• bruise
• abuse

We write to draw attention to two problems with the recent study on a scoring system for bruising by Dunstan et al.¹

Firstly, the authors did not publish confidence intervals for the likelihood ratios (LRs) derived from different score threshold values (table 3), thereby not allowing readers to judge whether the LRs are statistically—let alone clinically—significant.

Secondly, the authors neglect the phenomenon of spectrum bias. This is a well described feature of many tests, whereby sensitivity and specificity (and hence derived LRs) of a test vary with disease severity or prevalence. Examples of spectrum bias have been described with several tests including exercise stress testing² and UTI diagnosis.³

The study population had a prevalence of physical abuse of 40%, much higher than the general paediatric population. Since test performance—that is, LR—is not independent of the pre-test probability, the LRs generated by a study done on this population cannot necessarily be used in a population with a much lower prevalence of abuse, as the authors have done in table 4. Since spectrum bias tends to reduce test performance as the pre-test probability falls,⁴ the LR for any given score threshold would be smaller than that quoted when applied to a population with a lower prevalence of physical abuse.

As most settings would expect to have a lower prevalence of physical abuse than the study, this reduces the value of the proposed scoring system as a clinical tool.