

Comparison of Femoral nerve block with Dexmedetomidine and Adductor canal block with Dexmedetomidine for postoperative analgesia for Total Knee Arthroplasty . , NEHA GEORGE

Assessment Of Cardiovascular Risk Factors In Patients With Osteoarthritis Knee , Sagar Goel

Effectiveness of Intermittent Cervical Traction with and without Neural Mobilization in Discogenic Cervical Radiculopathy , Aditi Goyal

Study of maternal and cord blood vitamin B12 levels with anthropometry in term neonates born to normal and malnourished mothers: a hospital based cross sectional study , Sugapradha a. GR

Development of a Questionnaire to Determine the Intervention and Service Delivery Practices of Speech-Language Pathologists for Children with Speech Sound Disorders in India , Shaily Gupta

Relationship between Physical Activity, Objective Sleep Parameters and Circadian Rhythm in Patients with Head and Neck Cancer receiving Chemoradiotherapy- A Longitudinal Study , Rachita Gururaj

“Emotional Contagion, Perceived Stress and Coping Strategies Among Nurses” , Saumya Hariharan

Assessment of knowledge and belief about stuttering among undergraduate medical students , Anushree Harihar

Association of serum lipid levels and other systemic risk factors with retinal hard exudates in diabetic retinopathy patients. , Harshita Mukesh Hiran

Assessment of risk of Diabetes Mellitus by using Indian Diabetes Risk Score among Housekeeping staff , Ramesh Holla

“Emotional Intelligence, Self-compassion, and Life-Satisfaction In Clinical Psychologists” , Vania Jacob

UPPER-CROSSED SYNDROME AND DISABILITY IN SHOULDER ADHESIVE CAPSULITIS. , Aishwarya Jaideep

Study to assess the role of doppler ultrasound in evaluation of arteriovenous hemodialysis fistula and the complications of hemodialysis access , Ishank Jain

Relationship between burnout compassion fatigue, work environment & mindfulness in medical residents , Pranay Javeri

“Relationship Between Burnout, Compassion Fatigue, Work Environment and Mindfulness in Medical Residents” , Pranay Harichandra Javeri

“Dating Anxiety in Emerging Adults” , Jisha V. Jayaprakash

“Relationship Between Tolerance for Disagreement and Mindfulness in Married Males and Married Females” , Jahnavi Jha

Antibiotic usage and susceptibility patterns in Uncomplicated UTI in a Tertiary Hospital in South India , Christy John

Association of bed rise difficulty scale with trunk impairment and functional scales among stroke patients , Leena G. John

Is there a correlation between Pediatric Berg Balance Scale and Centre of Pressure Excursion measured through Dual Axis Static Force Plate™ to assess Balance in Children with Spastic Cerebral Palsy and Typically Developing? , Niharika Joshi

Comparison of Sensory Processing Responses in Cerebral Palsy Subtypes and Typically Developing Children (7-36 months): A Cross Sectional Study. , Archana Antony K

‘A study on the Role of Learned Helplessness, Selfefficacy and Perceived Social Support in Determining Resilience in Parents of Children with Neurodevelopmental Disorders’ , Benaisha Khurshed Katrak

A study of correlation of maternal serum zinc levels with breast milk and cord blood of late preterm neonates , Rashmi Katti

Correlation of histopathology and direct immunofluorescence findings in clinically diagnosed prurigo nodularis , Haritha K

Difference in proximal femur loading due to muscle activity during partial weight bearing and NWB standing- A cross-sectional study. , Smital Kshirsagar

Effect of Sesamol on neurobiochemical changes in diet induced (DIO) obesity model of Zebra fish (Danio rerio) , Rashmii K.S.

Importance of integration of medical ethics with undergraduate medical curriculum- Instructors and student’s perspectives. , Rashmii K.S.

Long-term potentiation (LTP): A simple yet powerful cellular process in learning and memory , Rashmii K.S.

Parkinson's Disease Overview: Alternative Potential Curcumin Treatment, Current Treatment and Prevalence Among Ethnic Groups , Rashmii K.S.

