Intermodal Reliability Research Articles

Comparing the properties of traditional and novel approaches to the modified Rankin scale: Systematic review and meta-analysis.

The Modified Rankin Scale (mRS) is the most commonly used functional measure in stroke research but is limited by inter-rater reliability (IRR). Various interventions to improve mRS application have been described. We aimed to compare properties of differing approaches to mRS assessment. Multidisciplinary databases (MEDLINE, EMBASE, Health and Psychosocial Instruments [OVID], CINAHL, PsycINFO [EBSCO]) were searched for adult human stroke studies describing psychometric properties of mRS. Two researchers independently screened 20% titles and abstracts, reviewed all full studies, extracted data, and conducted risk of bias (ROB) analysis. Primary outcomes for random-effects meta-analysis were IRR measured by kappa (K) and weighted kappa (KW). Validity and inter-modality reliability measures (Spearman's rho, KW) were also summarised. From 897 titles, 46 studies were eligible, including twelve differing approaches to mRS, 8608 participants. There was high ROB in 14 (30.4%) studies. Overall, reliability was substantial (n = 29 studies, K = 0.65, 95% CI: 0.58-0.71) but IRR was higher for novel approaches to mRS, for example, the Rankin Focussed Assessment (n = 2 studies, K = 0.94, 95% CI: 0.90-0.98) than standard mRS (n = 13 studies, K = 0.55, 95%CI:0.46-0.64). Reliability improved following the introduction of mRS training (K = 0.56, 95% CI: 0.44-0.67; vs K = 0.69, 95% CI: 0.62-0.77). Validity ranged from poor to excellent, with an excellent overall concurrent validity of novel scales (n = 6 studies, KW = 0.86, 95% CI: 0.75-0.97). The agreement between face-to-face and telephone administration was substantial (n = 5 studies, KW = 0.80, 95% CI: 0.74-0.87). The mRS is a valid measure of function but IRR remains an issue. The present findings are limited by a high ROB and possible publication bias. Interventions to improve mRS reliability (training, structured interview, adjudication) seem to be beneficial, but single interventions do not completely remove reliability concerns.

Inter-observer and inter-modality concordance of non-contrast MR angiography and CT angiography for preoperative assessment of potential renal donors

BackgroundMagnetic resonance angiography (MRA) is rapidly being employed as an effective substitute for CTA, particularly in situations of poor kidney function. We aimed to examine the inter-observer and inter-modality reliability of non-contrast MR angiography (NC-MRA) and CTA as a non-invasive tool for assessing the anatomical findings of potential living kidney donors.ResultsAll potential donors were referred from specialized kidney transplantation center and underwent NC-MRA of the renal arteries using a respiratory-triggered magnetization prepared 3D balanced steady-state free precession (b-SSFP) with inversion recovery pulses and fat saturation (Inhance 3D Inflow Inversion Recovery (IFIR)). Two experienced radiologists reviewed NC-MRA images and were asked to evaluate both renal arteries anatomy and their branching pattern, presence of accessory or aberrant renal arteries, and identify any anatomical variant. Lin’s correlation test was performed to test MRA readings by each of the two observers against CTA findings which considered as the gold standard for assessment of renal arteries. Additionally, observers were asked to assess the image quality. The study included 60 potential kidney donors (43 males and 17 females) with mean age ± SD of 31.3 ± 5.6 years. Excellent to very good inter-observer agreement was found between both observers in the assessment of renal arteries by NC-MRA. There was perfect concordance between MRA and CTA findings in detecting early arterial division, caliber, and length of left extra-parenchymal segmental branches. Moderate concordance was found in the assessment of the supplied segments of extra-parenchymal segmental renal arterial branches and substantial concordance between both MRA observers’ findings in the remaining variables of the study. There was excellent agreement between both observers in the assessment of image quality parameters.ConclusionsNC-MRA for the renal arteries is an effective alternative for CTA without the risks of radiation or contrast media.

Craniocervical Morphometry in Pomeranians-Part I: Intra-Observer, Interobserver, and Intermodality (CT vs. MRI) Agreement.

