To the Editor—We read with interest the developmental study of the HANDOC score by Sunnerhagen et al [1], which stratified the risk of infective endocarditis (IE) in patients with non-beta-hemolytic streptococci (NBHS). The authors reported that the score had a sensitivity of 100% in both the derivation and validation cohorts. They stated that the performance of the score when applied to the whole cohort, including the unknown category, was similar to the performance of the score when applied only to IE and non-IE cases. They did not clearly describe in the article how they dealt with the unknown category, and we guess from the prevalence of IE in the main cohort (7.6%) that they handled the patients in the unknown category as if they were non-IE cases. However, this handling seemed to be too optimistic to be accepted. According to the authors’ definition of the unknown category, patients who were clinically treated as having IE without fulfilling the modified Duke criteria would have been classified into this category. Such patients would have a moderate risk for IE. When we calculated backward from the sensitivity and specificity they presented, there were 25 patients with a score of 3 or more, and there were 92 patients with a score of 2 or less in the unknown category of the main cohort (the numbers might be 26 and 91, respectively, due to rounding off). If we assumed that all the patients in the unknown category had IE as a pessimistic scenario, the sensitivity and the specificity would be 36% and 73%, respectively. Therefore, the point estimate of the sensitivity could have the range of 36% to 100% in the main cohort. Similarly, the sensitivity could be in the range of 42% to 100% in the validation cohort.

中文翻译：

---

HANDOC分数过于乐观

致编辑-我们感兴趣地阅读了Sunnerhagen等[1]对HANDOC评分的发展研究，该研究对非β-溶血性链球菌（NBHS）患者的感染性心内膜炎（IE）风险进行了分层。作者报告说，在派生和验证队列中，该分数的敏感度均为100％。他们表示，将分数应用于整个队列（包括未知类别）时的表现与仅应用于IE和非IE案例时的分数表现相似。他们没有在文章中清楚地描述他们如何处理未知类别，从主要人群中IE的患病率（7.6％）中我们猜测，他们像对待非IE病例一样对待未知类别的患者。但是，这种处理似乎过于乐观，无法接受。根据作者对未知类别的定义，在临床上被视为患有IE且未满足修改后的Duke标准的患者将被归为该类别。这类患者有中等程度的IE风险。当我们从他们呈现的敏感性和特异性进行倒算时，在主要队列的未知类别中，有25名患者的得分为3分或更高，有92名患者的得分为2分或更低（数字可能是26和91（由于四舍五入）。如果我们假设所有未知类别的患者都将IE视为悲观场景，那么敏感性和特异性将分别为36％和73％。因此，在主要队列中，敏感性的点估计可能在36％到100％的范围内。相似地，