Fleiss Kappa Statistic Research Articles

Assessment of Inter-observer Reproducibility of the Residual Cancer Burden Index and Neoadjuvant Chemotherapy Response in Breast Carcinoma

Background : Locally advanced breast cancers are nowadays treated with neoadjuvant chemotherapy (NAC) to downstage the tumor. One way to assess the NAC response is to use “Residual cancer burden index (RCB).” The aim of the study was to assess inter-pathologist reproducibility of residual cancer burden index and to evaluate different clinico-pathological parameters that determine the pathological response. Methods: In this retrospective cohort study, surgically excised specimens of 49 NAC treated breast cancer were examined by histopathology and immunohistochemistry over a period of one and half years. Four pathologists with different level of experience reviewed the reports (unaware of original RCB index) and slides and assigned the RCB indices for each case. Clinical, histopathological and immunohistochemical parameters were evaluated.. Fleiss- Kappa statistics was applied to assess interobserver reproducibility of RCB index. Results: No significant relationship was observed between RCB index (of original report) with age, largest tumor dimension and number of chemotherapy cycles . The RCB index of 49 cases as assigned by four pathologists was calculated by Fleiss-kappa statistics and it showed good overall agreement (82.6%). Conclusion: It has been observed that there is no significant relation between pathological response to NAC with age, largest tumor dimension and number of chemotherapy cycles of breast carcinoma. It can also be concluded that RCB can be reliably used to report neoadjuvant chemotherapy treated specimens of breast cancer.

Kinetics of EBV antibody-based NPC risk scores in Taiwan NPC multiplex families.

Nasopharyngeal carcinoma (NPC) risk prediction models based on Epstein-Barr virus (EBV)-antibody testing have shown potential for screening of NPC; however, the long-term stability is unclear. Here, we investigated the kinetics of two EBV-antibody NPC risk scores within the Taiwan NPC Multiplex Family Study. Among 545 participants with multiple blood samples, we evaluated the stability of a 2-marker enzyme-linked immunosorbent assay score and 13-marker multiplex serology score using the intra-class correlation coefficient (ICC) by fitting a linear mixed model that accounted for the clustering effect of multiple measurements per subject and age. We also estimated the clustering of positive tests using Fleiss's kappa statistic. Over an average 20-year follow-up, the 2-marker score showed high stability over time, whereas the 13-marker score was more variable (p < .05). Case-control status is associated with the kinetics of the antibody response, with higher ICCs among cases. Positive tests were more likely to cluster within the same individual for the 2-marker score than the 13-marker score (p < .05). The 2-marker score had an increase in specificity from ~90% for single measurement to ~96% with repeat testing. The 13-marker score had a specificity of ~73% for a single measurement that increased to ~92% with repeat testing. Among individuals who developed NPC, none experienced score reversion. Our findings suggest that repeated testing could improve the specificity of NPC screening in high-risk NPC multiplex families. Further studies are required to determine the impact on sensitivity, establish optimal screening intervals, and generalize these findings to general population settings in high-risk regions.

Predicting pedestrian-vehicle interaction severity at unsignalized intersections

Objectives This study aims to develop and validate a novel deep-learning model that predicts the severity of pedestrian-vehicle interactions at unsignalized intersections, distinctively integrating Transformer-based models with Multilayer Perceptrons (MLP). This approach leverages advanced feature analysis capabilities, offering a more direct and interpretable method than traditional models. Methods High-resolution optical cameras recorded detailed pedestrian and vehicle movements at study sites, with data processed to extract trajectories and convert them into real-world coordinates via precise georeferencing. Trained observers categorized interactions into safe passage, critical event, and conflict based on movement patterns, speeds, and accelerations. Fleiss Kappa statistic measured inter-rater agreement to ensure evaluator consistency. This study introduces a novel deep-learning model combining Transformer-based time series data capabilities with the classification strengths of a Multilayer Perceptron (MLP). Unlike traditional models, this approach focuses on feature analysis for greater interpretability. The model, trained on dynamic input variables from trajectory data, employs attention mechanisms to evaluate the significance of each input variable, offering deeper insights into factors influencing interaction severity. Results The model demonstrated high performance across different severity categories: safe interactions achieved a precision of 0.78, recall of 0.91, and F1-score of 0.84. In more severe categories like critical events and conflicts, precision and recall were even higher. Overall accuracy stood at 0.87, with both macro and weighted averages for precision, recall, and F1-score also at 0.87. The variable importance analysis, using attention scores from the proposed transformer model, identified ‘Vehicle Speed’ as the most significant input variable positively influencing severity. Conversely, ‘Approaching Angle’ and ‘Vehicle Distance from Conflict Point’ negatively impacted severity. Other significant factors included ‘Type of Vehicle’, ‘Pedestrian Speed’, and ‘Pedestrian Yaw Rate’, highlighting the complex interplay of behavioral and environmental factors in pedestrian-vehicle interactions. Conclusions This study introduces a deep-learning model that effectively predicts the severity of pedestrian-vehicle interactions at crosswalks, utilizing a Transformer-MLP hybrid architecture with high precision and recall across severity categories. Key factors influencing severity were identified, paving the way for further enhancements in real-time analysis and broader safety assessments in urban settings.

