Fleiss Kappa Statistic Research Articles

Acute benign vertebral compression fractures: "see-through sign" on contrast-enhanced MR images.

To retrospectively evaluate the diagnostic role of the contrast-enhanced MRI (CE-MRI) for differentiation between benign VCFs and malignant VCFs focusing on the internal transparent trabecular bone on CE-MRI (the "see-through sign"). The institutional review board approved this study and informed consent was waived due to the retrospective nature of the study. From January 2012 to December 2013, all 149 consecutive benign or malignant VCF patients were enrolled for consideration in this study from a CE-MRI database. In the first analysis, four radiologists independently evaluated the presence or absence of the see-through sign. The see-through sign was defined as internal transparent trabecular bone morphology on CE-MRI. The intraclass correlation coefficient (ICC), percentage agreement, and Fleiss's kappa statistics were obtained. Fifty-seven patients (M:F=27:30; mean age, 63years; age range, 20-88years) who diagnosed as acute benign (n=24) and malignant (n=33) VCFs were finally included for the analysis. The results of all readers showed that the see-through sign was associated with acute benign VCFs (p<0.05). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of the see-through sign ranged from 75-96, 70-88, 66-85, 81-97%, respectively. The inter-observer reliability of the see-through sign was sufficient with ICC=0.847, percentage agreement=78.9, and κ=0.578. The see-through sign on CE-MRI is featured in acute benign VCFs, and it can be a useful finding to differentiate between benign and malignant VCFs.

SURG-01IS UNRESECTED GLIOBLASTOMA TRULY UNRESECTABLE? AN ANALYSIS OF BASAL MRI'S OF PATIENTS WITH UNRESECTED GLIOBLASTOMA INCLUDED IN THE GENOM009 TRIAL AND THE VARIABILITY OF SURGICAL APPROACHES

BACKGROUND: The percentage of patients with unresected glioblastoma ranges from 20 to 40%. There exists variability in the selection of the surgical approach. METHODS: The main inclusion criteria for the randomized neoadjuvant trial GENOM 009 was unresected disease. Both diagnosis and progression of all patients MRIs were reviewed. In this sub analyses we performed a blinded revision of basal MRIs from 77 patients included in the trial. MRIs were uploaded to the web where five neurosurgeons (NS) from 3 different institutions, blinded to clinical status and other NS evaluations, decided which surgical approach could be performed based solely on the MRI of each patient: B = biopsy, PR = partial resection or RR = radical resection. Finally, the neurosurgeons chose which pre-operative assessments they would ask for before surgery and the intra-surgical technology they would need to perform it. RESULTS: Each of the 77 cases had T1Gd and T2 or FLAIR sequences. Basal surgery performed to the patient before being included in the trial was: B = 68, PR = 9. For each NS the evaluation of the pre-planned surgery was: NS-1: B = 44, PR = 24, RR = 9; NS-2: B = 47, PR = 24, RR = 6; NS-3: B = 56, PR = 17, RR = 4; NS-4: B = 26, PR = 23, RR = 23;NS-5: B = 45, PR = 5, RR = 26. Evaluated pre-surgical assessments were: neuro-navigation sequences, functional MRI, tractography, neuropsicologic basal assessment. Evaluated intra-surgical tools were: neuro-navigation, mapping, physiologic monitoring, intra-surgical echography and fluorescence. The Fleiss kappa statistics about the surgical approach was 0.234 (95%CI = 0.156-0.312), P = 0.0001. (Fair, less than moderate). CONCLUSIONS: The approach to radical surgery in glioblastoma has a great variability among different neurosurgeons and even centers. An analysis of the causes of this variability is needed as well as an effort to develop guidelines based on tumor location, size and eloquence of adjacent brain based on MRI.

