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lung function equipment from MGC DIAGNOSTICS&#46; Predicted values were calculated using the GLI-2012 equations<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and spirometries that met validity and reproducibility criteria were included&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The gold standard for obstruction was defined as a FEV1&#47;FVC ratio <span class="elsevierStyleItalic">z</span>-score of less than &#8722;1&#46;64 &#40;GLI-2012&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using Stata&#174; version 15 software from StataCorp LLC&#46; A descriptive analysis was performed using frequency measures &#40;&#37;&#41; and central tendency and dispersion measures &#40;mean and standard deviation&#41;&#44; according to the type of variable&#46; A diagnostic analysis was performed between the different cut-off points of the FEV1&#47;FVC ratio &#40;between &#60;90&#37; and &#60;75&#37;&#41; versus the gold standard of a FEV1&#47;FVC <span class="elsevierStyleItalic">z</span>-score of less than &#8722;1&#46;64&#46; The study was approved by the reference ethics committee&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We included 324 Caucasian patients&#58; 198 males &#40;61&#46;1&#37;&#41;&#44; mean age 10&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9 years&#44; height 141&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;0<span class="elsevierStyleHsp" style=""></span>cm&#44; and weight 40&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;6<span class="elsevierStyleHsp" style=""></span>kg&#46; Mean FEV1&#44; FVC&#44; and FEV1&#47;FVC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation were 1&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;70<span class="elsevierStyleHsp" style=""></span>L&#44; 2&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;82<span class="elsevierStyleHsp" style=""></span>L&#44; and 87&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;0&#37;&#44; and the FEV1&#44; FVC&#44; and FEV1&#47;FVC <span class="elsevierStyleItalic">z</span>-scores were &#8722;0&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;07&#44; &#8722;0&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;04&#44; and &#8722;0&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;16&#44; respectively&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The prevalence of obstruction in our series according to LLN was 8&#46;0&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows prevalence&#44; classification errors&#44; sensitivity&#44; specificity&#44; negative predictive value&#44; positive predictive value&#44; and area under the curve of the cut-off points analyzed from the FEV1&#47;FVC ratio in the whole series and in 2 different age ranges&#46; These results were similar when analyzed by sex &#40;data not shown&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of obstruction in our study was comparable with other studies in the pediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Currently&#44; there are 2 different approaches to the interpretation of spirometries&#46; On the one hand&#44; some authors advocate the use of the fixed ratio for its simplicity and applicability&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7&#8211;9</span></a> This is based on studies that showed worse survival in patients with an FEV1&#47;FVC ratio &#60;70&#37; and &#62;LLN compared with patients with FV1&#47;FVC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In contrast&#44; other authors support the use of LLN and the <span class="elsevierStyleItalic">z</span>-score&#44; based on studies showing that morbidity or all-cause mortality is not higher in patients with suspected COPD unless the FEV1&#47;FVC ratio is<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Our study shows that using cut-off points with high sensitivity and low specificity values &#40;90&#37; and 85&#37;&#41; overestimates the prevalence of obstruction&#44; and can lead to overtreatment and higher costs&#46; Thus&#44; compared with the gold standard&#44; the cut-off point of 90&#37; recommended by GINA<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> would overestimate obstruction in our patients by 57&#46;4&#37;&#44; whereas the 85&#37; recommended by GEMA<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> would overestimate obstruction by 26&#46;2&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no other studies have evaluated the validity of the fixed ratio using the GLI-2012 LLN as a gold standard&#46; Our study&#44; conducted in a Caucasian population&#44; shows that a fixed value of 80&#37; for the FEV1&#47;FVC ratio has greater validity than higher cut-off points&#59; however&#44; this value still leads to an overdiagnosis of up to 3&#46;7&#37;&#46; Lower cut-off points &#40;78&#37; and 79&#37;&#41; in our series showed lower rates of overdiagnosis&#44; with no increase in the rate of underdiagnosis&#59; comparable results were reported by Stanojevic et al&#46; using an LLN of 78&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; Primarily&#44; patients&#8217; symptoms