An inter-assessor reliability study on the categorization and staging of pressure injuries

BackgroundThe first step in effective management of pressure injuries (PIs) is to assess, categorize and stage correctly. PurposeThis study aims to examine the agreement regarding the classification and staging of PIs among nurse academicians working on chronic wounds and with different stage of expertise. MethodsThree nurse academicians were assigned as assessors according to Benner's stages of clinical competence (Competent, Proficient, and Expert). The assessors independently evaluated PIs photographs (n = 694). The assessors then met for the wounds where there was disagreement, and a Consensus agreement was reached. Kappa Statistics analysed the agreement between two assessors; Fleiss Kappa Statistics analysed the agreement between Competent, Proficient, Expert, and Consensus. ResultsStatistically, almost perfect agreement was obtained between Competent, Proficient, Expert, and Consensus assessments, respectively (Ƙ = 0.871; p < 0.001, Ƙ = 0.842; p < 0.001, Ƙ = 0.937; p < 0.001). The highest agreement between the assessors were Unstageable PIs, Deep Tissue PIs, and Stage 3 PIs respectively. The most common disagreements were between Deep Tissue PIs and Stage 1 PIs, and between Deep Tissue PIs and Stage 2 PIs. ConclusionIn the study, it was found that the categorization, and staging of PIs had varying degrees of reliability among the assesors, although at a statistically acceptable level.

Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications.

Reconstruction of segmental bone defects with bone transport is a well-established treatment. Mechanical complications at the docking site after frame removal are common. These complications include malunion, non-union, axial deviation and refracture. A simple tool to assess the healing of the docking site is currently lacking. The aim of this study is to evaluate the use of the modified RUST (mRUST) score in the setting of bone transport and to identify factors associated with an increased risk of docking site complications. This retrospective study was conducted at a single tertiary centre in South Africa, included 24 patients with a tibial bone defect treated with bone transport and a circular frame between 2014 and 2023. Demographic data, clinical and bone transport characteristics were recorded. Mechanical complications, such as fracture, non-union, any angulation >5°, shortening >5 mm, or any other complication requiring reoperation, were recorded. The mRUST was adapted as a ratio for the purpose of this study to overcome the common occurrence of cortices being obscured by the frame. The mRUST ratio was applied before and after frame removal for each patient by three appraisers. Comparison between the groups with and without complications was performed regarding bone transport characteristics, docking site configuration and mRUST ratio. The correlation of the score between radiographs before and after frame removal was assessed. The inter-rater reliability of the mRUST was analysed using Fleiss Kappa statistics for each cortex individually and the intraclass correlation coefficient (ICC) for the mRUST ratio. In this study, 20 men and 4 women with a median age of 26 years were included. The overall rate of mechanical complications after frame removal was 21.7%. Complications were all related to the docking site, with two angulations, two fractures and one non-union. Demographics, bone transport characteristics and mRUST ratio before and after frame removal were similar between the two groups. Regarding the configuration of the docking site, an angle of 45° or more between the bone surfaces was associated with the occurrence of mechanical complications (p < 0.001). The correlation of the mean mRUST ratio before and after frame removal showed a moderate relationship, with a Spearman correlation coefficient of 0.50 (p-value 0.13). The inter-rater reliability of the mRUST was "fair" (kappa 0.21-0.40) for the scoring of individual cortices, except for one score which was "slight" (kappa 0.00-0.20). The ICC of the mRUST ratio was 0.662 on radiographs with the frame, and 0.759 after frame removal. This study did not find the mRUST or mRUST ratio useful in assessing the healing of the docking site to decide on the best time to remove the frame. However, a notable finding was that the shape and orientation of the bone ends meeting at the docking site might well be relevant to decrease complication rates. If the angle between the bony surfaces is 45° or more, it may be associated with an increased risk of complications. It may be worthwhile considering reshaping these bone ends at the time of debridement or formal docking procedure to be more collinear, in order to reduce the potential for mechanical complications such as non-union, axial deviation or refracture at the docking site. Kummer A, Nieuwoudt L, Marais LC. Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications. Strategies Trauma Limb Reconstr 2024;19(2):73-81.