Spine Instability Neoplastic Score: agreement across different medical and surgical specialties

Background ContextSpinal instability is an acknowledged complication of spinal metastases; in spite of recent suggested criteria, it is not clearly defined in the literature. PurposeThis study aimed to assess intra and interobserver agreement when using the Spine Instability Neoplastic Score (SINS) by all physicians involved in its management. Study DesignIndependent multicenter reliability study for the recently created SINS, undertaken with a panel of medical oncologists, neurosurgeons, radiologists, orthopedic surgeons, and radiation oncologists, was carried out. Patient SampleNinety patients with biopsy-proven spinal metastases and magnetic resonance imaging, reviewed at the multidisciplinary tumor board of our institution, were included. Outcome MeasuresIntraclass correlation coefficient (ICC) was used for SINS score agreement. Fleiss kappa statistic was used to assess agreement on the location of the most affected vertebral level; agreement on the SINS category (“stable,” “potentially stable,” or “unstable”); and overall agreement with the classification established by tumor board. MethodsClinical data and imaging were provided to 83 specialists in 44 hospitals across 14 Spanish regions. No assessment criteria were pre-established. Each clinician assessed the SINS score twice, with a minimum 6-week interval. Clinicians were blinded to assessments made by other specialists and to their own previous assessment. Subgroup analyses were performed by clinicians' specialty, experience (≤7, 8–13, ≥14 years), and hospital category (four levels according to size and complexity). This study was supported by Kovacs Foundation. ResultsIntra and interobserver agreement on the location of the most affected levels was “almost perfect” (κ>0.94). Intra-observer agreement on the SINS score was “excellent” (ICC=0.77), whereas interobserver agreement was “moderate” (ICC=0.55). Intra-observer agreement in SINS category was “substantial” (k=0.61), whereas interobserver agreement was “moderate” (k=0.42). Overall agreement with the tumor board classification was “substantial” (κ=0.61). Results were similar across specialties, years of experience, and hospital category. ConclusionsAgreement on the assessment of metastatic spine instability is moderate. The SINS can help improve communication among clinicians in oncology care.

Qualitative FDG PET Image Assessment Using Automated Three-Segment MR Attenuation Correction Versus CT Attenuation Correction in a Tertiary Pediatric Hospital: A Prospective Study.

The purpose of this study was to systematically evaluate the diagnostic quality of (18)F-FDG PET images generated using MR attenuation correction (MRAC) compared with those images generated using CT attenuation correction (CTAC) in a pediatric population. Forty-two patients (mean age, 12.8 years; percentage who were male, 57%) who were referred for 62 indicated whole-body PET/CT studies were prospectively recruited to undergo PET/MRI examinations during the same clinic visit in which PET/CT was performed. MRAC was performed using an automatic three-segment model. Three nuclear radiologists scored the diagnostic quality of the PET images generated by MRAC and CTAC using a Likert scale (range of scores, 1-5). Images graded with a score of 1-3 were considered clinically unacceptable, whereas images with a score of 4-5 were considered clinically acceptable. A Wilcoxon signed-rank test was used to compare differences in the grading of PET/MRI and PET/CT images. The Fisher exact test was used to evaluate potential differences in clinically acceptable image quality and the presence of artifact. Fleiss kappa statistics were used to examine interobserver agreement. There was no statistically significant difference in the proportion of PET images generated with MRAC and CTAC for which image quality was considered clinically acceptable. A total of 3.9% of PET assessments generated with MRAC were of unacceptable image quality, compared with 2.2% of PET images generated with CTAC. Two of the three radiologists who reviewed the PET images reported the presence of artifacts more often on MRAC-derived images, and they graded the mean quality of these images 0.48 and 0.29 points lower on the 5-point Likert scale than they graded the mean quality of CTAC-derived images (p < 0.0001). Interobserver agreement was fair (κ = 0.39). The diagnostic quality of PET images obtained from a pediatric population with the use of an automatic three-segmentation MRAC method was comparable to that of PET images obtained with the use of CTAC.

Clasificaciones de hallux rigidus: ¿todos vemos lo mismo?

