Inter-rater Research Articles

Inter-Rater Disagreements in Applying the Montreal Classification for Crohn's Disease: The Five-Nations Survey Study.

The Montreal classification has been widely used in Crohn's disease since 2005 to categorize patients by the age of onset (A), disease location (L), behavior (B), and upper gastrointestinal tract and perianal involvement. With evolving management paradigms in Crohn's disease, we aimed to assess the performance of gastroenterologists in applying the Montreal classification. An online survey was conducted among participants at an international educational conference on inflammatory bowel diseases. Participants classified 20 theoretical Crohn's disease cases using the Montreal classification. Agreement rates with the inflammatory bowel diseases board (three expert gastroenterologists whose consensus rating was considered the gold standard) were calculated for gastroenterologist specialists and fellows/specialists with ≤2years of clinical experience. A majority vote <75% among participants was considered a notable disagreement. The same cases were classified using three large language models (LLMs), ChatGPT-4, Claude-3, and Gemini-1.5, and assessed for agreement with the board and gastroenterologists. Fleiss Kappa was used to assess within-group agreement. Thirty-eight participants from five countries completed the survey. In defining the Montreal classification as a whole, specialists (21/38 [55%]) had a higher agreement rate with the board compared to fellows/young specialists (17/38 [45%]) (58% vs. 49%, p=0.012) and to LLMs (58% vs. 18%, p<0.001). Disease behavior classification was the most challenging, with 76% agreement among specialists and fellows/young specialists and 48% among LLMs compared to the inflammatory bowel diseases board. Regarding disease behavior, within-group agreement was moderate (specialists: k=0.522, fellows/young specialists: k=0.532, LLMs: k=0.577; p<0.001 for all). Notable points of disagreement included: defining disease behavior concerning obstructive symptoms, assessing disease extent via video capsule endoscopy, and evaluating treatment-related reversibility of the disease phenotype. There is significant inter-rater disagreement in applying the Montreal classification, particularly for disease behavior in Crohn's disease. Improved education or revisions to phenotype criteria may be needed to enhance consensus on the Montreal classification.

NeoScore: a new tool to assess technical and non-technical skills during neonatal resuscitation.

Training with high-technology manikins improves cardio-pulmonary resuscitation (CPR) skill retention, but a checklist to assess both technical and non-technical skills is lacking. This study aimed to develop a standardized checklist to evaluate healthcare's performance during simulated Neonatal Resuscitation Program (NRP) scenarios. Twenty-two international neonatal resuscitation experts participated in a two-step modified Delphi process, rating each checklist item on a scale of 1-5 and providing feedback. Items with a mean rating below 4 or receiving comments were reviewed. Inter-rater reliability (IRR) of the final tool was assessed using video-recordings of simulated scenarios. The final checklist, validated by 15 experts, includes 33 items. Mean expert rating of all items was 4.35. The checklist showed moderate inter-rater reliability (ICC = 0.67) overall, with excellent reliability (ICC = 0.8) for technical skills. The tool effectively evaluates technical skills but requires further refinement for non-technical skills assessment.

A reproducible representation of healthy tibiofemoral kinematics during stair descent using REFRAME – part I: REFRAME foundations and validation

In clinical movement biomechanics, kinematic measurements are collected to characterise the motion of articulating joints and investigate how different factors influence movement patterns. Representative time-series signals are calculated to encapsulate (complex and multidimensional) kinematic datasets succinctly. Exacerbated by numerous difficulties to consistently define joint coordinate frames, the influence of local frame orientation and position on the characteristics of the resultant kinematic signals has been previously proven to be a major limitation. Consequently, for consistent interpretation of joint motion (especially direct comparison) to be possible, differences in local frame position and orientation must first be addressed. Here, building on previous work that introduced a frame orientation optimisation method and demonstrated its potential to induce convergence towards a consistent kinematic signal, we present the REference FRame Alignment MEthod (REFRAME) that addresses both rotational and translational kinematics, is validated here for a healthy tibiofemoral joint, and allows flexible selection of optimisation criteria to fittingly address specific research questions. While not claiming to improve the accuracy of joint kinematics or reference frame axes, REFRAME does enable a representation of knee kinematic signals that accounts for differences in local frames (regardless of how these differences were introduced, e.g. anatomical heterogeneity, use of different data capture modalities or joint axis approaches, intra- and inter-rater reliability, etc.), as evidenced by peak root-mean-square errors of 0.24° ± 0.17° and 0.03 mm ± 0.01 mm after its implementation. By using a self-contained optimisation approach to systematically re-align the position and orientation of reference frames, REFRAME allows researchers to better assess whether two kinematic signals represent fundamentally similar or different underlying knee motion. The openly available implementation of REFRAME could therefore allow the consistent interpretation and comparison of knee kinematic signals across trials, subjects, examiners, or even research institutes.