Currently, there are no diagnostic imaging-based studies that have focused specifically on the craniocervical morphology of Pomeranian dogs in relation to Chiari-like malformation and syringomyelia (CM/SM). The aims of Part I of this two-part study are to assess the intra-observer, interobserver, and intermodality reliability and agreement for various aspects of the craniocervical morphology of Pomeranians with and without CM/SM. Prospectively, Pomeranians were included that underwent both CT and MRI studies of the head and cervicothoracic vertebral column. Two observers (experienced and novice) independently performed CM and SM classifications, qualitative assessments, and quantitative measurements. The experienced observer performed these assessments twice. A third observer (experienced) performed CM and SM normal or abnormal classifications. Ninety-nine (99) dogs were included. Interobserver reliability was influenced by observer experience level. For the experienced versus novice observers, substantial interobserver agreement was found for classification of SM as normal or abnormal (Cohen's kappa = 0.63), while interobserver agreement was fair for classification of SM as normal or abnormal (Cohen's kappa = 0.31). Interobserver, intra-observer, and intermodality reliability were variable for different measurements and assessments, and best overall for the CT-based measurements. Interobserver reliability and agreement results should be taken into account in the evaluation of results of future studies as well as the evaluation of imaging studies of Pomeranians presented clinically.

Mitral annular disjunction and its progression during childhood in Marfan syndrome.

Data on mitral annular disjunction (MAD) in children with Marfan syndrome (MFS) are sparse. To investigate the diagnostic yield of MAD by echocardiography and cardiac magnetic resonance imaging (CMR), its prevalence and progression during childhood. We included patients <21 years old with MFS, defined by 2010 Ghent criteria and a pathogenic FBN1 variant or ectopia lentis. Two readers measured systolic separation between the mitral valve (MV) posterior hinge point and left ventricular (LV) myocardium on initial and subsequent imaging. MAD was defined as MV-LV separation ≥2 mm, MV prolapse (MVP) as atrial displacement ≥2 mm. Kappa coefficients evaluated echocardiogram-CMR agreement. Bland-Altman and intraclass correlation coefficients (ICCs) assessed inter-rater and inter-modality reliability. Univariable mixed-effects linear regression was used to evaluate longitudinal changes of MAD. MAD was detected in 60% (110/185) eligible patients. MVP was present in 48% (53/110) of MAD and MAD in 90% (53/59) of MVP. MAD detection by CMR and echocardiography had 96% overall agreement (Kappa = 0.89, P < 0.001) and a 0.32 mm estimate bias (95% CI 0.00, 0.65). ICC by echocardiography, CMR, and between modalities were 0.97 (95% CI 0.93, 0.98), 0.92 (95% CI 0.79, 0.97), and 0.91 (95% CI 0.85, 0.94), respectively. MAD was associated with aortic root dilation (P < 0.001). MAD was found in children of all ages, increased +0.18 mm/year (95% CI +0.14, +0.22) during a median duration of 5.5 years (IQR 3.1, 7.5 years). MAD indexed by height yielded a constant value +0.0002 mm/m/year (95% CI -0.0002, +0.0005 mm/m/year). MAD was common in pediatric MFS and was associated with aortic root dilation. MAD detection by echocardiography and CMR was highly reliable, suggesting that routine assessment in MFS is feasible. MAD was present in neonates and progressed over time but remained constant when indexing by height. Further studies are needed to evaluate MAD as a biomarker for clinical outcomes in pediatric MFS.

Reliability and modality analysis of patellar height measurement in pediatric knee.

Various measurement methods and imaging technique are in use to measure patellar height in pediatric patients. However, there is no gold standard as to which measurement method and modality are the most reliable for pediatric patients. Therefore, the aim of this study was to determine the inter-observer reliability, intra-observer reliability, and applicability of various patellar height measurement methods in pediatric knee. Additionaly, we analyzed the reliability across different imaging modalities. Total 450 pediatric patients (age: 5-18 years) were evaluated using lateral knee radiographs and magnetic resonance imaging (MRI). The patellar height ratios were measured using five methods. Five methods were Insall-Salvati (IS), Koshino-Sugimoto (KS), Blackburne-Peel (BP), modified Insall-Salvati (MIS), and Caton-Deschamps (CD). The patients were categorized into two age groups: P (ages 5-13) and Q (ages 14-18). Each measurement was conducted twice by two raters. The intra-observer reliability, inter-observer reliability and inter-modality reliability were calculated. In addition, applicability was defined as the possibility to apply each measurement method to each age group. The KS method showed the highest inter-observer reliability and intra-observer reliability when using MRI for both age groups. The inter-observer reliability and intra-observer reliability of the IS for lateral knee radiographs was highest among all observers for group Q. The CD method showed the highest inter-observer reliability in group P, while the KS showed the highest intra-observer reliability in group P using lateral radiographs. The KS method showed the highest inter-modality reliability in group P, while the IS showed the highest inter-modality reliability in group Q. The KS method was applicable to all patients when using lateral knee radiography, and the IS method was applicable to all patients when using MRI. Our results show that the reliability of various measurement method and imaging technique differed based on pediatric knee age group when measuring patellar height. Therefore, in the case of pediatric patients, reliability measurement methods and imaging techniques according to the patient's age should be applied.