IntroductionHallux rigidus (HR) is one of the most common causes of pain in the forefoot. We can find 18 different classifications to evaluate this disease without exist nowadays a clear consensus on which to use, although the most widespread it would be Coughlin & Shurnas classification. Making a critical review of the literature we can see that all of them have been developed based on the experience and expert opinion, existing a lack of validity and inter / intra observer reliability studies. ObjectivesTo assess the inter /intraobserver reliability of the classification of Coughlin & Shurnas in their radiological paragraph. Material and Methods6 orthopedic surgeons (2 experts, 2 seniors, 2 novice) analyzed the radiographs (F and P load) of 70 patients with HR and categorized them based on the Coughlin & Shurnas classification. After randomizing the sample, the observation was repeated 3 days after the first. Inter-intraobserver reliability was analyzed using Fleiss Kappa statistic and Kendall Coefficient of Concordance using the statistical package Minitab 16.1.1. ResultsA Fleiss Kappa interobserver reliability of 0.46 and CC Kendall of 0.8183 was obtained. Regarding the internal consistency or intraobserver reliability Fleiss Kappa values ranged from 0.52 and 0.84 for different observers. ConclusionsThe classification of Coughlin & Shurnas in their radiological paragraph has good intraobserver reliability and a moderate interobserver agreement based on our results.

Tu1144 Quantifying Esophageal Bolus Emptying With Novel High-Resolution Impedance Manometry (HRIM) Parameters in 3 Subtypes of Achalasia

G A A b st ra ct s 2013 and 11/2014, six experienced gastroenterologists with a clinical focus in esophageal disease (attendings) and six gastroenterology trainees with minimal manometry experience (fellows) from 3 academic centers interpreted each of the 40 studies using both EPT and CLT formats, separated by at least 2 weeks. Inter-rater agreement was assessed by multirater Fleiss kappa (κ) statistic; κ values of 0.21-0.4, 0.41-0.6, and 0.61-0.8 were interpreted as fair, moderate, and substantial agreement, respectively. Diagnostic accuracy, defined by rater agreement with diagnoses designated by the consensus of two independent lead authors of each of the corresponding classification schemes (EPT: Bredenoord and Pandolfino. CLT: Spechler and Castell), was compared between the two display formats using conditional logistic regression. Accuracy was assessed both for correct diagnosis of esophageal motility diagnosis (exact diagnosis) and for identification of a major esophageal motility disorder. Results: The overall Fleiss κ statistic was 0.57 (95% CI 0.56-0.59) for EPT and 0.32 (0.300.33) for CLT. Inter-rater agreement between attendings and fellows was 0.68 (0.65-0.71) and 0.48 (0.45-0.50), respectively, for EPT and 0.46 (0.43-0.50) and 0.20 (0.17-0.24), respectively, for CLT. Among all raters, the odds of an incorrect exact esophageal motility diagnosis were 3.1 times higher with CLT assessment than with EPT (OR 3.1; 95% CI 2.04.7; p<0.0001) and the odds of incorrect identification of a major motility disorder were 3.4 times higher with CLT than EPT (OR 3.43; 2.4-5.0; p<0.0001). Accuracy results as assessed by position (attending/fellow) are displayed in Table 1. Pooled accuracy results are depicted in Figure 1. Conclusions: Superior inter-rater agreement and diagnostic accuracy of esophageal motility diagnoses was demonstrated with analysis using EPT over CLT in our selected group of raters. Esophageal pressure topography should be considered the primary assessment modality of esophageal motility. Diagnostic accuracy of esophageal motility disorders assessed by rater position.

CT outperforms radiographs at a comparable radiation dose in the assessment for spondylolysis.