Reliability of Hand-Held Dynamometer Measurement for Thumb Palmar Abduction Strength in Carpal Tunnel Syndrome.

Background: In carpal tunnel syndrome (CTS), pain and sensory disturbance are the main symptoms, but thumb palmar abduction (TPA) paralysis cannot be ignored as a concurrent symptom. The reliable quantitative measurement of TPA power was not established. The purpose of this study was to report on the reliability of TPA strength measurements by the hand-held dynamometry (HHD) in large samples of CTS and its superiority over other tests, including grip, pinch powers, TPA angles and manual muscle testing, in terms of clinical progress indicators. Methods: We examined the relative and absolute reliabilities of the perioperative TPA strength measured by HHD (HHD-TPA) in 566 participants with CTS and the correlation coefficient between the HHD-TPA and other clinical tests. Results: The reliability of the HHD-TPA was intraclass correlation coefficients: 97% or higher. The Bland-Altman absolute reliability showed a random pattern of bias, and the minimal detectable changes (MDC) of the inter-rater and intra-rater reliabilities indicated 9.0 N and 7.0 N individually. The HHD-TPA showed statistically significant recoveries between perioperative stages; however, the mean difference larger than the MDC was recognised only between the preoperative and 12-month postoperative stages by intra-rater comparison. More individual patients showed recovery of HHD-TPA beyond the MDC when the same examiner continuously measured HHD-TPA than when multiple examiners continuously measured HHD-TPA. Grip strength and pinch strength measurements showed a strong correlation with HHD-TPA and did not show statistically significant improvement during the perioperative period. Conclusions: HHD-TPA is the most reliable method for quantifying muscle strength in the perioperative course of TPA force in CTS. HHD-TPA is a more reliable assessment of CTS motor recovery when measured consistently for each patient by the same hand therapist. Level of Evidence: Level IV (Diagnostic).

Clinical feasibility of deep learning-driven magnetic resonance angiography collateral map in acute anterior circulation ischemic stroke

To validate the clinical feasibility of deep learning-driven magnetic resonance angiography (DL-driven MRA) collateral map in acute ischemic stroke. We employed a 3D multitask regression and ordinal regression deep neural network, called as 3D-MROD-Net, to generate DL-driven MRA collateral maps. Two raters graded the collateral perfusion scores of both conventional and DL-driven MRA collateral maps and measured the grading time. They also qualitatively assessed the image quality of both collateral maps. Interrater and inter-method agreements for collateral perfusion grading between the two collateral maps were analyzed, along with a comparison of grading time and image quality. In the analysis of the 296 acute ischemic stroke patients, the inter-method agreement for collateral perfusion grading was almost perfect (κ = 0.96, 95% CI: 0.95–0.98). Compared to conventional MRA collateral maps, the time taken for collateral perfusion grading on DL-driven MRA collateral maps was shorter (P < 0.001 for rater 1 and P = 0.003 for rater 2), and the image quality of the DL-driven MRA collateral maps was superior (P < 0.001 for rater 1 and P = 0.002 for rater 2). The DL-driven MRA collateral map demonstrates clinical feasibility for collateral perfusion grading in acute ischemic stroke, with the added benefits of reduced generation and interpretation time, along with improved image quality of the MRA collateral map.

