High Interobserver Reliability Research Articles

Accuracy of the Finnegan Scoring Based on Nursing Experience

Background: Neonatal Abstinence Syndrome (NAS) often follows the abrupt discontinuation of drugs at time of delivery. The Modified Finnegan Scoring System (MFSS), commonly used to assess infants with NAS, quantifies the severity of the symptoms and guides treatment. Previous studies showed that the FSS has a high inter-observer reliability of 0.996 and has convergent validity. Goal: To determine MFSS inter-rater reliability among NICU nurses and examine the impact of nursing experience. Methodology: A standardized video of infant exhibiting …

The Rising Moon sign is specific and sensitive in the diagnosis of bucket handle tears of the medial meniscus.

Bucket handle tears of the meniscus are common and can lead to locking, extension deficit and functional impairment. The diagnosis is determined by a combination of physical examination and imaging, but in some cases the diagnosis may be challenging since specific clinical tests are lacking. The aim of the present study was to assess the value of a new clinical test, the elective pain at the anterior aspect of the joint line (defined as the "Rising Moon sign") in the diagnosis of bucket handle tears of the medial meniscus. Forty patients treated for a bucket handle of the medial meniscus were enrolled as the study group and were compared to a matched group of 40 patients with a posterior horn tear of the medial meniscus and 50 healthy subjects. The following aspects were investigated in the groups: body mass index, extension deficit, pain at the posterior aspect of the joint line (PPJL), at the middle joint line (PMJL), at the anterior join line (PAJL) and at combined hyperflexion of the knee and external rotation of the foot (PHE). Pain at the anterior joint line (PAJL) was defined as the Rising Moon sign. In the bucket handle group the average flexion contracture was 12° (0-30°). The average PPJL was one (0-2), the average PMJL was 1.6 (0-3), PAJL was 2.5 (1-3) and PHE was 1.6 (1-2). In the posterior horn tear group the average flexion contracture was 0.9° (-10 to 5°). The average PPJL was 2.2 (1-3), the average PMJL was 1.4 (0-3), PAJL was 0.6 (0-2) and PHE was 2.5 (1-3). The rising moon showed 95% sensitivity and 98% specificity in the diagnosis of bucket handle tears. In addition it showed a positive predictive value of 97.4% and negative predictive value of 96%. Finally it also demonstrated high inter-observer reliability (0.905). The "Rising Moon" sign has shown to be highly predictive for bucket handle tears of the medial meniscus with very high specificity and sensitivity. In addition it is easy to perform with very high inter-observer reliability. Level IV.

Identification of long thoracic nerve on high-resolution 3T MRI

ObjectiveLong thoracic neuropathy results in serratus anterior muscle denervation and presents with scapular winging. Previously published studies have been unable to identify the long thoracic nerve on MRI; instead, secondary imaging features of serratus anterior muscle denervation are used to infer nerve injury. Our study's purpose was to evaluate the ability of high-resolution MRI to depict the long thoracic nerve. Materials and methodsIn this HIPAA-compliant, IRB-approved retrospective study, two musculoskeletal radiologists reviewed the brachial plexus MRI exans of 24 subjects performed for clinical suspicion of long thoracic neuropathy. The radiologists evaluated whether the long thoracic nerve could be identified and for the presence of serratus anterior denervation; when the nerve was seen, assessment for nerve enlargement, signal hyperintensity, and morphologic change was performed. Inter-observer reliability was estimated with Cohen's kappa (κ). Clinical presentation and electromyogram (EMG) were then reviewed. ResultsThe long thoracic nerve was identified in 18 cases (75%), with high inter-observer reliability for nerve visualization. Kappa values of 1.0, 0.9, 1.0, and 0.9 were obtained for identification of the LTN on coronal sequences of the brachial plexus, identification of the LTN on proximal and mid segments of the nerve on oblique sagittal sequences, and identification of the distal segment of the LTN on axial sequences through the chest, respectively. The nerve was identified in 91% of patients with positive EMG findings for a long thoracic neuropathy. In patients with EMG features of long thoracic neuropathy, 70% had corresponding abnormal MRI features. When denervation edema was present, the nerve was identified 86% of the time. ConclusionHigh-resolution MRI can be used to visualize segments of the long thoracic nerve.