Lumbar spondylolysis, a unilateral or bilateral fracture at pars interarticularis, is a common cause of low back pain in children. The initial imaging study in the diagnosis of lumbar spondylolysis has historically been lumbar spine radiographs; however, radiographs can be equivocal or false-negative. Definitive diagnosis can be achieved with computed tomography (CT), but its use has been limited due to the dose of ionizing radiation to the patient. By limiting the z-axis coverage to the relevant anatomy and optimizing the CT protocol, we are able to provide a definitive diagnosis of fractures of the pars interarticularis at comparable or lower radiation dose than commonly performed lumbar spine radiographs. As there is no gold standard for the diagnosis of spondylolysis besides surgery, we compared interobserver agreement and degree of confidence to determine which modality is preferable. Sixty-two patients with low back pain ages 5-18 years were assessed for the presence of spondylolyis. Forty-seven patients were evaluated by radiography and 15 patients were evaluated by limited field-of-view CT. Both radiographic and CT examinations were assessed anonymously in random order for the presence or absence of spondylolyisis by six raters. Agreement was assessed among raters using a Fleiss Kappa statistic for multiple raters. CT provided a significantly higher level of agreement among raters than radiographs (P < 0.001). The overall Kappa for rater agreement with radiographs was 0.24, 0.34 and 0.40 for 2, 3 or 4 views, respectively, and 0.88 with CT. Interobserver agreement is significantly greater using limited z-axis coverage CT when compared with radiographs. Radiologist confidence improved significantly with CT compared to radiographs regardless of the number of views.

A standardized lingual tonsil grading system: interexaminer agreement.

Comparisons among studies involving the tongue base are limited by lack of a universal system for grading lingual tonsils. The authors propose a new standardized clinical grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study. Kappa interrater agreement study. Tertiary academic center. Video assessment: The proposed grading system consists of a 0-to-4 scale: 0 = complete absence of lymphoid tissue; 1 = lymphoid tissue scattered over tongue base; 2 = lymphoid tissue covering entirety of tongue base with limited vertical thickness; 3 = significantly raised lymphoid tissue covering entirety of the tongue base, approximately 5 to 10 mm in thickness; 4 = lymphoid tissue rising above the tip of the epiglottis, ≥1 cm in thickness. The vertical height of the tonsils is a clinical approximate. A teaching video demonstrated identification of this grading system. Fourteen trained otolaryngologists graded 20 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy. Video assessment: The overall Fleiss kappa statistic was 0.775 (P < .0001). This denotes substantial agreement. Live assessment: The overall kappa for nominal data was 0.8665 (P < .0001). This denotes near perfect agreement. The substantial interexaminer correlation demonstrated during video assessment and perfect interexaminer correlation in live assessment indicate that the proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

Postchemotherapy histopathological evaluation of ovarian carcinoma: a 40-case study.

Ovarian carcinomas are conventionally treated with primary debulking surgery followed by chemotherapy. Nowadays neoadjuvant chemotherapy followed by surgery is an upcoming treatment modality for ovarian carcinoma. This study highlights the histopathological changes observed after neoadjuvant chemotherapy. Present study is a 40-case study stressing five histological parameters: residual tumour, fibrosis, necrosis, inflammation, and psammoma bodies. All these parameters carry prognostic significance and they are easily reproducible. Fleiss kappa statistics were used to measure intraobserver agreement between pathologists which was found to be substantial to almost perfect with κ ranging between 0.621 and 1.00. This study highlights easily reproducible parameters and their incorporation in histopathology report, thus helping in patient management.

Development and validation of an endoscopic activity score for canine inflammatory bowel disease