and exacerbations were not analyzed&#44; and it is not known whether the lower ratio was observed in the most symptomatic patients&#46; However&#44; Bacharier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> showed that asthma severity correlated with the FEV1&#47;FVC ratio&#44; which decreased progressively as severity increased&#46; Another weakness of our study is that obstruction was overestimated by 1&#46;9&#37; when the fixed value of 79&#37; was used&#46; However&#44; this is clearly lower than the overestimation produced by the criteria recommended by GINA or GEMA&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> for which the rate of overdiagnosis was between 26&#46;2 and 57&#46;4&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The study also has its strengths&#58; it is the first to evaluate the validity of the fixed ratio using the GLI-2012 LLN as a gold standard&#46; Our findings are important because the software of many spirometry devices used in both primary and specialized care does not include the GLI-2012 equations&#44; and most clinicians do not have the time to use these equations to calculate predicted values in clinical practice&#46; In its favor&#44; the fixed criterion is simple&#44; applicable&#44; and supported by authors who advocate its use for its high degree of sensitivity&#44; specificity&#44; positive and negative predictive value&#44; and the fact that it has an area under the curve close to 1 of the gold standard that is supported by those who prefer to use the LLN criterion&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; we believe that the discriminative criterion for defining the presence of obstruction should be the LLN&#44; rather than a fixed criterion&#46; If a fixed limit must be used&#44; our study shows that the best sensitivity and specificity values are obtained with an FEV1&#47;FVC value of less than 79&#37;&#46; This improves diagnostic accuracy compared to the criteria previously used and is easily applied in routine clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study has not received specific grants from public sector agencies&#44; the commercial sector&#44; or non-profit organizations&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Calculated from total patients by age range&#58; 210 patients in the range &#62;6&#8211;&#8804;11 and 114 patients in the age range &#62;11&#8211;&#8804;18&#46;</p>"
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                  \t\t\t\t">Overdiagnosis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Underdiagnosis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specificity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ROC area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;688</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;856</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;980</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;990</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;937</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prevalence and errors in classification with different cut-off points in 2 age ranges&#46; Sensitivity&#44; specificity&#44; positive predictive value &#40;PPV&#41;&#44; negative predictive value &#40;NPV&#41;&#44; and ROC curve &#40;area under the curve&#41; of each parameter at the global level&#46;</p>"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Spirometry&#46; Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Garc&#237;a-R&#237;o"
                            1 => "M&#46; Calle"
                            2 => "F&#46; Burgos"
                            3 => "P&#46; Casan"
                            4 => "F&#46; del Campo"
                            5 => "J&#46;B&#46; Galdiz"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.arbres.2013.04.001"
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                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2013"
                        "volumen" => "49"
                        "paginaInicial" => "388"
                        "paginaFinal" => "401"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23726118"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Pellegrino"
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                            2 => "V&#46; Brusasco"
                            3 => "R&#46;O&#46; Crapo"
                            4 => "F&#46; Burgos"
                            5 => "R&#46; Casaburi"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00035205"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "948"
                        "paginaFinal" => "968"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16264058"
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Scientific Letter
FEV1/FVC Cut-off Values for the Diagnosis of Airflow Obstruction in Pediatric Patients: The Pediatric Airflow Obstruction (PAO) Study
Valores de corte de FEV1/FVC para el diagnóstico de obstrucción al flujo aéreo en población pediátrica: estudio PAO (Pediatric Airflow Obstruction)
Chunshao Hu-Yanga,
Corresponding author
chunshao@hotmail.com

Corresponding author.