High inter-observer reliability in standardized ultrasound measurements of subcutaneous adipose tissue in children aged three to six years

BackgroundA procedure to measure subcutaneous adipose (SAT) using brightness-mode ultrasound has recently been standardized and applied to various groups of adults including underweight, overweight and obese adults. High reliability of this procedure was found in each of the examined groups. The purpose of this study was to determine inter-observer reliability of the standardized brightness-mode ultrasound measurement of uncompressed SAT in three to six-year-old children.MethodsThree experienced observers independently captured the ultrasound images at the eight standardized measurement sites in each of the 20 children and evaluated their images using an interactive software that detects the SAT contour and automatically measures multiple thicknesses in each image; the mean of these represents SAT thickness at a given site. The children were aged 4.9 ± 1.0 years; their body mass index ranged from 13.6–17.7 kgm− 2. Sound speed was set to 1450 ms− 1 for SAT.ResultsSAT thickness sums with fibrous structures included (DI) ranged from 25.7–86.4 mm, mean DI was 48.1 ± 15.5 mm. For DI, resulting from 160 measurements by each observer, the intra-class correlation coefficient was 0.998 (95% confidence interval 0.980–0.999), standard error of the estimate was 1.1 mm, and 95% limits of agreement were within ±2.1 mm. The median difference in DI was 0.8 mm, i.e. about 1.9% of mean DI.ConclusionsInter-observer results in children are comparable to previously described high reliability in adults. This method, which provides a technical thickness measurement accuracy of about 0.1 to 0.2 mm, enables monitoring of subcutaneous adipose tissue in children with a similarly high reliability as was obtained in adults previously.Trial registrationGerman Institute of Medical Documentation and Information, German Clinical Trials Register (DRKS) ID: DRKS00010089; Date 24/02/2016.

Can EOS imaging substitute traditional AP pelvis radiographs? A Comparative study

INTRODUCTION:Young patients followed for hip disorders often require serial imaging and incur significant radiation to the abdomen and pelvis. The EOS imaging system offers a low-radiation alternative. However, consistency with radiographic parameters from conventional radiographs (CR) have not been studied. We evaluated the reliability and validity of EOS imaging in comparison to CR in evaluating acetabular morphology.METHODS:48 hips (27 patients, 66.67% female, 14.4 ± 3.6 years old), indicated for open hip preservation procedure between 2015-2017, which had both EOS imaging and AP pelvis CR taken pre-operatively were examined. Both symptomatic and contralateral hips were measured, excluding hips with prior osteotomies.Three orthopaedic surgeons measured Tonnis angle, lateral center edge angle (LCEA), acetabular depth ratio (ADR), and extrusion index (EI) in both imaging modalities. Images were measured twice, two weeks apart. Reliability was assessed using intraclass correlation coefficients (ICC). Bland-Altman analysis was used to evaluate test-retest agreement and inter-modality agreement.RESULTS:Test-retest reliability was excellent for all raters on all tests (ICC range 0.8047 to 0.9714). Inter-rater reliability was also excellent for all measures on both modalities (ICC range 0.8593 to 0.9547). ICC values were consistent across EOS and CR.By Bland-Altman analysis, test-retest agreement was high, with no statistically significant mean differences in any test or modality (p > 0.6) except LCEA measured on EOS images (p = 0.02), which was 1.16° lower.Tonnis angle (p < 0.005) and ADR (p < 0.001) were statistically different from EOS to CR. Bias was also not uni-directional across tests: LCEA and ADR were, on average, higher on CR while Tonnis angle and EI were, on average, higher on EOS images. Reliability between the EOS and CR images was excellent for all raters on all tests (ICC range 0.8402 to 0.9458).DISCUSSION AND CONCLUSION:LCEA, ADR, EI, and Tonnis angle have consistently high test-retest reliability, test-retest agreement, and inter-observer reliability in both EOS imaging and CR to evaluate acetabular morphology. Inter-modality disagreement was observed between EOS and CR, but the difference was small and likely not clinically significant.When establishing acetabular morphology, these results suggest that EOS may provide an opportunity to minimize radiation exposure for patients followed long-term for hip pathology while maintaining the accuracy of diagnostic measures.Table 1.Reliability between EOS and traditional X-ray modalities for each of three raters, measured by the intra-class correlation coefficient (ICC).1 Table 2.Agreement between modalities in rater 2 at time point 1 using the Bland-Altman analysis of mean difference. Group means and standard deviation are shown for reference.

