Inter-rater Intraclass Correlation Research Articles

Periocular Asymmetry Index in Caucasian Populations Using Three-dimensional Photogrammetry Assessment.

To quantitatively assess the periocular asymmetry and investigate its sex and age-related differences in a Caucasian population using three-dimensional (3D) stereophotogrammetry. Standardized 3D photos of the periocular region of 301 Caucasians were taken using the VECTRA M3 3D Imaging System. Standardized landmarks were positioned, and data measurements in the periocular region were obtained from these images using VAM software and assessed using intraclass correlation coefficients (ICC) for reliability. Absolute differences and asymmetry index between the right and the left periocular region were calculated with a focus on gender and age-related differences. Fissure height asymmetry was positively correlated with age (p < 0.01). Furthermore, reflex distance asymmetry was positively correlated with age in the elderly group (p < 0.05). Absolute differences of upper eyelid crease were 0.65 ± 0.79 mm for females and 0.90 ± 0.94 mm for males (p < 0.05). In the elderly group, the absolute differences of reflex distance were 0.664 ± 0.471 mm for males and 0.470 ± 0.408 mm for females (p < 0.05), while the absolute differences of fissure height were 0.619 ± 0.469 mm and 0.436 ± 0.372 mm, respectively (p < 0.05). All measurements had an inter-rater ICC and intra-rater ICC between 0.761 and 0.957. Periocular asymmetry is more prominent in older and male people. 3D photogrammetry is a reliable tool to detect periocular asymmetry and might provide an accurate and effective reference for periocular cosmetic, plastic, and reconstructive surgery in the clinical routine. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Assessing the interrater and intrarater reliability of subglottic stenosis grading systems

BackgroundSubglottic stenosis (SGS) is a condition leading to narrowing of the upper airway which can lead to dyspnea and life-threatening airway obstruction. Although other proposed grading systems exist, the Cotton Myer (CM) and percent stenosis systems are the most widespread in clinical practice. Despite this, the CM system has not yet been validated for visual assessment of SGS. ObjectiveTo determine the interrater and intrarater reliability of the CM grading system among a cohort of physicians who manage patients with SGS. MethodsAn online survey created with videos of tracheoscopies from 20 adult patients with subglotticstenosis (SGS) was sent individually to 9 expert physicians from various medical specialties, all of whom managed patients with SGS. Physicians were asked to view the 20 tracheoscopy videos and assess both the percent stenosis and Cotton Myer (CM) grade of each patient. After a period of 4 weeks, the physicians were sent the same survey of the 20 tracheoscopy videos. The interrater and intrarater reliability was calculated using the intraclass correlation coefficient (ICC), a measurement used to evaluate the reliability (the extent to which a measurement can be replicated) of two or more raters measuring the same subject. ResultsOverall, CM and percent stenosis systems were found to have an ICC of 0.94 and 0.90 within the domain of interrater reliability, respectively, and ICC of 0.71 and 0.81 within the domain of intrarater reliability, respectively. ConclusionOur findings suggest that the CM and percent stenosis grading systems remain a valid clinical tool to measure and communicate the severity of airway obstruction in SGS.

Analyse systématique des évaluations de circuits multiples d’examen clinique objectif structuré (ECOS) : variables explicatives et corrélations inter-évaluateurs

IntroductionObjective Structured Clinical Examinations (OSCEs) assess professional performance in a simulated environment. Following their integration into the reform of the 2nd cycle of medical studies (R2C), this pedagogical modality was implemented in France. This study investigates the variability of students’ OSCE scores, as well as their inter-rater reproducibility. MethodsThis single-center retrospective study covered several sessions of evaluative OSCE circuits conducted between January 2022 and June 2023. Variables collected were: baseline situation family, competency domain, presence of a standardized participant for stations; gender and professional status for evaluators; scores (global, clinical and communication skills), number of previously completed OSCE circuits and faculty scores for students. ResultsThe variability of the overall score was explained mainly (79.7%, CI95% [77.4; 82.0]) by the station factor. The student factor and the circuit factor explained 7.5% [12.9; 20.2] and<0.01% [2.10-13; 2.10-9] respectively. The inter-rater intra-class correlation coefficient was 87.2% [86.4; 87.9] for the global score. Station characteristics (starting situation, domain) and evaluator characteristics (gender, status) were significantly associated with score variations. ConclusionThis first study on the variability of OSCE circuit scores in France shows good reproducibility with influence of station characteristics. In order to standardize circuits, variability linked to the domain competency should be considered as well.