Trauma-related preventable death; data analysis and panel review at a level 1 trauma centre in Amsterdam, the Netherlands.

Trauma-related death is used as a parameter to evaluate the quality of trauma care and identify cases in which mortality could have been prevented under optimal trauma care conditions. The aim of this study was to identify trauma-related preventable death (TRPD) within our institute by an external expert panel and to evaluate inter-panel reliability. Trauma-related deaths between the 1st of January 2020 and the 1st of February 2022 at the Amsterdam University Medical Centre were identified. The severely injured patients (injury severity score ≥ 16) were enrolled for preventability analysis by an external multidisciplinary panel, consisting of a trauma surgeon, anaesthesiologist, emergency physician, neurosurgeon, and forensic physician. Case descriptions were provided, and panellists were asked to classify deaths as non-preventable, potentially preventable, and preventable. Agreements between the five observers were assessed by Fleiss kappa statistics. In total 95 trauma-related deaths were identified. Of which 36 fatalities were included for analysis, the mean age was 55.3 years (± 24.5), 69.4% were male and 88.9% suffered blunt trauma. The mean injury severity score was 35.3 (± 15.3). Interobserver agreement within the external panel was moderate for survivability (Fleiss kappa 0.474) but low for categorical preventable death classification (Fleiss kappa 0.298). Most of the disagreements were between non-preventable or potentially preventable with care that could have been improved. Multidisciplinary panel review has a moderate inter-observer agreement regarding survivability and low agreement regarding categorical preventable death classification. A valid definition and classification of TRPD is required to improve inter-observer agreement and quality of trauma care.

Are Generative Pretrained Transformer 4 Responses to Developmental Dysplasia of the Hip Clinical Scenarios Universal? An International Review.

There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings. Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care. GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 ( P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores ( P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions ( P = 0.034). This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation. Level IV.

Diagnosis of Unruptured Intracranial Aneurysms Using Proton-Density Magnetic Resonance Angiography: A Comparison With High-Resolution Time-of-Flight Magnetic Resonance Angiography.

Differentiating intracranial aneurysms from normal variants using CT angiography (CTA) or MR angiography (MRA) poses significant challenges. This study aimed to evaluate the efficacy of proton-density MRA (PD-MRA) compared to high-resolution time-of-flight MRA (HR-MRA) in diagnosing aneurysms among patients with indeterminate findings on conventional CTA or MRA. In this retrospective analysis, we included patients who underwent both PD-MRA and HR-MRA from August 2020 to July 2022 to assess lesions deemed indeterminate on prior conventional CTA or MRA examinations. Three experienced neuroradiologists independently reviewed the lesions using HR-MRA and PD-MRA with reconstructed voxel sizes of 0.253 mm3 or 0.23 mm3, respectively. A neurointerventionist established the gold standard with digital subtraction angiography. We compared the performance of HR-MRA, PD-MRA (0.253-mm3 voxel), and PD-MRA (0.23-mm3 voxel) in diagnosing aneurysms, both per lesion and per patient. The Fleiss kappa statistic was used to calculate inter-reader agreement. The study involved 109 patients (average age 57.4 ± 11.0 years; male:female ratio, 11:98) with 141 indeterminate lesions. Of these, 78 lesions (55.3%) in 69 patients were confirmed as aneurysms by the reference standard. PD-MRA (0.253-mm3 voxel) exhibited significantly higher per-lesion diagnostic performance compared to HR-MRA across all three readers: sensitivity ranged from 87.2%-91.0% versus 66.7%-70.5%; specificity from 93.7%-96.8% versus 58.7%-68.3%; and accuracy from 90.8%-92.9% versus 63.8%-69.5% (P ≤ 0.003). Furthermore, PD-MRA (0.253-mm3 voxel) demonstrated significantly superior per-patient specificity and accuracy compared to HR-MRA across all evaluators (P ≤ 0.013). The diagnostic accuracy of PD-MRA (0.23-mm3 voxel) surpassed that of HR-MRA and was comparable to PD-MRA (0.253-mm3 voxel). The kappa values for inter-reader agreements were significantly higher in PD-MRA (0.820-0.938) than in HR-MRA (0.447-0.510). PD-MRA outperformed HR-MRA in diagnostic accuracy and demonstrated almost perfect inter-reader consistency in identifying intracranial aneurysms among patients with lesions initially indeterminate on CTA or MRA.