The aim of this study was to develop and prospectively validate a simple endoscopic score of disease activity for dogs with inflammatory bowel disease (IBD). Archived endoscopic still images and video recordings of gastric, duodenal, and colonic endoscopic examinations were displayed to novice and experienced endoscopists for assessment of inflammatory activity using established descriptions. The mucosal appearances evaluated were normal tissue, erosions, friability, increased granularity, lymphangiectasia (duodenum), and mass (colon). Fleiss and Cohen's Kappa statistics were used to estimate the inter-observer agreement of the index.For duodenal assessment, there were statistically significant (P < 0.05) differences in inter-observer agreement, with experienced endoscopists performing better than novice endoscopists in the accurate identification of mucosal appearance of the duodenum. In contrast, there was no significant difference between novice and experienced endoscopists in their interpretation of gastric (P = 0.10) and colonic (P = 1.0) mucosal appearances. Validation studies using endoscopic video clips to assess the same endoscopic parameters by quantitative (lesion number and severity) and qualitative (presence of mucosal lesions) methods showed moderate-to-substantial agreement between experienced endoscopists. Based on the observations that the quantitative and qualitative scores of mucosal appearances are virtually identical, and that qualitative assessment was performed more quickly and objectively than quantitative assessment, we propose a simple endoscopic activity score based on qualitative criteria alone in dogs with inflammatory bowel disease.

Management of Acute Bleeding in Severe Haemophilia Using Homeopathic Medicines: a Multicentric Case Series

Background & Introduction: Homeopathic medicines are extensively used in India and are recognized by the Government for regular management of different ailments. Though factor concentrates are being supplied increasingly at government hospital yet the distribution is erratic and patchy across the country. Present study builds our previous experience and explores the utility of homeopathic medicines along with non-factor managements in arresting the acute bleeding episodes in severe haemophilia patients who has very little access to factor concentrates. Materials and Methods: Severe haemophilia patients (PWH) having acute bleeding episodes of various types with very little access to factor concentrates who continued to bleed or remained symptomatic at least for 6 hr after all measures (RICE, EACA/ Tranexamic acid locally or systemically, in small number of patients single dose of factor concentrates/ FEIBA or novoseven. Local pressure etc) failed to arrest the bleeding or the symptoms were included in this analysis in this multicentric report. All the patients maintained a bleeding diary. The study was conducted at three centres at Mumbai. Nashik and Surat between December 2007 to march 2014 involving 494 patients between 9 days to 51years of age. Evaluation of bleeding and the degree of relief by homeopathic medicines was done by experts in modern medicine in a blind fashion. Homeopathic Medicines were given by trained homeopaths with experience in treating haemophilia for at least 5 years. For objective selection of medicine computer based repertorisation was initially done using RADAR software and from the list of appropriate medicines the homeopathic practitioner selected his own medicine for the occasion. Efficacy of the intervention was assessed by i) Stoppage of bleeding withinn 6 hr of treatment ii) No drop in haemoglobin of more than 1 Gm/dl over 24 hr iii) No need for blood transfusion and/ or factor insfusion after homeopathic intervention iv) Relief of pain and swelling and other features of inflammation in cases of haemarthrosis.All coagulation related investigation of the patients were done at the haemostasis laboratory of National institute of Immunohaematology at Mumbai, which is an International Haemophilia Training Centre (IHTC). Initial correlation of selection of similar class of homeopathic medicines between three homeopathic physicians at three centres was tested by requesting them to select homeopathic medicines in hypothetical cases and analysing them by Fleiss kappa statistic. Chi square (X2) test was done to see the statistical significance of management compared to those cases where at least one dose of factor concentrate was given. Results:Four hundred and ninety four severely affected PWH from Nashik (292), Mumbai (182) and Surat (20) presented with 636 episodes of bleeding. Five hundred and seventy eight bleeding episodes (91%) were success fully managed with homeopathic medicines only. In 21 episodes (3.1%) homeopathic medicines failed but responded to additional factor concentrates. 37 patients who received factor concentrates without any apparent benefit in the given time responded to homeopathic medicines. Out of 31 patients who bled with inhibitor (2.4–6.7 BU/ ml) but 23 of these patient responded (65%) to homeopathic medicines. The inter prescriber correlation on the class of medicine prescribed by three homeopathic physicians was substantial (Fleiss kappa of 0.67).Pain relief in these patients were also substantial (87/105 i.e., 83% patient with acute haemarthrosis). Single patient of severe factor XIII deficienct who continuously bled from umbilical stump responded to abrotanum Conclusion:Homeopathic medicine prescribed by homeopaths experienced in managing haemophilia patients can significantly reduce bleeding and improve symptoms in a large majoriy of severely affected haemophilia patients along with non-factor supportive therapy and can be an alternative way of treating these patients where factor concentrates are not optimally available.