Measurement properties of the falls efficacy scale in patients on hemodialysis

BackgroundThe measurement properties of the falls efficacy scale have not been evaluated in patients on hemodialysis. This study determined the inter- and intrarater reliability, standard error of measurement, minimal detectable change, and limits of agreements of the falls efficacy scale in patients on hemodialysis.MethodsA cross-sectional study was conducted with 65 patients (57.5 ± 13.9 years, 63.1% male) on hemodialysis. The fear of falling was assessed by two previously trained raters using the falls efficacy scale. The intraclass correlation coefficient, standard error of measurement, minimal detectable change, and Bland–Altman plot were calculated to assess the inter- and intrarater reliability of the falls efficacy scale.ResultsThe interrater intraclass correlation coefficient was 0.91, and the intrarater intraclass correlation coefficient was 0.78, representing excellent interrater and good intrarater reliability. The standard error of measurement for inter- and intrarater assessments were 2.99 and 4.46, and the minimal detectable change for inter- and intrarater assessments were 9.26 and 12.33, respectively. The interrater mean difference score was 0.26 (95% limits of agreement: − 8.01 to 8.53), and the intrarater mean difference score was − 1.06 (95% limits of agreement: − 13.39 to 11.27).ConclusionIn patients on hemodialysis, the falls efficacy scale showed excellent and good inter- and intrarater reliability, respectively. Additionally, standard error of measurement, minimal detectable change, and limits of agreements of the falls efficacy scale score were satisfactory.

Spine surgeon versus AI algorithm full-length radiographic measurements: a validation study of complex adult spinal deformity patients.

Spinal measurements play an integral role in surgical planning for a variety of spine procedures. Full-length imaging eliminates distortions that can occur with stitched images. However, these images take radiologists significantly longer to read than conventional radiographs. Artificial intelligence (AI) image analysis software that can make such measurements quickly and reliably would be advantageous to surgeons, radiologists, and the entire health system. Institutional Review Board approval was obtained for this study. Preoperative full-length standing anterior-posterior and lateral radiographs of patients that were previously measured by fellowship-trained spine surgeons at our institution were obtained. The measurements included lumbar lordosis (LL), greatest coronal Cobb angle (GCC), pelvic incidence (PI), coronal balance (CB), and T1-pelvic angle (T1PA). Inter-rater intra-class correlation (ICC) values were calculated based on an overlapping sample of 10 patients measured by surgeons. Full-length standing radiographs of an additional 100 patients were provided for AI software training. The AI algorithm then measured the radiographs and ICC values were calculated. ICC values for inter-rater reliability between surgeons were excellent and calculated to 0.97 for LL (95% CI 0.88-0.99), 0.78 (0.33-0.94) for GCC, 0.86 (0.55-0.96) for PI, 0.99 for CB (0.93-0.99), and 0.95 for T1PA (0.82-0.99). The algorithm computed the five selected parameters with ICC values between 0.70 and 0.94, indicating excellent reliability. Exemplary for the comparison of AI and surgeons, the ICC for LL was 0.88 (95% CI 0.83-0.92) and 0.93 for CB (0.90-0.95). GCC, PI, and T1PA could be determined with ICC values of 0.81 (0.69-0.87), 0.70 (0.60-0.78), and 0.94 (0.91-0.96) respectively. The AI algorithm presented here demonstrates excellent reliability for most of the parameters and good reliability for PI, with ICC values corresponding to measurements conducted by experienced surgeons. In future, it may facilitate the analysis of large data sets and aid physicians in diagnostics, pre-operative planning, and post-operative quality control.