Low Inter-Rater Reliability of Calculating the 4T's Score for Heparin Induced Thrombocytopenia

Introduction Heparin induced thrombocytopenia (HIT) is an immune-mediated drug reaction that can cause thromboembolism in the setting of thrombocytopenia following heparin exposure. The “4T's score” has been validated to determine the pre-test probability of HIT and to assist in decision making around ordering testing for HIT. The 4T's scoring system requires an individual clinician to determine each component of the score. The objective of our study is to investigate the inter-rater reliability of calculating the 4T's score among clinicians. Methods Through retrospective query of Northwestern Enterprise Data Warehouse, we identified patients who had a HIT antibody (Ab) test ordered between 10/2019 and 10/2022 after implementation of a clinical decision support (CDS) tool that asked clinicians to calculate a 4T's score as part of HIT PF-4 Ab orders. From this cohort, an independent clinician randomly selected 15 patients. Four raters, including an attending hematologist, a hospital medicine attending, a hematology/oncology fellow, and an internal medicine resident, performed manual chart review of the randomly selected subjects to calculate a 4T's score. Data collected for each case included individual components of the 4T's score and overall 4T's score from each rater. In addition, we compared raters' scores to the 4T's score entered by the ordering clinician for the patient. We then categorized the numerical scores into validated pre-test probability categories: 0-3 as low, 4-5 as intermediate, and ≥6 as high. Inter-rater reliability for the categories was calculated using the Fleiss kappa statistic. Our study was approved by the Northwestern University Institutional Review Board. Results Of 15 cases selected, 5 each were scored as low, intermediate, and high probability 4T's scores by the ordering clinician (associated with the HIT Ab order). The overall agreement between the score categories for the 5 clinicians (4 raters and the ordering clinician) was 50.7%, with a Fleiss Kappa statistic of 0.26 (95% CI [0.07-0.45]), indicating poor inter-rater reliability (Figure 1). Excluding the ordering clinician, the overall agreement in score category between the 4 raters was 58.9%, with a Fleiss Kappa statistic of 0.38 (95% CI [0.14-0.62]). The same 4T's score pre-test probability category was calculated by the 4 raters in 5 cases, with only one case in which all four raters calculated the same numerical 4T's score. There was one case in which all 5 clinicians calculated the same 4T's score probability category, but none with the same numerical 4T's score. The hematology/oncology fellow had highest inter-rater agreement with the original clinical (Kappa 0.30 [-0.09-0.69]), whereas the internal medicine attending and resident had the lowest (both with Kappa 0.00 [-0.37-0.37]). Of the 15 4T's scores, 12/15 ordered by the hematology attending, 5/15 by the internal medicine attending, 12/15 by the hematology/oncology fellow, and 11/15 by the internal medicine resident were lower than those calculated by the original ordering clinicians. Conclusion Our study demonstrates poor inter-rater reliability of HIT 4T's score calculation, across levels of training and specialty. Importantly, poor inter-rater reliability was seen across 4T's categories, which has implications for clinical management of patients undergoing evaluation for HIT. This suggests that different strategies are necessary to help clinicians better use the 4Ts score.

Assessing clinical reasoning in the OSCE: pilot-testing a novel oral debrief exercise

IntroductionClinical reasoning (CR) is a complex skill enabling transition from clinical novice to expert decision maker. The Objective Structured Clinical Examination (OSCE) is widely used to evaluate clinical competency, though there is limited literature exploring how this assessment is best used to assess CR skills. This proof-of-concept study explored the creation and pilot testing of a post-station CR assessment, named Oral Debrief (OD), in the context of undergraduate medical education.MethodsA modified-Delphi technique was used to create a standardised domain-based OD marking rubric encapsulating the key skills of CR that drew upon existing literature and our existing placement-based CR tool. 16 OSCE examiners were recruited to score three simulated OD recordings that were scripted to portray differing levels of competency. Adopting a think-aloud approach, examiners vocalised their thought processes while utilising the rubric to assess each video. Thereafter, semi-structured interviews explored examiners’ views on the OD approach. Recordings were transcribed, anonymised and analysed deductively and inductively for recurring themes. Additionally, inter-rater agreement of examiners’ scoring was determined using the Fleiss Kappa statistic both within group and in comparison to a reference examiner group.ResultsThe rubric achieved fair to good levels of inter-rater reliability metrics across its constituent domains and overall global judgement scales. Think-aloud scoring revealed that participating examiners considered several factors when scoring students’ CR abilities. This included the adoption of a confident structured approach, discriminating between relevant and less-relevant information, and the ability to prioritise and justify decision making. Furthermore, students’ CR skills were judged in light of potential risks to patient safety and examiners’ own illness scripts. Feedback from examiners indicated that whilst additional training in rubric usage would be beneficial, OD offered a positive approach for examining CR ability.ConclusionThis pilot study has demonstrated promising results for the use of a novel post-station OD task to evaluate medical students’ CR ability in the OSCE setting. Further work is now planned to evaluate how the OD approach can most effectively be implemented into routine assessment practice.