Identification and characteristics of signature whistles in wild bottlenose dolphins (Tursiops truncatus) from Namibia.

A signature whistle type is a learned, individually distinctive whistle type in a dolphin's acoustic repertoire that broadcasts the identity of the whistle owner. The acquisition and use of signature whistles indicates complex cognitive functioning that requires wider investigation in wild dolphin populations. Here we identify signature whistle types from a population of approximately 100 wild common bottlenose dolphins (Tursiops truncatus) inhabiting Walvis Bay, and describe signature whistle occurrence, acoustic parameters and temporal production. A catalogue of 43 repeatedly emitted whistle types (REWTs) was generated by analysing 79 hrs of acoustic recordings. From this, 28 signature whistle types were identified using a method based on the temporal patterns in whistle sequences. A visual classification task conducted by 5 naïve judges showed high levels of agreement in classification of whistles (Fleiss-Kappa statistic, κ = 0.848, Z = 55.3, P<0.001) and supported our categorisation. Signature whistle structure remained stable over time and location, with most types (82%) recorded in 2 or more years, and 4 identified at Walvis Bay and a second field site approximately 450 km away. Whistle acoustic parameters were consistent with those of signature whistles documented in Sarasota Bay (Florida, USA). We provide evidence of possible two-voice signature whistle production by a common bottlenose dolphin. Although signature whistle types have potential use as a marker for studying individual habitat use, we only identified approximately 28% of those from the Walvis Bay population, despite considerable recording effort. We found that signature whistle type diversity was higher in larger dolphin groups and groups with calves present. This is the first study describing signature whistles in a wild free-ranging T. truncatus population inhabiting African waters and it provides a baseline on which more in depth behavioural studies can be based.

A Standardized Lingual Tonsil Grading System: Interexaminer Agreement

Objectives: Comparisons between studies involving the tongue base are limited by the lack of a universal system for grading lingual tonsils. The authors propose a new standardized grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study. Methods: Video assessment: The proposed grading system consists of a 0 to 4 scale with: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covering entirety of the tongue base with limited vertical thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue &gt;1 cm in thickness (above tip of the epiglottis). A teaching video was created to demonstrate identification of this grading system. After viewing the teaching video, 8 trained otolaryngologists graded 25 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy during a routine clinic visit. Each examiner viewed and recorded the grade of the lingual tonsils independently. Results: Video assessment: The overall Fleiss kappa statistic was found to be κ = 0.449 ( P &lt; .0001). This value denotes moderate agreement. Live assessment: The overall kappa for nominal data were found to be κ = 0.8665 ( P &lt; .0001). This value denotes perfect agreement. Conclusions: The moderate interexaminer correlation demonstrated during video-assessment, and perfect interexaminer correlation demonstrated during live assessment, indicate that this proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

Reliable and valid: A procedure for establishing item-level interrater reliability for child maltreatment risk and safety assessments

Child protective service caseworkers need validated instruments to assist them in assessing safety and risk factors for child maltreatment. The literature provides growing evidence that actuarial risk assessments can be valid tools for classifying families according to risk of future maltreatment. However, compared to validity, we know less about the reliability of both whole assessments and individual items. In this study we tested interrater reliability for 108 individual risk and safety items. We used 31 realistic case vignettes for testing. Each item was completed six times for each vignette. Fifty-four caseworkers and supervisors participated in rating, generating a total of 20,088 ratings for analysis. To determine item reliability, we used measures of prevalence and percentage agreement and the Fleiss's kappa statistic. Results show that interrater reliability varies widely from item to item. Items with higher prevalence and items documenting demographics, current CPS system involvement, substance abuse, or mental health issues tend to be most reliable. We provide an overview of the testing process, which is replicable in other contexts. We also discuss implications for child protective services practice and for developing or revising risk and safety assessment instruments.