How Often Do Patients Presenting With Severe Adolescent Idiopathic Scoliosis Have Underlying Hip Dysplasia?

Adolescent idiopathic scoliosis radiographic screening will often include the hips. The purpose of this study is to evaluate the prevalence of hip dysplasia by lateral center edge angle (LCEA) on scoliosis radiographs in patients presenting with severe range (>45 deg) idiopathic curves. We reviewed 200 consecutive patients (400 hips) with idiopathic scoliosis with major coronal curves ≥45 degrees between October 2009 and October 2022. The presenting scoliosis radiograph PA were reviewed for the following variables: major coronal curve direction, coronal balance, and lateral center edge angles. An LCEA value ≤18 was considered dysplastic. To assess potential measurement variability related to parallax of the scoliosis radiographs, the intermodality intraclass correlation coefficient (ICC) was measured from a subset of 20 hip LCEA values from patients with both scoliosis and pelvis radiographs. A total of 200 patients [mean age: 13.6 (1.8) years; Female: 79%] were reviewed. The mean major curve (SD) was 58.6 degrees (11.4 deg). Overall 19% (37/200) patients or 11% (43/400) of hips had hip dysplasia. Of the dysplastic hips, 16% (6/43, P <0.001) were bilateral and 57% (21/43, P =0.04) were right sided. There was no association between dysplastic hip laterality and ipsilateral or contralateral coronal balance ( P =0.26) or curve direction ( P =0.49). The interobserver ICC for assessment of LCEA on scoliosis radiographs was 0.85, and the intermodality ICC between pelvic and scoliosis radiographs was 0.78. Hip dysplasia was present in 19% of patients presenting with large major curves, and many of these patients had right sided hip dysplasia. There was no association between hip dysplasia laterality and the patient's major curve direction or coronal balance. There was good intermodality reliability (ICC=0.78) between LCEA values in patients who had both scoliosis and pelvis radiographs, and good inter-rater reliability between raters. Radiographic interpretation of adolescent idiopathic scoliosis should focus not only on the description of the curve and ruling out underlying segmentation anomalies but should also include critical assessment of the hips to exclude co-existing hip dysplasia. Therapeutic study-level IV.

3D zero-echo time and 3D T1-weighted gradient-echo MRI sequences as an alternative to CT for the evaluation of the lumbar facet joints and lumbosacral transitional vertebrae.

Computed tomography (CT) is the reference standard for assessment of the bone. Magnetic resonance imaging (MRI) developments enable a CT-like visualization of the osseous structures. To assess the diagnostic performance of 3D zero-echo time (3D-ZTE) and 3D T1-weighted gradient-echo (3D-T1GRE) MRI sequences for the evaluation of lumbar facet joints (LFJs) and the detection of lumbosacral transitional vertebrae (LSTV) using CT as the reference standard. In total, 87 adult patients were included in this prospective study. Evaluation of degenerative changes of the facet joints at the L3/L4, L4/L5, and L5/S1 levels on both sides was performed by two readers using a 4-point Likert scale. LSTV were classified according to Castelvi et al. Image quality was quantitatively measured using the signal-to-noise (SNR) and contrast-to-noise (CNR) ratios. Intra-reader, inter-reader, and inter-modality reliability were calculated using Cohen's kappa statistic. Intra-reader agreement for 3D-ZTE, 3D-T1GRE, and CT was 0.607, 0.751, and 0.856 and inter-reader agreement was 0.535, 0.563, and 0.599, respectively. The inter-modality agreement between 3D-ZTE and CT was 0.631 and between 3D-T1GRE and CT 0.665. A total of LSTV were identified in both MR sequences with overall comparable accuracy compared to CT. Mean SNR for bone, muscle, and fat was highest for 3D-T1GRE and mean CNR was highest for CT. 3D-ZTE and 3D-T1GRE MRI sequences can assess the LFJs and LSTV and may serve as potential alternatives to CT.