Wrist ROM measurements using smartphone photography: Reliability and validity

No one has validated measuring the wrist's active range of motion (ROM) using smartphone images in patients. It is not known whether pathological factors affect the accuracy of this measurement technique. The purpose of this study was to assess if smartphone photography is as reliable and valid as manual goniometry for measuring wrist joint ROM. We reviewed 38 wrists in 38 patients (21 women and 17 men) with a mean age of 45 years (range, 26–60). Smartphones were used to take digital photos of injured wrists at extremes of wrist motion, including flexion, extension, radial and ulnar deviation. The mean difference in measured ROM between the two measurement methods (digital photos and handheld goniometer) was compared using Student's t test and the relationship determined using Pearson correlation coefficients. Bland-Altman analysis was used to define the limits of agreement (LOA). No significant difference was found when comparing the wrist ROM in the four positions using manual goniometry and digital measurements from photos taken by a surgeon. Between the goniometer measurements and digital photos taken by a surgeon, the Pearson coefficients were high, with most being above 0.8 for the four positions. The Pearson coefficients also show the smartphone measurements were highly precise. There was high reliability between the photographs taken by surgeons and by patients, as well as high interobserver reliability. Smartphone photography is a reliable and valid method to measure wrist joint ROM in patients. This measurement method can be used to measure outcomes.

Interobserver reliability in the ultrasonic evaluation with graf method of developmental dysplasia of the hip: the importance of education for ultrasonography classification

Aim: Developmental dysplasia of the hip is a hip deformity that can be diagnosed early by numerous ultrasonic measurements. The purpose of this study was to evaluate the interobserver reliability of ultrasonic measurements using the Graf Ultrasound (USG) method. Methods: Ultrasonic measurements that were used by Graf Ultrasound (USG) method were obtained at presentation for 62 randomized and consecutive patients. Bilateral hip USG measurements were made for each patient. Each USG outcome was evaluated on multiple occasions by an orthopedic surgery specialist, a pediatric specialist, and a 25-year experienced radiologist. The statistical measurements were made by SPSS 20.0 (Windows, IL, USA). Intraclass Correlation Coefficient was determined. 95% Confidence Interval and F Test with True Value 0 was detected. P values were accepted as statistically significantly less than 0,05. Results: At the evaluation before education for Graf USG classification, the results were established. In the interobserver reliabilities, Intraclass Classification Correlations (ICC) values were 0,939 for USG classification evaluation with Graf Method for right hips. ICC values were 0,907 for USG classification evaluation with Graf Method for left hips. At the evaluation after education for Graf USG classification, the results were established. ICC values were 0,975 for USG classification evaluation with Graf Method for right hips. ICC values were 0,970 for USG classification evaluation with Graf Method for left hips. All p values were significant. While before education for Graf USG classification ICC was 0,838 in right hips, 0,765 in left hips; after education, it was 0,928 in right hips, 0,915 in left hips. Conclusion: Diagnosis of DDH deformity with USG is a complex and difficult condition that needs a serious education period. Graf USG method was found to have high interobserver reliability. And also, we detected that education for Graf USG classification increased intra-observer reliability, especially among pediatrists.

Radiographic Sagittal Tibio-Talar Offset in Ankle Arthrodesis-Accuracy and Reliability of Measurements.