Assessment of the Tumor-Stroma Ratio and Tumor-Infiltrating Lymphocytes in Colorectal Cancer: Inter-Observer Agreement Evaluation.

To implement the new marker in clinical practice, reliability assessment, validation, and standardization of utilization must be applied. This study evaluated the reliability of tumor-infiltrating lymphocytes (TILs) and tumor-stroma ratio (TSR) assessment through conventional microscopy by comparing observers' estimations. Intratumoral and tumor-front stromal TILs, and TSR, were assessed by three pathologists using 86 CRC HE slides. TSR and TILs were categorized using one and four different proposed cutoff systems, respectively, and agreement was assessed using the intraclass coefficient (ICC) and Cohen's kappa statistics. Pairwise evaluation of agreement was performed using the Fleiss kappa statistic and the concordance rate and it was visualized by Bland-Altman plots. To investigate the association between biomarkers and patient data, Pearson's correlation analysis was applied. For the evaluation of intratumoral stromal TILs, ICC of 0.505 (95% CI: 0.35-0.64) was obtained, kappa values were in the range of 0.21 to 0.38, and concordance rates in the range of 0.61 to 0.72. For the evaluation of tumor-front TILs, ICC was 0.52 (95% CI: 0.32-0.67), the overall kappa value ranged from 0.24 to 0.30, and the concordance rate ranged from 0.66 to 0.72. For estimating the TSR, the ICC was 0.48 (95% CI: 0.35-0.60), the kappa value was 0.49 and the concordance rate was 0.76. We observed a significant correlation between tumor grade and the median of TSR (0.29 (95% CI: 0.032-0.51), p-value = 0.03). The agreement between pathologists in estimating these markers corresponds to poor-to-moderate agreement; implementing immune scores in daily practice requires more concentration in inter-observer agreements.

Interrater Agreement of CT Grading of Blunt Splenic Injuries: Does the AAST Grading Need to Be Reimagined?

Introduction: The Revised Organ Injury Scale (OIS) of the American Association for Surgery of Trauma (AAST) is the most widely accepted classification of splenic trauma. The objective of this study was to evaluate inter-rater agreement for CT grading of blunt splenic injuries. Methods: CT scans in adult patients with splenic injuries at a level 1 trauma centre were independently graded by 5 fellowship trained abdominal radiologists using the AAST OIS for splenic injuries - 2018 revision. The inter-rater agreement for AAST CT injury score, as well as low-grade (IIII) versus high-grade (IV-V) splenic injury was assessed. Disagreement in two key clinical scenarios (no injury versus injury, and high versus low grade) were qualitatively reviewed to identify possible sources of disagreement. Results: A total of 610 examinations were included. The inter-rater absolute agreement was low (Fleiss kappa statistic 0.38, P < 0.001), but improved when comparing agreement between low and high grade injuries (Fleiss kappa statistic of 0.77, P < .001). There were 34 cases (5.6%) of minimum two-rater disagreement about no injury vs injury (AAST grade ≥ I). There were 46 cases (7.5%) of minimum two-rater disagreement of low grade (AAST grade I-III) versus high grade (AAST grade IV-V) injuries. Likely sources of disagreement were interpretation of clefts versus lacerations, peri-splenic fluid versus subcapsular hematoma, application of adding multiple low grade injuries to higher grade injuries, and identification of subtle vascular injuries. Conclusion: There is low absolute agreement in grading of splenic injuries using the existing AAST OIS for splenic injuries.

Predictor of failed cancer resuscitation by expert agreement

Purpose: Cardiopulmonary resuscitation (CPR) in end-of-life and critical patients, specifically cancer in hospitals, often faces a dilemma between resuscitation or non-resuscitation. This study will determine the predictors of resuscitation failure for cancer patients by expert agreement. Materials and Methods: Predictor’s variables were collected from review 20 research journals based on cancer patients who expired and were not successfully resuscitated. From 20 research journal, we found only 11 articles that mentioned the variables involved in resuscitation failure and death in cancer patients. To find out which predictors occur the most in Indonesia, we asked 5 expert palliative anesthesiologists as an expert from a palliative center hospital in Indonesia to choose the predictor that relate to resuscitation failure. To measure the agreement, we use Fleiss–Kappa statistic method with SPSS software ver. 20. Results: Based on the agreement of the experts (k &gt;0.8), eight of 44 predictors were noted for cardiopulmonary resuscitation failure in cancer patients that are expected to occur in Indonesia, namely: AIDS (acquired immunodeficiency syndrome), CPR &gt; 15′, non-recovery of heart rate after CPR &gt;20 min, electrocardiogram (ECG) rhythm asystole, early coma, hepatic insufficiency, non-shockable heart rhythm, and pulseless electrical activity (PEA). Conclusions: Experts agree that AIDS, CPR &gt;15′, non-recovery of heart rate after CPR &gt;20 min, ECG asystole rhythm, early coma, hepatic insufficiency, non-shockable heart rhythm, and PEA are dominant predictors for CPR failure in cancer patients.