Added value of ultra-short echo time and fast field echo using restricted echo-spacing MR imaging in the assessment of the osseous cervical spine

PurposeTo evaluate the added value of ultra-short echo time (UTE) and fast field echo resembling a CT using restricted echo-spacing (FRACTURE) MR sequences in the assessment of the osseous cervical spine using CT as reference.Materials and methodsTwenty-seven subjects underwent postmortem CT and MRI within 48 h. Datasets were anonymized and analyzed retrospectively by two radiologists. Morphological cervical spine alterations were rated on CT, UTE and FRACTURE images. Afterward, neural foraminal stenosis was graded on standard MR and again after viewing additional UTE/FRACTURE sequences. To evaluate interreader and intermodality reliability, intra-class correlation coefficients (ICC) and for stenosis grading Wilcoxon-matched-pairs testing with multiple comparison correction were calculated.ResultsModerate interreader reliability (ICC = 0.48–0.71) was observed concerning morphological findings on all modalities. Intermodality reliability was good between modalities regarding degenerative vertebral and joint alterations (ICC = 0.69–0.91). Compared to CT neural stenosis grades were more often considered as nonsignificant on all analyzed MR sequences. Neural stenosis grading scores differed also significantly between specific bone imaging sequences, UTE and FRACTURE, to standard MR sequences. However, no significant difference was observed between UTE and FRACTURE sequences.ConclusionCompared to CT as reference, UTE or FRACTURE sequence added to standard MR sequences can deliver comparable information on osseous cervical spine status. Both led to changes in clinically significant stenosis gradings when added to standard MR, mainly reducing the severity of neural foramina stenosis.

Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study

ObjectivesEfforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys...

Abstract WMP45: Feasibility, Acceptability, And Accuracy Of A Text-messaging Program For Outcomes Data Collection In Patients After Stroke

Introduction: Robust outcome data collection is critical for stroke care and clinical trials. However, reaching patients after discharge from acute care is challenging. This study examined the feasibility, acceptability, and accuracy of collecting outcomes through a text message-based program after stroke. Methods: Patients discharged between June 8 th , 2020 and February 1 st , 2021 from Massachusetts General Hospital with an ICD-10 Code of stroke who consented to receiving messages, were enrolled in a message-based program upon acute stroke discharge. Participants received weekly brain health tips and assessments of the Modified Rankin Scale (mRS) and PROMIS Global-10 at 30, 60, and 90 days post-stroke via text message prompts. Participants were sent a satisfaction survey upon program conclusion. Data from routine 90-day follow-up phone calls were extracted from clinical charts of patients discharged during a representative 3 month period for comparison. Descriptive statistics, group comparisons, and inter-modal reliability (text message versus phone) were performed. Results: Of 530 patients with stroke discharged during the study period, 350 enrolled in the message program. Forty-one percent of the patients answered one or more of the assessment prompts. The 90-day mRS collected by messaging was 1[0-3] and the PROMIS Global Physical and Mental Health were 15[12.5-17] and 13[11-16], respectively. We reached 104/169 (61.54%) patients by phone. There were no statistically significant differences on 90-day outcome scores between those who responded via messages or phone. Inter-modal reliability (message versus phone) was moderate for mRS (κ=.521) but poor for PROMIS scores (κ&lt;.1). Nearly all participants (90%) felt it was helpful to receive information about stroke via messages and found the program adequate (63%) and not burdensome (94%). Discussion: Post-stroke outcomes data collection via text-messaging is feasible, acceptable, and moderately accurate compared to phone-based methods. Inter-modal reliability was higher for functional outcomes as compared to PROMs. Further validation of specific measures is required; yet, these findings suggest that future programs could use messaging to identify patients at risk for poor outcome.