, Virginia Perez-Fernandezb, Ada Luz Andreu Rodrígueza, Rubén Andújar Espinosac,d, José Valverde-Molinae
a Departamento de Neumología, Hospital General Universitario Los Arcos del Mar Menor, Pozo Aledo-San Javier, Murcia, Spain
b Departamento de Ciencias Sociosanitarias, Universidad de Murcia, Murcia, Spain
c Departamento de Neumología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
d Universidad de Murcia, Ciencias de la Salud (Medicina), Murcia, Spain
e Medicina Respiratoria Pediátrica, Hospital General Universitario Santa Lucia, Cartagena, Murcia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Forced spirometry is a basic test in the study of lung function&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Different patterns are identified from the forced expiratory volume in 1 second &#40;FEV1&#41;&#47;forced vital capacity &#40;FVC&#41; ratio and the FVC value&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although numerous equations have been proposed for the calculation of predicted values&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> many scientific societies currently use the equations developed by the Global Lung Function Initiative 2012 &#40;GLI-2012&#41; that have been validated in many countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#44;5</span></a> In Spain&#44; these equations have been validated in preschool children&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Among the results they provide are the lower limits of normal &#40;LLN&#41; of different parameters&#44; any value below the LLN &#40;<span class="elsevierStyleItalic">z</span>-score &#8722;1&#46;64&#41; being considered abnormal&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An FEV1&#47;FVC ratio<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>LLN is defined as obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> However&#44; guidelines for the management of chronic obstructive pulmonary disease &#40;COPD&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> or asthma<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> continue to recommend the use of the fixed ratio as a discriminatory criterion&#44; and this approach is widely used in routine clinical practice&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In children&#44; there is currently no consensus on the value that defines the presence of obstruction&#44; and the recommended lower values range between 85&#37; and 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a cross-sectional observational study to assess the validity of different FEV1&#47;FVC ratios for the diagnosis of obstruction in the pediatric population&#46; Spirometries performed in pediatric patients &#40;6&#8211;18 years&#41; in our hospital between June and December 2016 were analyzed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Forced spirometry was performed by experienced operators following ATS&#47;ERS guidelines<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> using the MEDGRAPHICS ULTIMA PF&#174; lung function equipment from MGC DIAGNOSTICS&#46; Predicted values were calculated using the GLI-2012 equations<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and spirometries that met validity and reproducibility criteria were included&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The gold standard for obstruction was defined as a FEV1&#47;FVC ratio <span class="elsevierStyleItalic">z</span>-score of less than &#8722;1&#46;64 &#40;GLI-2012&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using Stata&#174; version 15 software from StataCorp LLC&#46; A descriptive analysis was performed using frequency measures &#40;&#37;&#41; and central tendency and dispersion measures &#40;mean and standard deviation&#41;&#44; according to the type of variable&#46; A diagnostic analysis was performed between the different cut-off points of the FEV1&#47;FVC ratio &#40;between &#60;90&#37; and &#60;75&#37;&#41; versus the gold standard of a FEV1&#47;FVC <span class="elsevierStyleItalic">z</span>-score of less than &#8722;1&#46;64&#46; The study was approved by the reference ethics committee&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We included 324 Caucasian patients&#58; 198 males &#40;61&#46;1&#37;&#41;&#44; mean age 10&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9 years&#44; height 141&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;0<span class="elsevierStyleHsp" style=""></span>cm&#44; and weight 40&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;6<span class="elsevierStyleHsp" style=""></span>kg&#46; Mean FEV1&#44; FVC&#44; and FEV1&#47;FVC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation were 1&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;70<span class="elsevierStyleHsp" style=""></span>L&#44; 2&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;82<span class="elsevierStyleHsp" style=""></span>L&#44; and 87&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;0&#37;&#44; and the FEV1&#44; FVC&#44; and FEV1&#47;FVC <span class="elsevierStyleItalic">z</span>-scores were &#8722;0&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;07&#44; &#8722;0&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;04&#44; and &#8722;0&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;16&#44; respectively&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The prevalence of obstruction in our series according to LLN was 8&#46;0&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows prevalence&#44; classification errors&#44; sensitivity&#44; specificity&#44; negative predictive value&#44; positive predictive value&#44; and area under the curve of the cut-off points analyzed from the FEV1&#47;FVC ratio in the whole series and in 2 different age ranges&#46; These results were similar when analyzed by sex &#40;data not shown&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of obstruction in our study was comparable with other studies in the pediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Currently&#44; there are 2 different approaches