Reliability of the unified multiple system atrophy rating scale using the telephone

ObjectiveThe unified multiple system atrophy rating scale (UMSARS) was used to evaluate various symptoms of multiple system atrophy (MSA). And UMSARS part 1 was originally developed for use in interviews, but the need for telemedicine is increasing in COVID-19 pandemic. The purpose of this study is to evaluate the reliability of the UMSARS part 1 telephone survey. MethodsThirty-two MSA patients took the UMSARS part 1 face-to-face, followed by two more telephone evaluations. Intraclass correlation coefficients (ICC) and Cronbach’s alpha (α) coefficients were calculated, and the inter-rater reliability was determined. At the same time, we asked about the problems in COVID-19 pandemic. ResultsThe study participants included 15 men and 17 women with mean age of 67.1 years (SD, 8.3). For the total UMSARS part 1 score, the inter-rater ICC and Cronbach’s α coefficient were 0.89 to 0.92, and 0.84 to 0.87, respectively. More than half of the items had a relatively high ICC. Cronbach’s α coefficients were more than 0.7 for all items. Changes that occurred in COVID-19 pandemic included reduced outings and lack of rehabilitation in about half of the cases. ConclusionThe UMSARS part 1 has high inter-rater reliability and internal consistency. Evaluation of subjective symptoms showed that some variability could occur. In addition, there was concern about the influence of lack of rehabilitation due to COVID-19 pandemic.

In-person validation of the Ichthyosis Scoring System.

Ichthyoses are a heterogeneous group of skin disorders characterized by scaling and erythema. Recognizing the variability of scale and erythema by region and ichthyosis subtype, we developed the Ichthyosis Scoring System (ISS) to quantify severity. We previously found ISS to have high inter- and intrarater reliability in evaluating photographic images. To confirm ISS clinical utility, we examined its performance at the 2022 Foundation for Ichthyosis and Related Skin Types conference. Sixty-five participants were evaluated by 3 of 9 medical professionals trained to score ichthyosis scale and erythema using ISS. Intrarater and interrater intraclass correlation coefficients (ICC) were analyzed using one-way and two-way random effects models, respectively. Intrarater reliability was excellent (ICC = 0.931, 95% CI, 0.921-0.940) for scale and good (ICC = 0.876, 95% CI, 0.853-0.899) for erythema scoring. Compared to photo validation with excellent intrarater reliability ratings for both scale (ICC = 0.956, 95% CI, 0.925-0.974) and erythema (ICC = 0.913, 95% CI, 0.855-0.949), ISS demonstrated equivalent reliability for live use. Overall interrater reliability for 10 body sites showed excellent (ICC >0.9) and good (ICC >0.75) agreement and consistency for both scale and erythema. Palms were an exception, demonstrating moderate (ICC >0.5) interrater agreement and consistency for erythema evaluation. ISS is a reliable measure of global and regional ichthyosis severity during in-person evaluations. Ease-of-use, accessibility, and content validity in both live and photographic evaluation endorse ISS as a standard for ichthyosis severity analysis.

Ultrasound assessment of malnutrition in infancy: a pilot case-control study

This study aimed at determining the intra- and inter-rater reliability in ultrasound body composition measurements and investigating the differences between malnourished and non-malnourished infants. Sonographic images for measurements of fat and muscle thickness were compared between 9 malnourished and 9 non-malnourished hospitalized infants. The mean of fat and muscle thickness sums were 12.44 ± 7.58 mm and 28.98 ± 7.18 mm, respectively. The intra- and inter-rater intraclass correlation coefficient were above 0.9 for both measurements, indicating high intra- and inter-rater reliability. Compared to non-malnourished infants, malnourished infants have 45% of fat thickness sum and 71% of muscle thickness sum. Ultrasound measurements of body composition in infants were different between hospitalized malnourished and non-malnourished infants. This approach has the potential to be utilized more broadly, from assessing the nutritional status of critically ill infants in intensive care units to screening for malnutrition in high-risk infant populations.

Influence of chest wall conformation on reproducibility of main echocardiographic indices of left ventricular systolic function.