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The Role of Professionalism and Ethics Training: Instructor’s and Student’s perspectives in a medical College , Rashmii K.S.

Violence Against Doctors: A Qualitative Study On This Rising Predicament , Rashmii K.S.

Morphometric study of the gracilis muscle and its pedicles , Chettiar Ganesh Kumar

Comparative study of bed side tests to assess difficult airway in paediatric patients , S.Abinandha Kumar

Euphorbia thymifolia (Linn.)- A review on ethno pharmacological properties , Vasavi Kumblekar

COMPARISON OF KNOWLEDGE, ATTITUDE, AND PRACTICE TOWARDS THE USE OF SUNSCREEN IN DAILY LIFE BETWEEN FIRST -AND THIRD -YEAR MEDICAL STUDENTS , Aarushi Lall

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Clinical & radiological assessment of intertrochanteric fractures treated with PFN A2 , Harish M

Effect of a home-based pulmonary rehabilitation programme on respiratory function, functional capacity, and quality of life in patients with chronic obstructive pulmonary disease , Vaibhavi Mhatre

Profiling Communication Characteristics of Individuals with Acquired Neuro-communication Disorder in a Tertiary Care Setup , Nikita Subudhi M

Relationship between weight bearing symmetry, trunk control and fear of fall amongst subjects with stroke: A cross sectional study , VIVIAN NEHAL MONIS

Lower extremity muscle recruitment pattern during sit to stand transfer in children with cerebral palsy as compared to typically developing children- a cross sectional study. , Kiran P. Nadgauda

Knowledge, attitudes and practices of Indian classical singers towards vocal healthcare , Raveena Muralidharan Nair

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Refractory errors, blood groups & diabetes mellitus: A corrleative study in south Indian population , Vinodini NA

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“The Effect of Culture Shock on Adjustment and Psychological Wellbeing Among College Going Students” , Akanksha Patra

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Morphometric study of the Sartorius muscle and its vascular pedicles , M.D. Prameela

Comparison of the analgesic duration using ultrasound guided popliteal sciatic nerve block between diabetics with neuropathy and non-diabetics without neuropathy , GANESH PRASAD

Early follicular and Mid-luteal phase associated changes in Lower extremity Muscle strength , length and Agility in amateur female athletes – a Prospective Analytical study , Vishnu Priya

Assessment of mobile device based educational intervention on breastfeeding technique in multigravida mothers and its effect on early infant feeding pattern- A randomized controlled trial. , Keerthi Raj

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Correlation of Histopathology and Direct Immunofluorescence: Findings in clinically diagnosed Prurigo nodularis in a Tertiary care hospital , Haritha Reddy

EFFECT OF POSITIONING ON THE PAIN RESPONSE OF INFANTS VACCINATED WITH IPV AND PENTAVALENT (dtwp-HEPATITIS B-HEMOPHILUS INFLUENZA B) VACCINES , Sontosh Reddy

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Profiling selected speech characteristics in individuals with Chronic Cough , Nawal Palakkal Sathar

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Stigmatizing Language, Patient Demographics, and Errors in the Diagnostic Process

• 1 Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco
• 2 Division of Hospital Medicine, Denver Health, University of Colorado, Denver
• 3 Division of Hospital Medicine, Department of Medicine, University of Colorado, Denver
• 4 Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
• Medical News in Brief Study: Stigma in Medical Records Tied to Diagnostic Errors Emily Harris JAMA

Stigmatizing language (SL) is widespread throughout medical documentation. 1 It is more likely to be found in the records of Black patients, 2 , 3 patients with public insurance, 2 and patients with certain comorbidities. 3 We investigated associations between SL, errors in the diagnostic process, and demographics for hospitalized patients.

Read More About

Brooks KC , Raffel KE , Chia D, et al. Stigmatizing Language, Patient Demographics, and Errors in the Diagnostic Process. JAMA Intern Med. 2024;184(6):704–706. doi:10.1001/jamainternmed.2024.0705

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