to the interpretation of spirometries&#46; On the one hand&#44; some authors advocate the use of the fixed ratio for its simplicity and applicability&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7&#8211;9</span></a> This is based on studies that showed worse survival in patients with an FEV1&#47;FVC ratio &#60;70&#37; and &#62;LLN compared with patients with FV1&#47;FVC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In contrast&#44; other authors support the use of LLN and the <span class="elsevierStyleItalic">z</span>-score&#44; based on studies showing that morbidity or all-cause mortality is not higher in patients with suspected COPD unless the FEV1&#47;FVC ratio is<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Our study shows that using cut-off points with high sensitivity and low specificity values &#40;90&#37; and 85&#37;&#41; overestimates the prevalence of obstruction&#44; and can lead to overtreatment and higher costs&#46; Thus&#44; compared with the gold standard&#44; the cut-off point of 90&#37; recommended by GINA<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> would overestimate obstruction in our patients by 57&#46;4&#37;&#44; whereas the 85&#37; recommended by GEMA<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> would overestimate obstruction by 26&#46;2&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no other studies have evaluated the validity of the fixed ratio using the GLI-2012 LLN as a gold standard&#46; Our study&#44; conducted in a Caucasian population&#44; shows that a fixed value of 80&#37; for the FEV1&#47;FVC ratio has greater validity than higher cut-off points&#59; however&#44; this value still leads to an overdiagnosis of up to 3&#46;7&#37;&#46; Lower cut-off points &#40;78&#37; and 79&#37;&#41; in our series showed lower rates of overdiagnosis&#44; with no increase in the rate of underdiagnosis&#59; comparable results were reported by Stanojevic et al&#46; using an LLN of 78&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; Primarily&#44; patients&#8217; symptoms and exacerbations were not analyzed&#44; and it is not known whether the lower ratio was observed in the most symptomatic patients&#46; However&#44; Bacharier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> showed that asthma severity correlated with the FEV1&#47;FVC ratio&#44; which decreased progressively as severity increased&#46; Another weakness of our study is that obstruction was overestimated by 1&#46;9&#37; when the fixed value of 79&#37; was used&#46; However&#44; this is clearly lower than the overestimation produced by the criteria recommended by GINA or GEMA&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> for which the rate of overdiagnosis was between 26&#46;2 and 57&#46;4&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The study also has its strengths&#58; it is the first to evaluate the validity of the fixed ratio using the GLI-2012 LLN as a gold standard&#46; Our findings are important because the software of many spirometry devices used in both primary and specialized care does not include the GLI-2012 equations&#44; and most clinicians do not have the time to use these equations to calculate predicted values in clinical practice&#46; In its favor&#44; the fixed criterion is simple&#44; applicable&#44; and supported by authors who advocate its use for its high degree of sensitivity&#44; specificity&#44; positive and negative predictive value&#44; and the fact that it has an area under the curve close to 1 of the gold standard that is supported by those who prefer to use the LLN criterion&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; we believe that the discriminative criterion for defining the presence of obstruction should be the LLN&#44; rather than a fixed criterion&#46; If a fixed limit must be used&#44; our study shows that the best sensitivity and specificity values are obtained with an FEV1&#47;FVC value of less than 79&#37;&#46; This improves diagnostic accuracy compared to the criteria previously used and is easily applied in routine clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study has not received specific grants from public sector agencies&#44; the commercial sector&#44; or non-profit organizations&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Calculated from total patients by age range&#58; 210 patients in the range &#62;6&#8211;&#8804;11 and 114 patients in the age range &#62;11&#8211;&#8804;18&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">100&#37;</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">100&#37;</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">100&#37;</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Specificity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">37&#46;6&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">71&#46;1&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">96&#46;0&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;0&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">99&#46;0&#37;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;2&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;4&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#46;3&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;5&#37;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;0&#37;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ROC area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;688</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;990</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t">0&#46;937</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prevalence and errors in classification with different cut-off points in 2 age ranges&#46; Sensitivity&#44; specificity&#44; positive predictive value &#40;PPV&#41;&#44; negative predictive value &#40;NPV&#41;&#44; and ROC curve &#40;area under the curve&#41; of each parameter at the global level&#46;</p>"
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ISSN: 03002896
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