The possible influence of chest wall conformation, as noninvasively assessed by Modified Haller Index (MHI, the ratio of chest transverse diameter over the distance between sternum and spine), on reproducibility of both left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) has never been previously investigated. Two equal groups of healthy individuals, matched by age, sex, and cardiovascular risk factors and categorized according to MHI in those with concave-shaped chest wall (MHI>2.5) and those with normal chest shape (MHI≤2.5), who underwent transthoracic echocardiography implemented with echocardiographic deformation imaging between June 2018 and May 2019, were retrospectively analyzed. LVEF and GLS were measured twice by the two echocardiographers in a double blinded manner. Intra-class correlation coefficients (ICCs), bias and limits of agreement determined with Bland-Altman analysis were calculated for repeated measurements of both LVEF and GLS. Thirty-four healthy individuals with MHI>2.5 (54.9±6.4 years, 58.8% females) and 34 matched controls with MHI≤2.5 (52.5±8.1 years, 50% females) were separately analyzed. In comparison to MHI≤2.5 group, the MHI>2.5 group was found with significantly smaller cardiac chambers and significantly lower GLS magnitude (-15.8±2.5 vs. -22.2±1.3%, P<0.001), despite similar LVEF (61.3±6.4 vs. 61.1±3.6%, P=0.87). In the MHI>2.5 group, intra-rater and inter-rater ICCs were ≤0.5 for both LVEF and LV-GLS, whereas in the MHI≤2.5 group intra-rater and inter-rater ICCs values indicated good reliability for LVEF and excellent reliability for GLS. The greatest bias and largest limits of agreement were detected for LVEF assessment (bias ranging from -1.09 to 2.94%, with the 95% limits of agreement ranging from -13.9 to 21.3%) in individuals with MHI>2.5. On the other hand, the smallest bias and narrowest limits of agreement were obtained for GLS measurement (bias ranging from -0.26 to 0.09%, with the 95% limits of agreement ranging from -1.4 to 1.4%) in participants with normal chest wall conformation (MHI≤2.5). The test reliability of LVEF and GLS is strongly influenced by the chest wall conformation. MHI might represent an innovative approach for selecting the best echocardiographic method for LV systolic function estimation in the individual case.

Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy.

Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area. Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used. The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good." We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.

Femoroacetabular Impingement Measurements Obtained From Two-Dimensional Radiographs Versus Three-Dimensional–Reconstructed Computed Tomography Images Result in Different Values

To compare the reliability and accuracy of radiographic measurements obtained from 2-dimensional (2D) radiographs and 3-dimensional (3D)-reconstructed computed tomography (CT) images in the assessment of femoroacetabular impingement syndrome (FAIS). Consecutive patients with FAIS from January 2018 to December 2020 were identified and included in this study. Two fellowship-trained surgeons and 2 fellows performed blinded radiographic measurements. Lateral center-edge angle (LCEA) and Tönnis angles were measured on anteroposterior pelvic radiographs, and alpha angles were measured on frog lateral radiographs. Reliability coefficients for individual measurement accuracy were performed using the Cronbach alpha and intra- and inter-rater intraclass correlation coefficients (ICCs). Composite measurements for LCEA, Tönnis angle, and alpha angle were compared with the corresponding 3D value using paired sample t-tests. Fifty-three patients with FAIS with standardized 2D radiographic and 3D-reconstructed CT imaging were included. All reliability metrics met thresholds for internal reliability. Inter-rater ICCs for LCEA, Tönnis angle, and alpha angle were (0.928, 0.888, 0.857, all P < .001). When we compared 2D radiographic measurements with 3D-reconstructed CT values, there was a significant difference in the LCEA for 2 authors: surgeon 1 (mean [M]= -9.14, standard deviation [SD]= 5.7); t(52)= -11.6, P < .001, and surgeon 2 (M= -5.9°, SD= 4.7); t(52)= -9.2, P < .001. Significant differences were seen for Tönnis angle for 2 authors: fellow 2 (M= 3.9°, SD= 5.6); t(52)= 5.1, P < .001, and surgeon 2 (M= -2.6°, SD= 4.1); t(52)= -4.6, P < .001. Alpha angle measurements compared to the 3D-reconstructed alpha angle at 2 o'clock was significantly different for 3 authors: fellow 1 (M= 11.9°, SD= 16.2); t(52)= 5.3, P < .001; fellow 2 (M= 10.4°, SD= 18.6); t(52)= 4.1, P= .002; and surgeon 2 (M= -6.5°, SD= 16.2); t(52)= -2.9, P= .005. Positive mean values indicate 2D radiographic measurements overestimated 3D reconstruction values and negative mean values indicate underestimation. The use of 2D radiographs alone for preoperative planning of FAIS may lead to inaccuracies in radiographic measurements. Level, III retrospective cohort study.