Discordance, accuracy and reproducibility study of pathologists’ diagnosis of melanoma and melanocytic tumors

Accurate melanoma diagnosis is crucial for patient outcomes and reliability of AI diagnostic tools. We assess interrater variability among eight expert pathologists reviewing histopathological images and clinical metadata of 792 melanoma-suspicious lesions prospectively collected at eight German hospitals. Moreover, we provide access to the largest panel-validated dataset featuring dermoscopic and histopathological images with metadata. Complete agreement is achieved in 53.5% of cases (424/792), and a majority vote ( ≥ five pathologists) in 90.9% (720/792). Considerable discordance is observed for non-invasive melanomas (complete agreement in only 10/73 cases). The expert panel disagrees with the local pathologists’ and dermatologists’ diagnoses in 14.9% and 33.5% of cases, respectively. This variability highlights the diagnostic challenges of early-stage melanomas and the need to reconsider how ground truth is established in routine care and AI research. Including at least two pathologists or virtual panels may contribute to more consistent diagnostic results.

Clinical SANTI classification of arthrogenic muscle inhibition has an excellent inter-rater and intra-rater reliability in preoperative and post-operative anterior cruciate ligament rupture.

Arthrogenic muscle inhibition (AMI) is a reflexive shutdown of the quadriceps muscles following a knee injury or surgery that presents with or without hamstring contracture. This complication can be classified according to the SANTI classification, but the reproducibility of this clinical classification has not yet been demonstrated. This single-centre longitudinal observational study included 140 patients who were within 6 weeks of an ACL rupture. The presence of AMI was assessed separately and blindly during the preoperative consultation and at 3 weeks post-operative by an Orthopaedic Surgeon, an Orthopaedic Resident, a Sports Medicine Physician and a Physiotherapist. AMI was also assessed a second time by the physiotherapist, 10 days after the first assessment, before and after reconstruction surgery, in order to measure intra-rater reliability. The inter-rater and intra-rater reliability of the AMI classification was determined by calculating the intraclass correlation coefficient (ICC). Agreement for the AMI classification between different examiners was excellent pre-operatively (ICC = 0.99 [95% confidence interval, CI: 0.99-0.99]) and post-operatively (ICC = 0.98 [95% CI: 0.98-0.99]). Agreement in the AMI classification, when determined repeatedly by the same assessor (physiotherapist), was excellent pre-operatively (ICC = 0.92 [95% CI: 0.89-0.94]) and post-operatively (ICC = 0.98 [95% CI: 0.97-0.99]). Excellent intra-rater and inter-rater reliability of the AMI classification system was found in patients with recent ACL rupture and post-operatively. Level II, diagnostic study prospective cohort study.

Balancing innovation: the role of paradoxical leadership and ambidexterity in fostering team creativity

Purpose This study, grounded in ambidexterity theory, aims to investigate how paradoxical leadership (PXL) fosters team creativity in high-tech manufacturing companies, with team ambidexterity as a mediator and leader vision as a moderator. Given the fast-paced, innovation-driven demands of the high-tech sector, this research provides insights into how managers can effectively balance contradictory behaviors to drive team innovation. Design/methodology/approach Data was collected through a two-wave survey from team leaders and members across 169 teams in high-tech manufacturing companies. The time interval between data collection waves was two weeks. The data was aggregated at the team level using estimates for interrater reliability and interrater agreement. The structural equation modeling in R was used to test hypotheses. Findings The findings indicate that PXL positively impacts team creativity directly and through its influence on team ambidexterity. Team ambidexterity mediates the relationship between PXL and team creativity, while leader vision moderates the effects of PXL on team ambidexterity. Practical implications PXL benefits high-performance teams in technology sectors, such as software development, where rapid innovation and iterative processes are essential. In health care, PXL can optimize team dynamics, enabling medical research and patient care delivery breakthroughs. Regular training in ambidextrous thinking and feedback mechanisms makes this approach actionable for managers striving to cultivate creativity in high-stakes environments. Originality/value This study extends ambidexterity theory by linking PXL and team ambidexterity to team creativity. It provides high-tech manufacturing managers with concrete strategies to balance exploration and exploitation. These findings highlight actionable pathways for companies to sustain innovation in competitive, technology-driven industries.