Evaluation of the degenerative lumbar osseous morphology using zero echo time magnetic resonance imaging (ZTE-MRI)

To determine and compare the performance of zero echo imaging (ZTE) with conventional MRI sequences on lumbar osseous morphology in patients suspected with lumbar degeneration with multi-slice computed tomography (MSCT) as standard reference. 22 subjects with concerned lumbar degeneration were recruited. All subjects were scanned with ZTE sequence after routine conventional MR sequences on a 3.0T system and also received MSCT examination. Image quality was assessed. The quantitative and qualitative parameters of lumbar osseous morphology on MSCT, ZTE and MRI images were evaluated by three musculoskeletal radiologists independently. Inter-reader and inter-modality reliability and the difference between the modalities were calculated. There was no difference for the osseous parameters between modalities, including axial orientation (p = 0.444), IAD (p = 0.381), lateral recess (p = 0.370), pedicle width (p = 0.067), pedicle height (p = 0.056), and osteophyte grade (p = 0.052). The measurement of the foramina diameter was statistically different between conventional MRI and MSCT (p < 0.05) but not between the MSCT and ZTE (p = 0.660). Conventional MRI was more likely to miss cortical bone abnormalities. ZTE appeared blurrier in cortical bone than MSCT, especially in cases with severe lumbar degeneration. The inter-reader agreement between MSCT and ZTE-MRI was higher than between MSCT and conventional MRI. ZTE-MRI could offer more cortical bone details than conventional MRI images and might be a valid alternative to CT for lumbar osseous morphology assessment to some extent.

Applying Compressed Sensing Volumetric Interpolated Breath-Hold Examination and Spiral Ultrashort Echo Time Sequences for Lung Nodule Detection in MRI.

This prospective study aimed to investigate the ability of spiral ultrashort echo time (UTE) and compressed sensing volumetric interpolated breath-hold examination (CS-VIBE) sequences in magnetic resonance imaging (MRI) compared to conventional VIBE and chest computed tomography (CT) in terms of image quality and small nodule detection. Patients with small lung nodules scheduled for video-assisted thoracoscopic surgery (VATS) for lung wedge resection were prospectively enrolled. Each patient underwent non-contrast chest CT and non-contrast MRI on the same day prior to thoracic surgery. The chest CT was performed to obtain a standard reference for nodule size, location, and morphology. The chest MRI included breath-hold conventional VIBE and CS-VIBE with scanning durations of 11 and 13 s, respectively, and free-breathing spiral UTE for 3.5–5 min. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and normal structure visualizations were measured to evaluate MRI quality. Nodule detection sensitivity was evaluated on a lobe-by-lobe basis. Inter-reader and inter-modality reliability analyses were performed using the Cohen κ statistic and the nodule size comparison was performed using Bland–Altman plots. Among 96 pulmonary nodules requiring surgery, the average nodule diameter was 7.7 ± 3.9 mm (range: 4–20 mm); of the 73 resected nodules, most were invasive cancer (74%) or pre-invasive carcinoma in situ (15%). Both spiral UTE and CS-VIBE images achieved significantly higher overall image quality scores, SNRs, and CNRs than conventional VIBE. Spiral UTE (81%) and CS-VIBE (83%) achieved a higher lung nodule detection rate than conventional VIBE (53%). Specifically, the nodule detection rate for spiral UTE and CS-VIBE reached 95% and 100% for nodules >8 and >10 mm, respectively. A 90% detection rate was achieved for nodules of all sizes with a part-solid or solid morphology. Spiral UTE and CS-VIBE under-estimated the nodule size by 0.2 ± 1.4 mm with 95% limits of agreement from −2.6 to 2.9 mm and by 0.2 ± 1.7 mm with 95% limits of agreement from −3.3 to 3.5 mm, respectively, compared to the reference CT. In conclusion, chest CT remains the gold standard for lung nodule detection due to its high image resolutions. Both spiral UTE and CS-VIBE MRI could detect small lung nodules requiring surgery and could be considered a potential alternative to chest CT; however, their clinical application requires further investigation.