The intra- and inter-rater reproducibility of bone level measurements at strategic mini-implants using dental panoramic radiography

ObjectivesThis experimental study focused on the intra- and inter-rater reproducibility of vertical bone level (VBL) measurements at strategic mini-implants (MI) using digital panoramic radiographs (PR). Study designVBLs of 152 MIs for removable partial denture stabilization at 50 randomly chosen PRs from a clinical trial were digitally evaluated by three ratters. Rater deviations exceeding 0.5 mm were re-examined. The intra-class correlation coefficient (ICC) was applied to estimate reliability. The smallest detectable change (SDC) was interrelated to the minimal clinically important change of 0.2 mm. ResultsThe first measurement round revealed intra- and inter-rater ICCs of > 0.8. However, 28 sites (9 %) were unreadable, and 97 sites (32 %) revealed differences between observers of ≥ 0.5 mm. Following a consensus session and re-training, an additional 8 sites were excluded and all remaining VBL differences were ≤ 0.5 mm. Thus, the SDCs with 95 % credibility were improved from 0.73 to 0.31 mm in the intra-rater and from 1.52 to 0.34 mm in the inter-rater statistics. Given a 50 % credibility for this special setting, both the intra- and inter-rater SDCs were 0.11 mm. ConclusionsDigital PR can be reliably utilized to determine VBLs around MIs under conditions of at least two trained observers, mutual calibration sessions, and exclusion of unquantifiable radiographs. German Clinical Trials Register IDDRKS00007589, www.germanctr.de

Reliability and Responsiveness of Histologic Indices for the Assessment of Crohn’s Disease Activity

The operating properties of histologic indices for evaluating Crohn's disease (CD) activity are poorly characterized. We assessed the reliability and responsiveness of existing histologic indices/items used in CD and ulcerative colitis (UC), in addition to 3 novel items, and developed exploratory ileal, colonic, and colonic-ileal CD instruments. Blinded central readers independently reviewed paired baseline and week 12 image sets from the EXTEND trial. Disease activity was scored using 4 indices (the Global Histologic Activity Score, Geboes Score, Nancy Histological Index, and Robarts Histopathology Index) and 3 items identified by an expert panel (mucin depletion, basal plasmacytosis, and ileal pyloric gland metaplasia). Reliability and responsiveness were quantified using the intraclass correlation coefficient (ICC) and area under the receiver operating curve (AUC), respectively. Exploratory indices were developed using backward stepwise linear regression analysis. Candidate independent variables were items with an inter-rater ICC ≥0.40 and AUC ≥0.56. The dependent variable was histologic disease activity measured by a 100-mm visual analogue scale. Paired image sets were available from 55 patients. Substantial to almost perfect inter-rater reliability (ICC, 0.63-0.87) and some responsiveness (AUC, 0.57-0.94) were observed for all existing indices regardless of whether individual colonic and ileal segments, combined colonic segments, or combined colonic and ileal segments were assessed and the calculation method used. Five items were tested as candidate items, and exploratory colonic, ileal, and colonic-ileal indices were developed. CD and UC indices were similarly reliable and responsive in measuring histologic CD activity. Exploratory index development did not offer benefit over current histologic instruments.

Reliability and Validity Analysis of the Distal Radioulnar Joint Ballottement Test

Triangular fibrocartilage complex injuries can cause distal radioulnar joint (DRUJ) instability, which can be evaluated clinically with the DRUJ ballottement test. However, the reliability and validity of the test are unclear. This study aimed to analyze the reliability and validity of the test using a tracking device on healthy participants and patients with triangular fibrocartilage complex injuries. In this cross-sectional study, three orthopedic hand surgeons performed the DRUJ ballottement test using a technique of holding the carpal bones to the radius on 25 healthy participants (50 hands; 10 men and 15 women; mean age, 33 years; range, 20-51 years) and eight patients with triangular fibrocartilage complex injuries (16 hands; six men and two women; mean age, 43 years; range, 27-59 years). We used a three-dimensional electromagnetic tracking device to quantify the movement of the DRUJ and verify the reliability and validity of the test. The intrarater and interrater intraclass correlation coefficients for DRUJ movement were 0.77 and 0.61, respectively, and the kappa coefficient for grading of DRUJ instability was 0.79. The correlation coefficient between DRUJ movement measured using the tracking device and instability judged clinically was 0.77. A comparison of healthy participants and the patients showed significantly greater DRUJ movement in the patients. The test showed substantial intrarater and interrater reliability for assessing DRUJ movement and instability. The significant positive correlation between DRUJ movement and instability indicates the concurrent validity of the test. Moreover, the test showed discriminative validity in identifying mild or moderate DRUJ instability. The DRUJ ballottement test using the holding technique has a relatively high diagnostic accuracy and can be used to assess DRUJ instability.