The impact of demographics and positioning on the imaging features of the optic nerve sheath and ophthalmic vessels

BackgroundThere are significant discrepancies in the optic nerve sheath diameter (ONSD) reported in the literature. We aimed to determine the ultrasonographic imaging features of ONSD and ophthalmic vessels in a healthy population, using a standardized protocol, and to estimate the effect of demographics and positioning changes on imaging measurements.MethodsWe measured the mean values of the ONSD in supine and sitting position and the Doppler imaging parameters of the ophthalmic, central retinal and short posterior ciliary arteries. Inter-observer reliability was assessed using intraclass correlation coefficient (ICC). Linear regression models were fitted to predict the effect of demographic and clinical determinants on the imaging features.ResultsA total of 50 measurements were obtained for each observer. The mean ONSD was 5.9 mm and there was a mean reduction of 0.2 mm when assessed in sitting position (p < 0.001). Doppler analysis showed higher peak-systolic velocity and resistive index in the ophthalmic artery (35.6 cm/s vs. 12.0 cm/s; 0.78 vs. 0.70) compared to the central retinal artery (p < 0.001). Age, sex, heart rate and systolic blood pressure were significant determinants of the imaging features, with ONSD being larger in males (p < 0.001) and increasing with heart rate (p = 0.001). ICC estimates indicated ‘good’ inter-observer reliability of the ONSD and the ophthalmic and central retinal arteries velocities and resistance.ConclusionsOur findings suggest a significant impact of patient demographics and positioning during ultrasonography on the normal imaging features of the ONSD and ophthalmic vessels. The heterogeneity in methodology and clinical cohorts may justify previous discrepancies in the literature. These findings can assist in the interpretation of imaging features in clinical settings and in the standardization of point of care ONSD ultrasonography.

Can surface topography reliably determine the Rigo classification system?

No studies have explored the reliability of the Rigo classification system using surface topography (ST), which would allow optimization without radiation exposure. This study aims to measure and compare the intra- and inter-observer reliability (Kappa values) and accuracy of the Rigo system between ST and X-ray for overall types and subtypes. X-ray and ST images of 31 adolescent idiopathic scoliosis patients were selected. Three investigators were blinded to assess images using the Rigo system, twice for each patient on different weeks, with 372 overall image readings. Afterwards, all investigators agreed upon the correct Rigo scores for finalized classifications. For Rigo types, the average intra-observer Kappa value was slightly better for ST (0.77, p<0.001) than X-ray (0.75, p<0.001). For Rigo subtypes, the average intra-observer Kappa value was again slightly better for ST (0.74, p<0.001) than X-ray (0.65, p<0.001). The inter-observer reliability was expectedly lower than intra-observer, with ST (0.53, p<0.001) comparable to X-ray (0.54, p<0.001) for the type. For subtype inter-observer reliability, ST (0.43, p<0.001) was slightly better than X-ray (0.36, p<0.001). For the type, the overall accuracy of the observers was slightly lower for ST (77.96%) than X-ray (79.57%). For the subtype, the accuracy of observers was slightly higher for ST (70.97%) than X-ray (65.05%). ST-based Rigo system demonstrates very good intra-rater reproducibility and moderately good inter-rater reproducibility. Surface topography is comparable to X-ray for the Rigo system, and therefore can be considered a reliable alternative in clinical application.

A systematic review on risk factors and reasons for e-cigarette use in adolescents.