Evaluation of the reliability of lower extremity alignment measurements using EOS imaging system while standing in an even weight-bearing posture

This study aimed to analyze the reproducibility and reliability of the alignment parameters measured using the EOS image system in both limbs while standing with an even weight-bearing posture. Overall, 104 lower extremities in 52 patients were analyzed retrospectively. The patients stood with an even load over both lower extremities then rotated 15° in both directions. Two EOS images were acquired and 104 pairs of lower extremities were compared according to the position of the indexed lower extremities. Then, the inter-observer reliability of the EOS system and the inter-modality reliability between EOS and computed tomography (CT) were evaluated. Femoro-tibial rotation (FTR) and tibial torsion demonstrated a significant difference between the anterior and posterior positions of the indexed lower extremity. In the inter-observer reliability analysis, all values except for FTR and tibial torsion demonstrated good or very good reliability. In the anterior position, FTR demonstrated moderate, and tibial torsion demonstrated poor reliability. In the posterior position, both FTR and tibial torsion demonstrated poor reliability. In the reliability analysis between the three-dimensional (3D) EOS model and 3D CT images, all measurements of the femur demonstrated very good reliability, but measurements of the tibia did not. For the coronal and sagittal alignment parameters measured by the EOS 3D system with rotated standing posture, except for the measurement including tibial torsion., there were no significant difference for either position of the indexed extremities with high agreement between the observers as well as with the CT 3D model.

Diagnostic Yield of Transabdominal Ultrasonography for Evaluation of Pancreatic Cystic Lesions Compared with Endoscopic Ultrasonography.

Detection rates of pancreatic cystic lesions (PCLs) have increased, resulting in greater requirements for regular monitoring using imaging modalities. We aimed to evaluate the capability of ultrasonography (US) for morphological characterization of PCLs as a reference standard using endoscopic ultrasonography (EUS). A retrospective analysis was conducted of 102 PCLs from 92 patients who underwent US immediately prior to EUS between January 2014 and May 2017. The intermodality reliability and agreement of the PCL morphologic findings of the two techniques were analyzed and compared using the intraclass correlation coefficient and κ values. The success rates of US for delineating PCLs in the head, body, and tail of the pancreas were 77.8%, 91.8%, and 70.6%, respectively. The intraclass correlation coefficient for US and the corresponding EUS lesion size showed very good reliability (0.978; p < 0.001). The κ value between modalities was 0.882 for pancreatic duct dilation, indicating good agreement. The κ values for solid components and cystic wall and septal thickening were 0.481 and 0.395, respectively, indicating moderate agreement. US may be useful for monitoring PCL growth and changes in pancreatic duct dilation, but it has limited use in the diagnosis and surveillance of mural nodules or cystic wall thickness changes.

Imaging Characteristics of the Proximal Lateral Collateral Ligament of the Knee: Findings on Ultrasound and MRI With Histologic Correlation.

ObjectivesDetermine prevalence of increased signal intensity of the lateral collateral ligament (LCL) of the knee on MRI and decreased echogenicity on ultrasound, and compare with cadaveric histologic evaluation.MethodsAfter IRB approval of this prospective study with informed consent, patients having knee MRI were additionally evaluated with ultrasound. Signal intensities of LCL on MRI (low, intermediate, high), echogenicity at ultrasound (hyperechoic, hypoechoic, anechoic), and extent of findings were assessed. Descriptive statistics, Wilcoxon signed ranked test, and intraclass correlation coefficient (ICC) were calculated. Two cadaveric knees were imaged with MRI and ultrasound, including histologic LCL evaluation.ResultsSeventy‐three subjects were included (39 males, 34 females; mean age 48 ± 14 years) with 77 knee examinations. On MRI, low, intermediate, and high signals were present in 21% (16/77), 75% (58/77), and 4% (3/77), respectively. On ultrasound, echogenicity was assessed as hyperechoic, hypoechoic, and anechoic in 62% (48/77), 38% (29/77), and 0% (0/77), respectively. Mean length of increased signal was 8.6 mm (±4.9) on MRI, and 6.5 mm (±4.8) on ultrasound. The ICC showed a good to excellent intermodality reliability (0.735–0.899) without statistically significant difference for interreader measurements (P = .163–.795). Histology evaluation showed transition of ligament fibers to fibrocartilage at its insertion with increased connective tissue mucin corresponding to MRI and ultrasound findings.ConclusionsIncreased signal intensity of the proximal LCL on ultrasound and MRI is common and corresponds to normal connective tissue mucin.

Comparison of MR Ultrashort Echo Time and Optimized 3D-Multiecho In-Phase Sequence to Computed Tomography for Assessment of the Osseous Craniocervical Junction.