Inter- and Intra-rater Agreement in Assessment of Adult Spinal Deformity Using the Scoliosis Research Society–Schwab Classification

Study DesignCross-sectional assessment of inter- and intra-rater agreement. ObjectivesTo assess inter- and intra-rater agreement between spine surgeons with different levels of experience in a large consecutive series of adult patients referred to a tertiary institution for evaluation of a spinal deformity using the Scoliosis Research Society (SRS)–Schwab classification. BackgroundThe development of the SRS-Schwab classification of adult spinal deformity is based on current knowledge about relevant radiographic variables related to health-related quality of life. Clinical implementation of the classification requires satisfactory reliability. Two recent reports on agreement were based on a small selected case sample using pre-marked radiographs and a large cohort of only surgical patients, including congenital deformity. MethodsScoliosis Research Society–Schwab classification of 67 consecutive adult patients referred for surgical evaluation of a spinal deformity was done in a blinded fashion without pre-marking by 2 senior spine surgeons, 1 attending, and 1 spine fellow. After 2 weeks, the classification was repeated on recoded radiographs. Inter- and intra-rater agreement was analyzed using Fleiss kappa statistics. Rater bias was assessed using Bhapkar test for marginal homogeneity. ResultsAccording to Landis and Koch, the observed agreements were considered substantial to almost perfect for curve type and sagittal modifiers and moderate for entire grade, with no consistent differences between surgeons with different levels of experience. ConclusionsThe results for each individual radiographic parameter correspond to previous findings and support use of the SRS-Schwab classification in adult spinal deformity. The results for entire grade were considered only moderate. The authors recommend that it is not used as an individual parameter.

Evaluating intrusive injuries in primary dentition from computed tomographic scans: a preliminary report.

Children sustaining maxillofacial trauma may undergo computed tomographic (CT) examination to exclude potential complications, which pave way for spread of infection into the meningeal region. Following treatment, these children report for management of their dental injuries as out-patients for which a separate conventional radiographic examination is usually done. The usefulness of the initial maxillofacial CT scan in evaluating dental injuries needs to be assessed so as to possibly avoid children from being subjected to a separate radiographic examination. The objective of this study was to evaluate the ability of pediatric dentists to assess intrusive injuries in primary dentition from preexisting maxillofacial CT scans of children. Hospital based cross-sectional study. Among 70 pediatric patients who were admitted following maxillofacial injuries, 10 children underwent CT examination. CT segments displaying the tooth bearing portions of the jaw were reformatted using the Dentascan software and three precalibrated pediatric dentists clinically examined the selected children and with the use of Dentascan based CT sections assessed the relative position of the intruded teeth in relation to the permanent successor and planned treatment for each individual intruded tooth. Fleiss Kappa statistics. There was perfect agreement between the interpretations of all participants (κ = 1.0000, 95% confidence interval = 0.6861-1.3139) and the interpretations of each participant with the "gold standard" evaluator (κ = 1.000). Maxillofacial CT scans made to assess maxillofacial injuries in children can also be reliably used for assessing intrusive injuries in primary dentition.