Grade Group accuracy is improved by extensive prostate biopsy sampling, but unrelated to prostatectomy specimen sampling or use of immunohistochemistry.

Assessing the accurate Grade Group of a prostate needle biopsy specimen is essential for choosing the adequate therapeutic modality for prostate cancer patients. However, it is well-known that biopsy Grade Group tends to up- or downgrade significantly at radical prostatectomy. We aimed to investigate the correlation between accuracy and biopsy core number, performed immunohistochemical staining (IHC) or prostatectomy specimen sampling, with the latest also being correlated with higher detection rates of adverse pathological features, e.g., positive surgical margins, higher pathological stage or presence of perineural invasion (PnI status). The study cohort consisted of 315 consecutive patients diagnosed with prostate adenocarcinoma via transrectal ultrasound-guided needle biopsy who later underwent radical prostatectomy. We grouped and compared patients based on Grade Group accuracy, presence of IHC on biopsy, margin status, pathological stage, and PnI status. Inter-observer reproducibility was also calculated. Statistical analyzes included ANOVA, Tukey's multiple comparisons post hoc test, Chi-squared test, and Fleiss kappa statistics. Undergraded cases harboured a significantly lower number of biopsy cores (p < 0.05), than accurately graded cases. Using IHC did not affect grading accuracy significantly, nor did the number of slides from prostatectomy specimens. The mean number of slides was virtually identical when margin status, pathological stage and PnI status of prostatectomy specimens were compared. Inter-observer reproducibility at our institute was calculated as fair (overall kappa = 0.29). Grade Group accuracy is significantly improved by obtaining more cores at biopsy but is unrelated to performed IHC. The extent of sampling prostatectomy specimens, however, did not affect accuracy and failed to significantly improve detection of adverse pathological features.

Reliability assessment of the 2018 classification case definitions of peri-implant health, peri-implant mucositis, and peri-implantitis.

The purpose of this study was to evaluate the reliability and accuracy in the assignment of the case definitions of peri-implant health and diseases according to the 2018 Classification of Periodontal and Peri-implant Diseases and Conditions. Ten undergraduate students, 10 general dentists, and 10 experts in implant dentistry participated in this study. All examiners were provided with clinical and radiographic documentation of 25 dental implants. Eleven out the 25 cases were also accompanied by baseline readings. Examiners were asked to define all cases using the 2018 classification case definitions. Reliability among examiners was evaluated using the Fleiss kappa statistic. Accuracy was estimated using percentage of complete agreement and quadratic weighted kappa for pairwise comparisons between each rater and a gold standard diagnosis. The Fleiss kappa was 0.50 (95% CI: 0.48 to 0.51) and the mean quadratic weighted kappa value was 0.544. Complete agreement with the gold standard diagnosis was achieved in 59.8% of the cases. Expertise in implantology affected accuracy positively (p<0.001) while the absence of baseline readings affected it negatively (p<0.001). Both reliability and accuracy in assigning case definitions to dental implants according to the 2018 classification were mostly moderate. Some difficulties arose in the presence of specific challenging scenarios.

Multilevel calibration procedure for the oral health national multicenter survey in primary teeth.

Early childhood caries (ECC) requires systematically collected and standardized data. To describe a novel multilevel calibration procedure in primary dentition. Calibration method involved two calibration levels: the first (L1 ) involved an interexaminer agreement between three main investigators, the group leaders (GLs) in the following level; the second level (L2 ) involved three groups of 11 paediatric dentists and interexaminer agreement assessment according to the GLs in each group. The study sample consisted of 650 primary teeth surfaces in eight children (mean age 6.56 ± 2.22 years). Surface-by-surface percent agreement, tooth-by-tooth percent agreement, Cohen's kappa, and Fleiss kappa statistics were used to calculate interexaminer reliability. Statistical analysis was performed with SPSS 27.0. Surface-by-surface percent agreement regarding ICDASepi-merged revealed almost perfect agreement (>90.00%) on both L1 and L2 . Kappa values and ranges showed good agreement at both L1 (overall κ = .95) and L2 (overall κ = .98) and almost perfect consistency was detected between GLs at L1 (>91.30%) and substantial agreement at L2 (>85.00%). All examiners at L2 showed almost perfect positive agreement (sensitivity = 96.77%-100%) when detecting the presence of dental plaque. The calibration procedure appeared feasible prior to organizing multicenter epidemiological oral health survey in large population groups of preschool children, with higher number of examiners.