The aim was to establish EC use risk and protective factors, the reasons for use, associations with tobacco and other substance use, and use for smoking cessation. A systematic review following PRISMA guidelines was registered in PROSPERO (CRD42024532771). Searches in Web of Science and PubMed/MEDLINE (March-April 2024) used terms like 'electronic cigarette' and 'adolescents' with a PICO framework. Inclusion criteria covered studies on adolescents aged 10-19 years, published in English or Spanish (2018-2024). Three reviewers independently screened studies, achieving 96% inter-rater reliability. Data extraction followed standardized tables, and methodological quality was assessed using MMAT and GRADE tools, ensuring a robust evaluation of evidence on adolescent electronic cigarette use. From 895 studies, 50 met the inclusion criteria. The strongest risk factors for adolescent EC use include social acceptance and use within peer or family circles (13 studies), male gender (10 studies), low risk perception (6 studies), younger age (3 studies), and greater financial resources (3 studies). Motives for use include low perceived risk and appealing flavors, supported by both longitudinal and cross-sectional studies. EC use is significantly associated with smoking initiation (7 studies), cannabis consumption (8 studies), and alcohol use (4 studies). Evidence on the effectiveness of ECs as harm reduction or smoking cessation tools in adolescents remains inconclusive, with some cross-sectional studies supporting their utility and others finding contrary evidence. High-quality research indicates ECs are predominantly used alongside traditional cigarettes, with dual nicotine consumption patterns commonly observed. Evidence on adolescent EC use identifies risk factors, motives, and links to substance use. However, its role in harm reduction and smoking cessation remains insufficient and controversial. High-quality research is needed, as most studies are low quality. Targeted prevention strategies addressing social influences, perceptions, and accessibility are crucial to reduce adolescent EC use.

Maximal mouth opening in infants and toddlers with spinal muscular atrophy: a prospective controlled study

BackgroundBulbar function is frequently impaired in patients with spinal muscular atrophy (SMA). Although extremely important for the patient’s quality of life, it is difficult to address therapeutically. Due to bulbar dysfunction, maximum mouth opening (MMO) is suspected to be reduced in children with SMA. However, no published MMO values exist for SMA children younger than 24 months. This study presents a novel approach to measuring MMO in infants and toddlers with SMA and compares it with healthy controls.MethodsChildren with SMA (0–24 months) who received disease-modifying therapy at a single neuropediatric center and similarly aged healthy children were prospectively recruited. MMO was measured using a cardboard scale and a custom-designed instrument.ResultsA total of 115 children were included (SMA = 24, healthy controls = 91). Inter-rater reliability between two examiners was excellent (ICC = 0.987, 95% CI 0.959 to 0.995), as was the reliability between the cardboard scale and the custom-designed instrument (ICC = 0.986, 95% CI 0.968 to 0.994). A mixed linear model showed a significant increase of MMO with age, and a significantly wider mouth opening in healthy controls (p < .001).ConclusionFor future research, MMO can provide valuable information about the involvement of cranial nerves, particularly in the context of disease-modifying therapies, even at a very early age.

Total functioning capacity scale in Huntington's disease: natural course over time.

The total functioning capacity (TFC) assessment has been integral to Huntington's disease (HD) research and clinical trials, measuring disease stage and progression. This study investigates the natural progression of function in HD, focusing on changes in TFC scores related to age and CAG-repeat length, and evaluates TFC's strengths and weaknesses in longitudinal studies. Using Enroll-HD platform's clinical dataset version 5, including Registry-3, we analysed data from 21,079 participants, with 16,083 having an expanded CAG repeat. Our final analysis encompassed 15,527 patients and 52,457 visits, with TFC scores ranging from 0 to 13. Alluvial charts show that most individuals maintain maximum functional capacity over time. 3505 individuals experienced change in TFC scores, over the subsequent 4 years, 2224 (64.1%) experienced declining TFC scores, while 661 (18.6%) showed improvement within a year. The remaining 17.3% exhibited stable TFC scores. Age-related changes followed a specific sequence: occupation, household chores/finances, daily living, and care. Longer CAG-repeat lengths were linked to earlier functional decline, with some geographic regions showing earlier losses in specific domains. Reduced penetrance CAG-repeat groups exhibited different trajectories from full penetrance HD participants. When we focus on those who experienced a change in TFC score, the number of HD patients with regained functional capacity is substantial, even considering interrater variability, which may influence outcome assessments in clinical trials. The TFC effectively reflects changes in functional domains as intended. Analysis of the reduced penetrance group suggests potential selection biases in seeking medical attention earlier and for reasons unrelated to HD.