Validity and reliability of a new hip flexor muscles flexibility assessment tool: The reactive hip flexor (RHF) test

BackgroundThe modified Thomas test is the most used and most reliable test to assess the hip flexors’ flexibility. However it does not evaluate the interaction of both legs. The objective of this study is to propose a new assessment tool for hip flexor flexibility, the Reactive Hip Flexion (RHF) Test. MethodsAn observational, intra-test, and test-retest study with repeated measures was carried out with the aim of assessing the validity and reliability of the RHF Test. The participants were males and females aged between 18 and 35 years old who had a training schedule of at least 2 days a week, without a musculoskeletal lower limb or lumbopelvic pathology. The reliability of the test was examined using the intraclass correlation coefficients (ICCs) by a two-way random model to establish inter-rater reliability and a two-way mixed model to assess intra-rater reliability. The precision was measured by the standard error of measurement (SEM). In addition, the minimum detectable change (MDC95%) was calculated. ResultsTwenty-six participants (52 hips) (47% female) completed the study. No correlations were observed between anthropometric variables and RHF peak force or active knee extension (AKE) measurements. There was an excellent intra-rater and inter-rater ICC in the hip flexors’ reactive peak force and the AKE measurements, with a low SEM. ConclusionsThis study demonstrated that the proposed RHF test technique is valid and reliable when used in healthy youth population.

Adapting to a Robotic Era: The Transferability of Open and Laparoscopic Skills to Robotic Surgery

The learning curve of robotic surgical skills is poorly understood. There is a lack of data on the transferability of skills from open and laparoscopic training to robotic surgery. In this retrospective cohort study, we investigated the impact of training acquired during intern year on the development of robotic skills in general surgery residents, prior to formal robotic training. Between 2019 and 2021, novice general surgery residents underwent robotic skill assessment using 3 validated inanimate drills before starting intern year. After completing basic open and laparoscopic proficiency-based curricula, they completed an identical robotic skill assessment at the end of intern year. Pre and post intern year robotic performances were recorded and analyzed by 2 blinded graders. Video-based assessment included completion time, errors, and the modified Objective Structured Assessment of Technical Skills (mOSATS) score. The total time needed to complete all 3 robotic drills decreased from a mean of 26 to 17 minutes after intern year (p < 0.001). The number of errors decreased from a mean of 2.16 to 0.56 errors per subject (p < 0.001). The aggregated mOSATS score increased by an average of 41% (p < 0.001), with a greater increase in technical skill domains compared to the knowledge-based domain. The interrater intraclass correlation coefficient was 0.91. Baseline robotic surgical skills are limited without formal training. Our findings suggest that acquiring basic open and laparoscopic skills, such as knot tying, needle driving, and tissue handling results in improved performance on the robotic platform, prior to formal robotic training. Therefore, requiring trainees to complete fundamental open and laparoscopic training prior to robotic training may be an efficient and effective strategy within a surgical residency curriculum.

Reproducibility of subscapularis muscle thickness measurement using ultrasound imaging. -Relationship between subscapularis muscle thickness and internal rotation torque of the shoulder joint-

BackgroundFew studies have reported on the morphometry of the subscapularis muscle using ultrasound imaging (USI); and their reproducibility has not been verified. ObjectivesThis study aimed to clarify the relative and absolute reproducibility of USI measurements of subscapularis muscle thickness at rest and during isometric contraction as well as the degree of change in muscle thickness caused by the amount of internal rotational torque in the shoulder joint. DesignTwo-group repeated-measures study. MethodsThe subjects were the inferior fibers of the subscapularis muscle of 40 healthy adult males. Muscle thickness was measured at rest and at 10%–30% of the maximum isometric internal rotation torque. Intraclass correlation coefficients (ICC) and Brand Altman analysis were used for reproducibility measurement. The degree of change in muscle thickness at each torque was also calculated. ResultsIntra- and inter-rater ICCs (ranged from 0.69 to 0.91) were good. A proportional error was observed in intra-rater measurements. Both minimal detectable change 95 (ranged from 2.33 to 6.47) were high. The subscapularis muscle thickness was significantly increased at 10% torque (25.49 ± 3.80 mm), 20% torque (26.07 ± 3.90 mm), and 30% torque (25.96 ± 3.82 mm) as compared to that in resting conditions (24.53 ± 4.46 mm) (p < 0.05). ConclusionThe reproducibility and error of the subscapularis muscle thickness measurement using USI used in this study were clarified when repeated measurements were made in the same limb position and under the same probe installation conditions, suggesting that the contraction of the subscapularis muscle can be estimated by muscle thickness measurement.