To assess changes of the craniocervical junction (CCJ), computed tomography (CT) is considered the reference standard. Recent advances in bone depiction on magnetic resonance imaging (MRI) enable high-quality visualization of osseous structures. Consequently, MRI may serve as an alternative to CT, without the use of ionizing radiation. To compare two MRI sequences optimized for bone visualization to the CT reference standard in the assessment of the osseous CCJ. Prospective. Twenty-seven decedents and five healthy volunteers. 3T/ultrashort-echo time gradient echo (UTE) and optimized 3D-multiecho in-phase gradient echo sequences (FRACTURE). All decedents were scanned with both MRI sequences and CT. Three observers rated degeneration to obtain a score for the upper (atlanto-dental and left/right atlanto-occipital joint) and for the lower part of the CCJ (left and right atlanto-axial joint). Two reader rated the following quantitative parameters: basion-axial-interval, atlanto-dental-interval, atlanto-occipital-interval, Powers-ratio, and signal/contrast-to-noise-ratio. As a proof of concept, five healthy volunteers were scanned with both MRI sequences. Degeneration was assessed on a Likert scale by three independent observers. Interrater and intermodality reliability were calculated using an intraclass correlation coefficient. To compare distance measurements between examination methods, a Friedman test, between-degenerative ratings, and a Kruskal-Wallis test were performed. Degenerative ratings of the CCJ between MRI sequences and CT showed a good interrater and intermodality agreement. MRI sequences tended to underestimate the degree of degeneration compared to CT, and this became more marked with increasing degeneration severity. There were no significant relationships between distance measurements and the degree of degeneration (PCT = 0.62, PUTE = 0.64, PFRACTURE = 0.67). The in vivo examination proved the feasibility of both MRI methods in a clinical setting. Quantitative and qualitative ratings on MR images were comparable to CT images; thus, MRI may be a valid alternative to CT assessing the CCJ. 1. 3.

The impact of limb loading and the measurement modality (2D versus 3D) on the measurement of the limb loading dependent lower extremity parameters

BackgroundDeformity assessment and preoperative planning of realignment surgery are conventionally based on weight-bearing (WB) radiographs. However, newer technologies such as three-dimensional (3D) preoperative planning and surgical navigation with patient-specific instruments (PSI) rely on non-weight bearing (NWB) computed tomography (CT) data. Additionally, differences between conventional two-dimensional (2D) and 3D measurements are known. The goal of the present study was to systematically analyse the influence of WB and the measurement modality (2D versus 3D) on common WB-dependent measurements used for deformity assessment.Methods85 lower limbs could be included. Two readers measured the hip-knee-ankle angle (HKA) and the joint line convergence angle (JLCA) in 2D WB and 2D NWB radiographs, as well as in CT-reconstructed 3D models using an already established 3D measurement method for HKA, and a newly developed 3D measurement method for JLCA, respectively. Interrater and intermodality reliability was assessed.ResultsSignificant differences between WB and NWB measurements were found for HKA (p < 0.001) and JLCA (p < 0.001). No significant difference could be observed between 2D HKA NWB and 3D HKA (p = 0.09). The difference between 2D JLCA NWB and 3D JLCA was significant (p < 0.001). The intraclass correlation coefficient (ICC) for the interrater agreement was almost perfect for all HKA and 3D JLCA measurements and substantial for 2D JLCA WB and 2D JLCA NWB. ICC for the intermodality agreement was almost perfect between 2D HKA WB and 2D HKA NWB as well as between 2D HKA NWB and 3D HKA, whereas it was moderate between 2D JLCA WB and 2D JLCA NWB and between 2D JLCA NWB and 3D JLCA.ConclusionLimb loading results in significant differences for both HKA and JLCA measurements. Furthermore, 2D projections were found to be insufficient to represent 3D joint anatomy in complex cases. With an increasing number of surgical approaches based on NWB CT-reconstructed models, research should focus on the development of 3D planning methods that consider the effects of WB on leg alignment.

Novel approaches to measuring knowledge among frontline health workers in India:Are phone surveys a reliable option?

BackgroundIn 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs’ knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India.MethodsWe carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses.FindingsThe average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age <30 years of age, education, experience as an ASHA, completion of seven or more client visits weekly, phone ownership and use as a communication tool for work, as well as the ability to navigate interactive voice response prompts (a measure of digital literacy). Efforts to develop a phone survey tool for measuring knowledge suggest that findings on inter-rater and inter-modal reliability were similar. Reliability was higher for shorter, widely known questions, including those about timing of exclusive breastfeeding or number of tetanus shots during pregnancy. Questions with lower reliability included those on sensitive topics such as family planning; questions with multiple response options; or which were difficult for the enumerator to convey.ConclusionsOverall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India.