A Systematic Review of the Evidence for Using Simulation to Replace Clinical Experience for Paramedic Students

Background In health professions education there is a shortage of clinical training opportunities and an increasing demand for workers, creating a need for alternative methods to clinical placements. One alternative method to replace clinical experience is simulation-based education. Currently, the efficacy of simulation as a clinical replacement in paramedicine is unknown. To understand the current state of evidence for substituting clinical experience with simulation in paramedic education, provide implications for SBE implementation, and direct further research in this area a systematic review, following the PRISMA checklist guide, was conducted. Methods Five databases were searched. Primary source studies of all designs investigating replacing clinical experience in paramedicine were included, with eight articles assessed for eligibility screening. Three studies were selected for final inclusion, quality assessment and critical appraisal. Results Inter-rater reliability was good for the quality assessment and quality appraisal ratings were moderate to strong, though the articles were of low levels of evidence. None of the studies directly addressed whether simulation-based education can be used as a clinical replacement, though both learners and program directors found value in simulation and felt a combination of simulation and clinical time was best. Communication skills and high-acuity low-frequency situations were identified as most appropriate for simulation substitution. Discussion The findings of the systematic review indicate a willingness to engage in simulation to replace some clinical experience and certain skill areas that could be suitable for simulation, but no practical recommendations can be made due to the low level of study design based on the levels of evidence and lack of evidence for direct clinical substitution. Simulation as a replacement for clinical experience has support in other health professions, but further research is needed in paramedicine to investigate its efficacy and to inform future educational practice.

Methods Comment: The Importance of Measuring Interrater Reliability in Radiology.

Methods Comment: The Importance of Measuring Interrater Reliability in Radiology.

Impact of gingival pigmentation on laypersons’ perception of smile aesthetics: an observational study

Aim: The study aims to assess laypersons’ perceptions of smile aesthetics before and after gingival depigmentation and to correlate these perceptions with the degree of gingival pigmentation. Methods: The retrospective observational study examined individuals who received gingival depigmentation following orthodontic treatment between 2019 and 2024. Fifteen records were selected based on the inclusion and exclusion criteria. The pre- and post-depigmentation frontal smile photos were standardized, included into a Google Form, and distributed to 40 laypeople for the assessment of smile aesthetics. The laypeople evaluated the attractiveness of smiles using a 10-point Likert scale. Experienced periodontists classified the gingival pigmentation utilizing the oral pigmentation index (OPI). The differences between the pre- and post-treatment OPI scores and smile esthetic scores were assessed using Wilcoxon signed-rank test. Spearman correlation was used to evaluate the association between smile scores and OPI scores. The intraclass correlation coefficient (ICC) was employed to evaluate the inter-rater reliability of the smile ratings and OPI scores. The statistical significance was established at p ≤ 0.05. Results: The average OPI scores before depigmentation were 2.67 ± 0.49; however, following depigmentation, the scores significantly declined to an average of 0.33 ± 0.5 (p &lt; 0.001). The mean smile aesthetic score pre-depigmentation was 6.72 ± 0.32, whereas after depigmentation the scores significantly improved to 7.91 ± 0.18 (p = 0.001). Spearman correlation indicated a statistically significant negative association between smile aesthetics scores and OPI scores (r = –0.76). ICC indicated excellent inter-rater reliability for the OPI (0.923) and good reliability for smile esthetic scores (0.756). Conclusions: The study found that gingival de-pigmentation procedures improve the OPI scores and laypeople perceive gingival hyperpigmentation unattractive. While gingival depigmentation is not mandatory, it may be recommended for individuals seeking cosmetic smile enhancements post-orthodontic therapy to improve the overall patient satisfaction.

Pediatric Supracondylar Humerus and Diaphyseal Femur Fractures: A Comparative Analysis of Chat Generative Pretrained Transformer and Google Gemini Recommendations Versus American Academy of Orthopaedic Surgeons Clinical Practice Guidelines.