Radiographic outcome assessment of ankle arthrodesis (AA) requires accurate measurement techniques. This study aimed to identify the most reliable methods for sagittal tibio-talar alignment measurements with regard to the tibio-talar offset after AA. Lateral weight-bearing radiographs of 38 fused ankles were selected for retrospective review. The sagittal tibio-talar angle (STTA), the modified tibio-talar ratio (mT-T ratio) and the sagittal tibio-talar offset (tibCOR, procLAT) were measured by three independent observers. Intra- and interobserver correlation coefficients (ICC) and mean measurement differences were calculated to assess measurement reliability and accuracy. By defining the talar longitudinal axis as a line from the inferior aspect of the posterior tubercle of the talus to the most inferior aspect of the talar neck, STTA showed excellent (ICC 0.924; CI 95% 0.862–0.959) and mTT-ratio provided high (ICC 0.836; CI 95% 0.721–0.909) interobserver reliability, respectively. For tibio-talar offset measurement the tibCOR method showed superior reliability and better interobserver agreement compared to the procLAT technique. The STTA and a modified T-T ratio are recommended for future scientific radiographic measurements in AA.

Monitoring Acute Pain in Donkeys with the Equine Utrecht University Scale for Donkeys Composite Pain Assessment (EQUUS-DONKEY-COMPASS) and the Equine Utrecht University Scale for Donkey Facial Assessment of Pain (EQUUS-DONKEY-FAP).

Simple SummaryPain can be difficult to objectively assess in animals, especially in prey animals that hide their symptoms from others. Donkeys are also known to mask and hide these signs. Owners often describe donkeys as “stubborn”, but veterinarians and equine ethologists describe donkeys more as “stoic”. Among veterinarians it is known that donkeys hide their pain symptoms even more than horses. Therefore, objective and valid pain measurement tools are needed to assess pain in donkeys. In this study, two pain scales (with behavioural elements, physiological elements, responses to interactions, and facial expressions) have been developed and tested in 79 donkeys with various types of acute pain (acute lameness, colic, head-related pain, and postoperative pain) and in 185 healthy pain-free control donkeys. The authors found that the Equine Utrecht University Scale for Donkey Composite Pain Assessment (EQUUS-DONKEY-COMPASS) and the Equine Utrecht University Scale for Donkey Facial Assessment of Pain (EQUUS-DONKEY-FAP) can both be effective to objectively assess various types of acute pain in donkeys and could potentially be used to monitor pain and improve welfare in donkeys.Objective pain assessment in donkeys is of vital importance for improving welfare in a species that is considered stoic. This study presents the construction and testing of two pain scales, the Equine Utrecht University Scale for Donkey Composite Pain Assessment (EQUUS-DONKEY-COMPASS) and the Equine Utrecht University Scale for Donkey Facial Assessment of Pain (EQUUS-DONKEY-FAP), in donkeys with acute pain. A cohort follow-up study using 264 adult donkeys (n = 12 acute colic, n = 25 acute orthopaedic pain, n = 18 acute head-related pain, n = 24 postoperative pain, and n = 185 controls) was performed. Both pain scales showed differences between donkeys with different types of pain and their control animals (p < 0.001). The EQUUS-DONKEY-COMPASS and EQUUS-DONKEY-FAP showed high inter-observer reliability (Cronbach’s alpha = 0.97 and 0.94, respectively, both p < 0.001). Sensitivity of the EQUUS-DONKEY-COMPASS was good for colic and orthopaedic pain (83% and 88%, respectively), but poor for head-related and postoperative pain (17% and 21%, respectively). Sensitivity of the EQUUS-DONKEY-FAP was good for colic and head-related pain (75% and 78%, respectively), but moderate for orthopaedic and postoperative pain (40% and 50%, respectively). Specificity was good for all types of pain with both scales (91%–99%). Different types of acute pain in donkeys can be validly assessed by either a composite or a facial expression-based pain scale.

Interobserver Analysis of Albertoni Classification for Mallet Finger, Using Plain Radiography: Importance of the Goniometer.

Objectives The objective of the present study is to evaluate the intraobserver and interobserver reliability of the Albertoni classification for mallet finger. Evaluation of goniometer device application is also an objective. Methods A total of 10 lateral radiographs of patients with mallet finger were selected and measured by 60 orthopedic surgeons with and without the use of goniometer. Results The intra- and interobserver reliability coefficients found were high. With the use of a goniometer, the interobserver reliability coefficient was even higher, but without statistical relevance. Conclusion The Albertoni classification showed high intraobserver and interobserver reliability in assessing mallet finger lesions, and the goniometer is dispensable for this purpose.