Near-Infrared Reflectance Imaging for Quantification of Atrophy Associated with Age-Related Macular Degeneration

To compare measurements of area of geographic atrophy (GA) in dry age-related macular degeneration (AMD) obtained by fundus autofluorescence (FAF) to those obtained by near-infrared reflectance (NIR). Interrater reliability analysis. Ninety-seven confocal NIR images (Heidelberg HRA+ Spectralis) and FAF images from 97 patients/eyes with GA with dry AMD were collected retrospectively from existing anonymized Doheny Image Reading Center datasets. Two masked reading center graders (N.S., J.S.) independently and blindly performed manual segmentation of the GA lesions on each NIR and FAF image using GNU Image Manipulation Program software (version 2.8.22). GA on NIR/FAF images was defined in accordance to recently published Classification of Atrophy Meeting criteria as sharply demarcated hyperreflective regions ≥250μm in diameter. The difference and point-to-point correspondence between gradings in GA area measurements between NIR and FAF were assessed by mean difference, overlap ratio, and Dice similarity coefficient. Among the 97 eyes with dry AMD, the mean GA area was 7.62 ± 7.77mm2 from FAF images and 7.65 ± 7.83mm2 from NIR, with a mean nonsignificant difference of 0.31 ± 0.55mm2 (2-tailed t test, P= .65). The overlap ratio in the segmented GA lesion between modalities was 0.84 ± 0.28 with a Dice similarity coefficient of 0.87 ± 0.27. Intermodal reliability was high (intraclass correlation coefficient= 0.998, P < .01). Of note, in 5 cases (5.2%), the GA lesion could be identified on the FAF image but not on the NIR image, translating into a sensitivity of 94.8%. GA lesions in dry AMD can be identified and quantified reliably using NIR images in many cases, though eyes with a thin choroid resulting in isoreflective GA lesions may be challenging. NIR imaging is comfortable for patients and is commonly obtained along with OCT, and therefore NIR-based GA assessment may be a useful surrogate in clinical settings.

Ferumoxytol-enhanced MRI for surveillance of pediatric cerebral arteriovenous malformations.

Children with intracranial arteriovenous malformations (AVMs) undergo digital DSA for lesion surveillance following their initial diagnosis. However, DSA carries risks of radiation exposure, particularly for the growing pediatric brain and over lifetime. The authors evaluated whether MRI enhanced with a blood pool ferumoxytol (Fe) contrast agent (Fe-MRI) can be used for surveillance of residual or recurrent AVMs. A retrospective cohort was assembled of children with an established AVM diagnosis who underwent surveillance by both DSA and 3-T Fe-MRI from 2014 to 2016. Two neuroradiologists blinded to the DSA results independently assessed Fe-enhanced T1-weighted spoiled gradient recalled acquisition in steady state (Fe-SPGR) scans and, if available, arterial spin labeling (ASL) perfusion scans for residual or recurrent AVMs. Diagnostic confidence was examined using a Likert scale. Sensitivity, specificity, and intermodality reliability were determined using DSA studies as the gold standard. Radiation exposure related to DSA was calculated as total dose area product (TDAP) and effective dose. Fifteen patients were included in this study (mean age 10 years, range 3-15 years). The mean time between the first surveillance DSA and Fe-MRI studies was 17 days (SD 47). Intermodality agreement was excellent between Fe-SPGR and DSA (κ = 1.00) but poor between ASL and DSA (κ = 0.53; 95% CI 0.18-0.89). The sensitivity and specificity for detecting residual AVMs using Fe-SPGR were 100% and 100%, and using ASL they were 72% and 100%, respectively. Radiologists reported overall high diagnostic confidence using Fe-SPGR. On average, patients received two surveillance DSA studies over the study period, which on average equated to a TDAP of 117.2 Gy×cm2 (95% CI 77.2-157.4 Gy×cm2) and an effective dose of 7.8 mSv (95% CI 4.4-8.8 mSv). Fe-MRI performed similarly to DSA for the surveillance of residual AVMs. Future multicenter studies could further investigate the efficacy of Fe-MRI as a noninvasive alternative to DSA for monitoring AVMs in children.