Artificial intelligence (AI) chatbots, including chat generative pretrained transformer (ChatGPT) and Google Gemini, have significantly increased access to medical information. However, in pediatric orthopaedics, no study has evaluated the accuracy of AI chatbots compared with evidence-based recommendations, including the American Academy of Orthopaedic Surgeons clinical practice guidelines (AAOS CPGs). The aims of this study were to compare responses by ChatGPT-4.0, ChatGPT-3.5, and Google Gemini with AAOS CPG recommendations on pediatric supracondylar humerus and diaphyseal femur fractures regarding accuracy, supplementary and incomplete response patterns, and readability. ChatGPT-4.0, ChatGPT-3.5, and Google Gemini were prompted by questions created from 13 evidence-based recommendations (6 from the 2011 AAOS CPG on pediatric supracondylar humerus fractures; 7 from the 2020 AAOS CPG on pediatric diaphyseal femur fractures). Responses were anonymized and independently evaluated by 2 pediatric orthopaedic attending surgeons. Supplementary responses were, in addition, evaluated on whether no, some, or many modifications were necessary. Readability metrics (response length, Flesch-Kincaid reading level, Flesch Reading Ease, Gunning Fog Index) were compared. Cohen Kappa interrater reliability (κ) was calculated. χ2 analyses and single-factor analysis of variance were utilized to compare categorical and continuous variables, respectively. Statistical significance was set with P <0.05. ChatGPT-4.0, ChatGPT-3.5, and Google Gemini were accurate in 11/13, 9/13, and 11/13, supplementary in 13/13, 11/13, and 13/13, and incomplete in 3/13, 4/13, and 4/13 recommendations, respectively. Of 37 supplementary responses, 17 (45.9%), 19 (51.4%), and 1 (2.7%) required no, some, and many modifications, respectively. There were no significant differences in accuracy (P = 0.533), supplementary responses (P = 0.121), necessary modifications (P = 0.580), and incomplete responses (P = 0.881). Overall κ was moderate at 0.55. ChatGPT-3.5 provided shorter responses (P = 0.002), but Google Gemini was more readable in terms of Flesch-Kincaid Grade Level (P = 0.002), Flesch Reading Ease (P < 0.001), and Gunning Fog Index (P = 0.021). While AI chatbots provided responses with reasonable accuracy, most supplemental information required modification and had complex readability. Improvements are necessary before AI chatbots can be reliably used for patient education. Level IV.

Early vs Late Anticoagulation After Ischemic Stroke in Patients With Atrial Fibrillation and Covert Brain Infarcts.

Covert brain infarcts (CBIs) in patients with first-ever ischemic stroke (IS) and atrial fibrillation (AF) are associated with an increased risk of stroke recurrence. We aimed to assess whether CBIs modify the treatment effect of early vs late initiation of direct oral anticoagulants (DOACs) in patients with IS and AF. We conducted a post hoc analysis of the international, multicenter, randomized-controlled ELAN trial, which compared early (<48 hours after ischemic stroke for minor and moderate stroke, 6-7 days for major stroke) vs late (>48 hours for minor, 3-4 days for moderate, 12-14 days for major stroke) initiation of DOACs in patients with IS and AF. The primary outcome was a composite of recurrent IS, symptomatic intracranial hemorrhage (sICH), major extracranial bleeding, systemic embolism, or vascular death within 30 days after stroke; secondary outcomes were the individual components. We estimated outcomes based on the presence of CBIs (any CBI vs no CBI) on prerandomization imaging (core-lab rating) using adjusted risk differences (aRDs) between treatment arms. Point estimates and 95% CIs are presented without reporting p values. Of the 1,694 participants with first-ever IS included (median age: 77 years, 45.9% female), 678 (40.0%) had CBI. The imaging core-lab interrater reliability for the presence of CBI was 0.87 (0.81-0.94). The primary outcome occurred in 8 (2.3%; recurrent IS: 3/342) of 342 participants with CBI assigned to the early treatment arm vs 20 (6.0%; recurrent IS: 12/336) of 336 assigned to the late treatment arm (aRD: -3.6%, 95% CI -6.6 to -0.6) (p for interaction: 0.063). With early DOAC treatment, IS recurrence risk was lower in participants with CBI (aRD: -2.7%, 95% CI -5.0 to -0.4), but not in participants without CBI (aRD: -0.4, 95% CI -2.1 to 1.2). No sICH was observed in the early treatment group. The presence of CBI may indicate a subgroup of patients with first-ever IS and AF who particularly benefits from early DOAC initiation to prevent ischemic event recurrence, without increasing harm. Our findings should be considered in clinical decision making regarding timely DOAC treatment in patients with stroke and AF. This study provides Class II evidence that in patients with covert brain infarcts, atrial fibrillation, and first-ever ischemic stroke, early (vs late) initiation of DOACs is associated with lower risk of recurrent stroke with no increase in harm. URL: clinicaltrials.gov/study/NCT03148457; Unique identifier: NCT03148457; submitted: April 7, 2017; first patient enrolled: November 6, 2017.