Use of SOPARC to assess physical activity in parks: do race/ethnicity, contextual conditions, and settings of the target area, affect reliability?

BackgroundSince its introduction in 2006, SOPARC (Systematic Observation of Play and Recreation in Communities) has become a fundamental tool to quantify park visitor behaviors and characteristics. We tested SOPARC reliability when assessing race/ethnicity, physical activity, contextual conditions at the time of observation, and settings of target areas to understand its utility when trying to account for individual characteristics of users.MethodsWe used 4725 SOPARC observations completed simultaneously by two independent observers to evaluate intraclass correlation and agreement rate between the two observers when trying to assess sex, age group, race/ethnicity, and level of physical activity of urban park users in different park settings. Observations were in 20 New York City parks during Spring and Summer 2017 within the PARC3 project.ResultsObservers counted 25,765 park users with high interobserver reliability (ICC = .94; %Agreement.75). Reliability scores were negatively affected by the population being observed, the intensity of physical activity, and the contextual conditions and settings of the target area at the time of observation. Specific challenges emerged when assessing the combination of physical activity and race/ethnicity.ConclusionsSOPARC training should aim to improve reliability when assessing concurrent measures such as physical activity, race/ethnicity, age, and sex. Similarly, observing crowded park areas with many active users areas may require more observation practice hours.

The Comprehensive AO CMF Classification System for Mandibular Fractures: A Multicenter Validation Study.

The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss' kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p < 0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p < 0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p < 0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p < 0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.

Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism.

The categorization of pulmonary embolism (PE) as non-massive, sub-massive, and massive helps guide acute management. The presence of right ventricular (RV) strain differentiates sub-massive from non-massive PEs. Unlike laboratory markers and electrocardiogram changes, the classic parameters used in the echocardiographic diagnosis of RV strain have a technical component that is operator-dependent. This narrative review will describe the physiologic effects of a PE on the RV and how this affects prognosis. It will summarize the literature evaluating the accuracy and prognostic ability of tricuspid annular plane systolic excursion (TAPSE) in the echocardiographic assessment of RVfunction. The review will describe the appeal of TAPSE for this purpose, provide cutoff measurements, and then illustrate how to perform the technique itself, while offering associated pearls and pitfalls in this bedside evaluation. RV function and dynamics undergo acute changes in the setting of a PE. RV dysfunction predicts poor outcomes in both the short and long term. However, RV strain is difficult to capture on echocardiography due to the chamber's complex geometric shape and contraction. From the apical four-chamber window, TAPSE offers a quantitative measure that is more easily performed with high interobserver reliability for evaluating systolic RV contraction. This measurement carries prognostic value in patients diagnosed with PE. Along with other more qualitative echocardiographic parameters, TAPSE can be used as a simple quantitative measure of RV dysfunction for differentiating sub-massive from non-massive PEs. This categorization helps guide acute management and disposition.

Intra-observer and Device-Dependent Inter-observer Reliability of Contrast-Enhanced Ultrasound for Muscle Perfusion Quantification

Muscle perfusion quantification by contrast-enhanced ultrasound (CEUS) may facilitate treatment decisions in musculoskeletal disorders. Translation into clinical routine relies on high intra-observer and inter-observer reliability and transferability between ultrasound devices to enable validation and multicenter studies. This study evaluates these aspects for deltoid muscle perfusion quantification, including possible multicenter study setups. One hundred sixty-six CEUS quantifications were conducted on 42 shoulders. Intra-observer reliability revealed a high intra-class correlation coefficient (ICC, r = 0.91) and low coefficient of variation (CV, 10.28%). Inter-observer reliability revealed an ICC of .84 and a CV of 17.1%, but these values decreased when different ultrasound devices were used (ICC = .60, CV = 18.6%). Re-evaluating subgroups with high sectional plane concordance significantly increased reliability (intra-observer: ICC = .97, CV = 5.49%, inter-observer/same device: ICC = .98, CV = 5.83%, varying devices: ICC = .78, CV = 9.8%). CEUS perfusion quantification of the deltoid seems applicable for multicenter studies, yet pooling different ultrasound devices remains critical. Sectional plane concordance appears to be crucial for reliability and transferability of CEUS muscle perfusion quantifications.