Impact of postoperative baseline MRI on diagnostic confidence and performance in detecting local recurrence of soft-tissue sarcoma of the limb

ObjectiveTo evaluate the impact of a postoperative baseline (PB) MRI on diagnostic confidence and performance in detecting local recurrence (LR) of soft-tissue sarcoma (STS) of the limb.Materials and methodsA total of 72 patients (8 with LR, 64 without LR) with primary STS of the limb were included. Routine follow-up MRI (1.5 T) at 6 and approximately 36 months (meanLR: 39.7 months; meanno LR: 34.9 months) after multimodal therapy or at time of LR were assessed by three independent readers using a 5-point Likert scale. Furthermore, the following imaging parameters were evaluated: presence of a mass, signal characteristics at T2- and T1-weighted imaging, contrast enhancement (CE), and in some of the cases signal intensity on the apparent diffusion coefficient (ADC). U-test, McNemar test, and ROC-analysis were applied. Interobserver reliability was calculated using Fleiss kappa statistics. A p value of 0.05 was considered statistically significant.ResultsThe presence of a PB MRI significantly improved diagnostic confidence in detecting LR of STS (p < 0.001) and slightly increased specificity (mean specificity without PE 74.1% and with presence of PB MRI 81.2%); however, not to a significant level. The presence of a mass showed highest diagnostic performance and highest interreader agreement (AUC [%]; κ: 73.1–83.6; 0.34) followed by T2-hyperintensity (50.8–66.7; 0.08), CE (52.4–62.5; 0.13), and T1-hypointensity (54.7–77.3; 0.23). ADC showed an AUC of 65.6–96.6% and a κ of 0.55.ConclusionThe presence of a PB MRI increases diagnostic confidence in detecting LR of STS of the limb.

Clinical utility of intraoperative Arterial Spin Labeling for resection control in brain tumor surgery at 3 T.

Resection control in brain tumor surgery can be achieved in real time with intraoperative MRI (iMRI). Arterial spin labeling (ASL), a technique that measures cerebral blood flow (CBF) noninvasively without the use of intravenous contrast agents, can be performed intraoperatively providing morpho-physiological information. This study aimed to evaluate the feasibility, image quality and potential to depict residual tumor of a pseudo-continuous-ASL (PCASL) sequence at 3T. 17 patients with brain tumors, primary (16) or metastatic (1), undergoing resection surgery with iMRI-monitoring were prospectively recruited (9 men, age:56±16.6 years). A PCASL sequence with long labeling duration (3000ms) and postlabeling delay (2000ms) was added to the conventional protocol that consisted of pre- and post-contrast 3D-T1-weighted (T1w) images, optional 3D-FLAIR, and diffusion. Three observers independently assessed image quality (4-point scale) of PCASL-derived CBF maps. In those with diagnostic quality (scores 2-4) they evaluated the presence of residual tumor using the conventional sequences first, and the CBF maps afterwards (3-point scale). Inter-observer agreement for image quality and the presence of residual tumor was assessed using Fleiss-kappa statistics. Intraoperative CBF-ratio of the surgical margins (i.e., perilesional CBF values normalized to contralateral gray matter CBF) was compared to preoperative CBF-ratio within the tumor (Wilcoxon's test). Diagnostic ASL image quality was observed in 94.1% of patients (inter-observer Fleiss-κ=0.76). PCASL showed additional foci suspicious of high-grade residual component in three patients, and a hyperperfused area extending outside the enhancing component in one patient. Interobserver agreement was almost perfect in the evaluation of residual tumor with the conventional sequences (Fleiss-κ=0.92) and substantial for PCASL (Fleiss-κ=0.80). No significant differences were found between pre and intraoperative CBF-ratios (p=0.578) in patients with residual tumor (n=7). iMRI-PCASL perfusion is feasible at 3T and is useful for the intraoperative assessment of residual tumor, providing in some cases additional information to the conventional sequences.

Accuracy and reliability of tele-ultrasonography in detecting gastrointestinal obstruction in dogs and cats.