The Reliability and Validity of Intraoral Photographs in Assessing Orthodontic Treatment Need.

Orthodontic treatment need has commonly been assessed using treatment need indices during clinical examinations or using photographs in combination with plaster casts. Recently, the use of intraoral photographs alone to screen malocclusions has increased. This study aimed to validate intraoral photographs for the assessment of orthodontic treatment need. The study sample consisted of case files from 30 pre-orthodontic patients aged 12-19 years. Each case file included intraoral photographs and casts. The cases were consecutively recruited from two orthodontic treatment waiting lists: 15 from the Department of Orthodontics at Folktandvården Eastmaninstitutet, Stockholm, Sweden and 15 from the Center for Orthodontics and Pediatric Dentistry, Norrköping, Public Dental Service Östergötland. Their orthodontic treatment need was assessed by four raters (calibrated orthodontists) using the indices IOTN-AC, IOTN-DHC, ICON, and DAI. The four raters individually assessed the 30 cases on three occasions: (1) photos only, (2) photos and casts, and (3) photos only. Finally, the four raters jointly made a consensus assessment using both photos and casts. For IOTN-AC and IOTN-DHC, interrater agreement was assessed with Fleiss' kappa, and validity with the Wilcoxon signed-rank test. For ICON and DAI, interrater agreement was assessed with Intra Class Correlation (ICC) (1, 2) and validity with a paired t-test. Interrater agreement for IOTN-AC was slight (0.14-0.18) and moderate for IOTN-DHC (0.51-0.57), regardless of whether photographs were used alone or combined with casts. ICON demonstrated moderate interrater agreement (0.57-0.72), while DAI showed moderate to excellent (0.70-0.91), similarly unaffected by the use of photographs alone or in combination with casts. The validity analysis, which compared the individual assessments to the consensus one, revealed equivalent differences whether the assessment involved intraoral photographs alone or in combination with casts. Intraoral photographs are sufficient for assessing orthodontic treatment need because interrater agreement and validity are similar whether photos are used alone or with casts. However, interrater variability was substantial for both assessment methods. ClinicalTrial.gov. identifier: NCT05038865.

Inter-rater agreement and characterization of pleural line and subpleural fields in canine lung ultrasound: a comparative pilot study between high-frequency linear and curvilinear transducers using B- and M-mode ultrasonographic profiles.

Lung ultrasound (LUS) is increasingly utilized in veterinary medicine to assess pulmonary conditions. However, the characterization of pleural line and subpleural fields using different ultrasound transducers, specifically high-frequency linear ultrasound transducers (HFLUT) and curvilinear transducers (CUT), remains underexplored in canine patients. This study aimed to evaluate inter-rater agreement in the characterization of pleural line and subpleural fields using B- and M-mode ultrasonography in dogs with and without respiratory distress. Eighty-eight ultrasound clips from nine dogs were analyzed. HFLUT demonstrated strong inter-rater agreement in B-mode (κ = 0.89) and near-perfect agreement in M-mode (κ = 1.00) for pleural line homogeneity. In contrast, CUT showed minimal agreement in both B-mode (κ = 0.34) and M-mode (κ = 0.37). Homogeneous pleural lines were predominantly observed in control dogs or those with cardiogenic pulmonary edema (CPE), while non-homogeneous pleural lines were more common in dogs with non-cardiogenic alveolar-interstitial syndrome (NCAIS). Vertical subpleural fields identified in M-mode were associated with both CPE and NCAIS, whereas horizontal fields were more often observed in control dogs. HFLUT offers superior inter-rater reliability for characterizing pleural and subpleural features in canine LUS compared to CUT, particularly in M-mode. These findings suggest HFLUT may enhance diagnostic accuracy for pulmonary conditions in dogs. Further studies are needed to explore the diagnostic potential of LUS in differentiating vertical artifact (e.g., B-lines) etiologies in veterinary patients.