A targeted method for standardized assessment of adverse drug events in surgical patients

This study demonstrates the development, reliability and outcome of a targeted method for standardized assessment of adverse drug events (ADEs) in surgical patients. Initial practice evaluation of this ADE assessment method was carried out in a prospective single centre cohort study. In total, 262 electively admitted surgical patients were included. The surgical trigger tool was applied to patients' medical records by two independent reviewers, and subsequent assessment of causality, severity and preventability of ADEs was carried out by two independent expert panels consisting of a consultant surgeon and a clinical pharmacologist. The surgical trigger tool and causality assessment method were each tested on reliability in a separate group of 50 randomly selected patients using Fleiss and Cohen's kappa statistics and percentages of agreement. Comparison of this method with an existing trigger tool method for ADEs was performed. Our surgical trigger tool contains 51 triggers. The inter- and intra-rater calculations showed substantial to almost perfect levels of agreement (kappa range 0.71-0.83), with a 97.8-98.5% percentage of agreement. Fair to substantial levels of agreement were calculated for causality, severity and preventability (kappa range 0.38-0.79). The percentages of inter- and intra-rater agreement were 68.9 and 70.5% for causality, 67.0 and 82.0% for severity, and both 98.4% for preventability, respectively. Compared with the existing trigger tool method for ADEs, we found an additional 363 triggers, 18 ADEs (an extra 20%) and 3 preventable ADEs in our surgical cohort. This targeted trigger tool for standardized assessment of ADEs in surgical patients shows excellent agreement between reviewers. The assessment of medication-related harm had acceptable agreement. Compared with an existing ADE trigger tool method, the present method found almost 20% extra ADEs. This method can be a useful alternative to existing trigger tool methods, in particular to assess medication safety in surgical patients.

The Subaxial Cervical Spine Injury Classification System: an external agreement validation study

Background contextIn 2007, the Subaxial Cervical Spine Injury Classification (SLIC) system was introduced demonstrating moderate reliability in an internal validation study. PurposeTo assess the agreement on the SLIC system using clinical data from a spinal trauma population and whether the SLIC treatment algorithm outcome improved agreement on treatment decisions among surgeons. Study designAn external classification validation study. Patient sampleTwelve spinal surgeons (five consultants and seven fellows) assessed 51 randomly selected cases. Outcome measuresRaw agreement, Fleiss kappa, and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules and latent class modeling were used for accuracy analysis. MethodsFifty-one randomly selected cases with significant injuries of the cervical spine from a prospective consecutive series of trauma patients were assessed using the SLIC system. Neurologic details, plain radiographs, and computed tomography scans were available for all cases as well as magnetic resonance imaging in 21 cases (41%). No funds were received in support of this study. The authors have no conflict of interest in the subject of this article. ResultsThe inter-rater agreement on the most severely affected level of injury was strong (κ=0.76). The agreement on the morphologic injury characteristics was poor (κ=0.29) and agreement on the integrity of the discoligamentous complex was average (κ=0.46). The inter-rater agreement on the treatment verdict after the total SLIC injury severity score was slightly lower than the surgeons' agreement on personal treatment preference (κ=0.55 vs. κ=0.63). Latent class analysis was not converging and did not present accurate estimations of the true classification categories. Based on these findings, no second survey for testing intrarater agreement was performed. ConclusionsWe found poor agreement on the morphologic injury characteristics of the SLIC system, and its treatment algorithm showed no improved agreement on treatment decisions among surgeons. The authors discuss that the reproducibility of the SLIC system is likely to improve when unambiguous true morphologic injury characteristics are being implemented.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Validation of a Grading System for Lateral Nasal Wall Insufficiency

This study was designed to validate a grading scheme for lateral nasal wall insufficiency with interrater and intrarater reliability measures. Representative endoscopic videos depicting varied degrees of lateral nasal wall insufficiency were collated into a 30-clip video (15 clips in duplicate). This was rated by five reviewers for a total of 150 observations. Interrater and intrarater reliability were determined using Fleiss kappa and intraclass correlation coefficient (ICC) statistics, respectively. Good agreement was established between reviewers (interrater reliability), with a Fleiss kappa of 0.7733 (p < 0.01). Analysis of intrarater variability with the ICC revealed a very strong agreement (ICC = 0.88; p < 0.01). The proposed grading system is shown to have good interrater and intrarater reliability. It provides a reliable instrument for assessing lateral wall insufficiency.