To assess the accuracy and interobserver agreement of tele-ultrasonography for the diagnosis of gastrointestinal obstruction in small animals by radiologists with different levels of experience. A retrospective cross-sectional study including dogs and cats admitted with gastrointestinal signs, between 2017 and 2019, that had abdominal ultrasonographic (US) examination performed and images saved for review. Patients were classified into two categories based on final diagnosis: animals with or without complete or partial gastrointestinal obstruction. Observers with four experience levels interpreted the archived ultrasound examinations, simulating a tele-ultrasonography consultation. Analyses of accuracy, sensitivity, specificity, positive and negative predictive values were obtained for each observer for detection of gastrointestinal obstruction. Agreement between observers for the gastrointestinal obstruction diagnosis was assessed using Fleiss's Kappa statistics. Ninety patients with gastrointestinal signs were included. Of these, 23 of 90 had partial or complete gastrointestinal obstruction. Interpretation of the images by observers via tele-ultrasonography showed intervals of accuracy, sensitivity, specificity, positive and negative predictive values, respectively, of 78.9% to 87.8%, 73.9% to 100%, 77.6% to 89.6%, 55.9% to 70.8% and 90.9% to 100% for diagnosis of gastrointestinal obstruction. Agreement for the gastrointestinal obstruction diagnosis across all reviewers was moderate (Kappa 0.6). Tele-ultrasonography had good accuracy for detection of gastrointestinal obstruction, however had a rather low positive predictive value and only moderate interobserver agreement. Therefore, this technique should be used with caution in this clinical context, given the potential surgical decision at hand.

Abstract PD1-09: Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB)

Abstract Background: The 21-gene RS (Oncotype DX) is a validated genomic signature that provides prognostic information for distant recurrence risk and is predictive of adjuvant chemotherapy benefit in patients with hormone receptor (HR)-positive, HER2-negative early breast cancer (EBC). Ki67 protein expression is a proliferation marker that is determined by immunohistochemistry (IHC) and is a prognostic biomarker in HR-positive EBC. Black race is associated with poorer prognosis in patients with EBC. RS, Ki67 and race have not been evaluated together and the impact of race on the association between Ki67 and RS is unknown. The goal of this study was to evaluate the association between the 21-gene RS and Ki67 based on race in patients with HR-positive EBC using the NCDB. Methods: Women with HR-positive EBC with 0-3 involved lymph nodes, diagnosed between 2018 and 2019, who had available information on RS, IHC-measured Ki67, and race in the NCDB dataset were identified. Patients were stratified by RS of low (0-10), intermediate (11-25) and high (26-100) and categorized into Ki67 low (/=30%) based on the International Ki67 Working Group prognostic classification (PMID: 33369635). Wilcoxon rank test was used to test for continuous variables and chi-square test was used for categorical variables. Agreement between Ki67 and RS was estimated using Fleiss Kappa statistic and corresponding p-value was reported. Results: 43,898 eligible women were included. 17.43% were lymph node positive. 78% were Non-Hispanic White, 7.98% Non-Hispanic Black, 6.42% Hispanic, and 4.26% Asian American/Pacific Islander (AAPI). The table below describes the distribution of Ki67 and RS in the overall population and racial subgroups. The distribution of Ki67 scores was significantly different between races with a higher proportion of Black patients having high Ki67 scores, p&amp;lt; 0.0001. RS distribution varied as well with a greater percentage of high RS in the Black group, p&amp;lt; 0.0001. There was only slight agreement (Kappa 0.01-0.20) between Ki67 and RS in the overall population (Kappa=0.1929, p&amp;lt; 0.0001), low Ki67 subgroup (Kappa=0.069, p&amp;lt; 0.0001) and intermediate group (Kappa=0.066, p&amp;lt; 0.0001). However, there was fair agreement (Kappa 0.21-0.40) between high Ki67 and RS (Kappa=0.351, p&amp;lt; 0.0001). Based on race as a covariate, in the overall population, agreement between Ki67 and RS remained slight for White, Hispanic, and AAPI groups but was fair for Black patients (Kappa=0.2345, p&amp;lt; 0.0001). In the low Ki67 and intermediate Ki67 groups, agreement remained slight across all races, p&amp;lt; 0.0001. While there was fair agreement between high Ki67 and RS in all racial subgroups, agreement between high Ki67 and RS was highest in the Black subgroup (Kappa=0.392, p&amp;lt; 0.0001) followed by the AAPI (Kappa=0.363, p&amp;lt; 0.0001), White (Kappa=0.342, p&amp;lt; 0.0001) and Hispanic (Kappa=0.339, p&amp;lt; 0.0001) groups. Conclusions: In this large patient population from the NCDB, there was only slight agreement between Ki67 and RS in the overall, low Ki67, and intermediate Ki67 groups but fair agreement in the high Ki67 group. Agreement between high Ki67 and RS was greatest in the Black subgroup compared to other races. This may be attributed to the higher proportion of patients with high Ki67 and RS in the Black subgroup. Future analyses on overall survival will determine the impact of race on the prognostic value of Ki67 and RS. Table 1. Distribution of Ki67 and RS by Racial/Ethnic Subgroup AAPI: Asian American/Pacific Islander AIAN: American Indian and Alaska Native Citation Format: Rima Patel, Deukwoo Kwon, Grace Van Hyfte, Joseph Sparano, Amy Tiersten. Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-09.