Intra- and Intraobserver Reliability of Radiologic Flatfoot Parameters Before and After Surgery

Category:HindfootIntroduction/Purpose:Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation?Methods:Measurements of the 11 parameters were recorded on anteroposterior and lateral weightbearing radiographs of 38 feet before and after surgery for flatfoot, by three observers with different experience in foot surgery (A, ten years; B, three years; C, third-year orthopaedic resident). The inter- and intraobserver reliability was calculated.Results:Preoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Postoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Intraobserver reliability was excellent for all parameters preoperatively as recorded by observer A (PB) and B (MP), and for eight parameters as recorded by observer C (SR). Intraobserver reliability was excellent for ten parameters postoperatively as recorded by observer A and B, and for eight parameters as recorded by observer C.Conclusion:The following parameters can be recommended. For preoperative and postoperative evaluation of flatfoot: anteroposterior, talonavicular coverage angle; lateral, talometatarsal I angle, calcaneal pitch angle, and cuneiform medial height (high interobserver reliability); and anteroposterior, talometatarsal II angle; lateral, talocalcaneal angle, tibiocalcaneal angle (moderate interobserver reliability). For more experienced observers, we also recommend the anteroposterior talometatarsal I angle (moderate reliability). The inter- and intraobserver reliability for most parameters were similar pre- and postoperatively. The experience of the observer and the definition and ability to measure the parameters themselves were sources of variation.

Reliability of ABC/2 Method in Measuring of Infarct Volume in Magnetic Resonance Diffusion-Weighted Image.

Aims:Manual planimetry is the current method defining infarct volume on magnetic resonance (MR) diffusion-weighted image. ABC/2 method is an ellipsoid geometric formula with advantage estimation of intraparenchymal hemorrhage volume. Our study aimed to find the reliability and reproducibility of ABC/2 method compared to manual planimetric segmentation method.Settings and Design:This was a cross-sectional analytical study with retrospective and prospective data collection.Subjects and Methods:A total of 109 patients with acute ischemic stroke and underwent MR images at Ramathibodi Hospital were retrospectively reviewed. Relationship between manual planimetric segmentation and ABC/2 methods (nonadjusted ABC/2 method and adjusted ABC*/2 method) was determined using Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot. Subgroup analysis by location, onset, shape, and size of infarct volume was performed. Interobserver reliability was established using intraclass correlation coefficient and Bland–Altman plot.Statistical Analysis Used:Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot were used for statistical analysis.Results:Infarct volume measured with nonadjusted ABC/2 method (23.56, 48.81, 4.25, 0.11, 318.94) (mean, standard deviation, median, minimum, maximum) and adjusted ABC*/2 method (13.37, 28.3, 2.08, 0.06, 170.10) was smaller than manual planimetric method (28.50, 58.64, 5.56, 0.27, 335.49) (P < 0.001). Linear regression's slope confirmed underestimation of volume infarct. In round-to-ellipsoid shape and white matter group, the differences found between nonadjusted ABC/2 and manual planimetric methods are not statistically significant.Conclusions:ABC/2 method is a simple, rapid, and reproducible method with an excellent positive correlation of both adjusted and nonadjusted ABC/2 methods to manual planimetric segmentation method but tendency to underestimated infarct volume. High interobserver reliability and good agreement between two observers have been established. The utilization of nonadjusted ABC/2 method should be used with caution due to its tendency to underestimate the infarct volume.

An Evaluation of the Arcus Corneae For Age Estimation

Although the arcus corneae (AC) has long been used as an age indicator for forensic purposes, its diagnostic value has not been evaluated. To evaluate the AC as a predictor of chronological age, the author has studied the correlation of AC with respect to age of the deceased. A cross-sectional study was conducted of 342 Thai corpses at the Maharat Nakhon Ratchasima Hospital, Thailand. AC was graded into three levels: no AC, incomplete ring, and complete ring. One-way analysis of variance, chi-square test, binomial logistic regression, sensitivity, specificity, predictive values, and likelihood ratios were used for analysis. The Cohen's kappa was used to determine the intraobserver and interobserver reliability. The prevalence of AC and the probability of complete AC were significant higher in corpses aged 60 years and above than in those under 60 years. Consequently, this study confirmed that the prevalence of AC was significantly correlated with the age of Thai individuals. If the complete AC is used as an indicator of age of 60 years and above, complete AC has high sensitivity (92.56%) but low specificity (72.85%), low positive predictive value (65.12%), but high negative predictive value (94.71%). For diagnostic value, the presence of AC can be used for age screening but not for absolute confirmation. The absence of AC indicates young age, incomplete AC indicates middle age, and complete AC indicates old age. The high intraobserver and interobserver reliability provides assurance of the value of AC as a means to estimate personal age.

The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study With Treatment Algorithm.

Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. Level IV.

Sequence and Observer Variability in Gadoxectic Acid-Enhanced MRI Lesion Measurements in Hepatocellular Carcinoma

The purpose of the study was to investigate interobserver and intersequence variability in measuring hepatocellular carcinoma on magnetic resonance imaging (MRI). Twenty treatment-naïve lesions on Gadoxetic Acid enhanced MRI scans from 20 patients were retrospectively measured by six reviewers with different levels of experience, twice, six weeks apart, on eight different MRI sequences, in randomized order. The sequences include arterial, hepatobiliary, transitional, portal venous, T2, and diffusion weighted images. The single longest diameter (SLD) and longest diameter perpendicular to the longest overall diameter were measured on axial images and products of diameters calculated in accordance to response evaluation criteria in solid tumors v1.1 and World Health Organization response criteria respectively. Lesion-wise intraclass correlation coefficients were used to estimate measurement agreement. All intraclass correlation coefficients were greater than 0.95. No substantive differences between SLD and products of diameters metrics. Means (∼2.8 mm, SLD) and standard deviations (∼2 mm, SLD) were similar across sequences and observers. Similarly, pairwise comparison between observers grouped by experience showed statistically significant differences, but the effect size was minor (∼2 mm). Arterial and HPB-weighted images had similar mean dimensions (2.76 cm) while the smallest mean was in the transitional phase (2.62 cm). A lesion was not measured on 140 occasions (7%), mostly in ADC. There is high interobserver and intersequence reliability despite small differences between observers based on experience level. Our results suggest that accurate measurements can be made on arterial phase despite the possibility of indistinct margins. Lesions, however, are more likely to be missed on diffusion-related sequences.

Clinical Utility Of An MRI Based Classification For Operative Versus Non-operative Management Of UCL Tears: Two-year Follow Up

Objectives: A recently introduced classification of medial ulnar collateral ligament (UCL) tears accounting for location and severity has demonstrated high interobserver and intraobserver reliability, but little is known about its clinical utility. The purpose of this study was to assess the relationship of the MRI-based classification system in predicting which athletes succeeded non-operative versus operative treatment after completing a standardized rehabilitative program. Secondary objectives included sub-analysis of baseball players, including return-to-play (RTP) and return-to-prior performance (RPP). Methods: After a priori power analysis, 58 consecutive patients with UCL tears and a minimum of two-year follow-up were retrospectively classified into those succeeding operative versus non-operative treatments. The MRI-based classification system accounting for UCL tear location and severity were correlated with non-operative and operative cohorts. Sub-analyses for baseball players, including RTP and RPP, were performed. Results: A total of 58 patients (40 baseball players, 34 pitchers) met inclusion criteria. A total of 35 patients (32 baseball players, 27 pitchers) underwent surgery, and 23 patients (8 baseball players, 7 pitchers) completed non-operative management. No patients in the non-operative arm crossed over to surgery after completing the rehabilitative program. Patients with distal (OR: 48.0, p=0.0004) and complete (OR: 5.4, p=0.004) tears were more likely to undergo surgery. Baseball players, regardless of position, were confounding determinants of operative management, although there was no difference in RTP and RPP between treatment arms. Conclusion: A six-stage MRI-based classification addressing UCL tear grade and location may confer early decision-making as patients likely to fail non-operative treatment have complete, distal tears whereas those with proximal, partial tears may be more amenable to non-operative modalities. [Table: see text]