Novel Validated Five-point Photonumeric Scales for Assessment of Static and Dynamic Forehead Lines.

The objective of this investigation was to create and validate five-point photonumeric scales which assess static and dynamic forehead lines. Two different novel five-point photonumeric scales for the assessment of static and dynamic forehead lines were developed. Moreover, a photoguide was created, including subjects from both sexes, all age groups, and different Fitzpatrick skin types. A total of 11 raters from all over the world were involved in the digital validation, whereas four raters performed a live validation. The Croma Static Forehead Lines-Assessment Scale showed almost perfect inter and intra-rater agreement in both the digital and the live setting with inter-rater intraclass correlation coefficients of 0.86 [95% confidence interval (CI): 0.82-0.89] in the first digital rating and 0.82 [95% CI: 0.78-0.86] in the second digital rating. The Croma Dynamic Forehead Lines-Assessment Scale showed almost perfect inter and intra-rater agreement in the digital setting with inter-rater intraclass correlation coefficients of 0.83 [95% CI: 0.79-0.86] in the first digital rating and 0.80 [95% CI: 0.75-0.84] in the second rating and almost substantial agreement in the live setting. The Croma Static Forehead Lines-Assessment Scale and the Croma Dynamic Forehead Lines-Assessment Scale have excellent inter and intra-rater agreements to be justifiably used in the clinical and study setting, both digitally and live across ethnic groups.

Feasibility of Cerebellar Measurements with Phased Array Sonography through the Anterior Fontanelle in Comparison to MRI.

Cerebral sonography (CS) through the anterior fontanelle is a neonatal brain imaging method that has become an integral part of modern neonatal bedside care for both screening and diagnostic purposes. Premature infants with cognitive delay have a reduction in cerebellar size at term corrected age on magnetic resonance imaging (MRI). We aimed to determine the level of agreement between postnatal MRI and CS for cerebellar biometry and to determine the level of agreement within one and between different examiners. Cerebellar sonography and MRI measurements of the cerebellum from 30 term infants was assessed by Bland-Altman plots. Measurements between both modalities were compared using Wilcoxon's signed rank test. A p-value < 0.01 was considered statistically significant. Intraclass correlation coefficients (ICC) for intra- and interrater reliabilities of CS measurements were calculated. There was no statistically significant difference between CS and MRI for linear measurements, but the measurements of perimeter and surface area differed significantly between the two techniques. There was a systematic bias between both modalities for most measurements except for anterior-posterior (AP) width and vermis height (VH). For measurements that were not statistically different from MRI, we found excellent intrarater ICC for the AP width, VH, and cerebellar width. The interrater ICC was excellent for the AP width and VH, but poor for the transverse cerebellar width. With a strict imaging protocol, cerebellar measurements of the AP width and the VH can be used as an alternative to MRI for diagnostic-screening purposes in a neonatal department where multiple clinicians perform bedside CS. · Abnormal cerebellar growth and injuries affect neurodevelopmental outcome.. · Cerebral sonography through the anterior fontanelle is used for bedside imaging.. · Postnatal sonographic cerebellar measurements are not validated against MRI.. · Measuring vermis height and anterior-posterior width are reliable.. · Measuring transverse cerebellar width through anterior fontanelle is unreliable..

A new alignment device for standardization of marker placement on the hindfoot

BackgroundFor multi-segment foot models, next to a (dorsal) heel marker, further markers are typically placed medially (MCL) and laterally (LCL) on the calcaneus. However, there is a lack of easily identifiable landmarks on the hindfoot limiting the repeatability of measurements. For a more consistent placement of these markers, an improved Hindfoot Alignment Device (HiAD) was developed. MethodsWith the HiAD, the position of the MCL and LCL can be individually scaled. Flexible bars allow the adaptation to foot deformities. Three rater placed markers with the HiAD four times on ten typical developed subjects (20 feet). Rigid segment residuals of the hindfoot were calculated and compared with the residuals when using the device of Simon et al. (2006) [12]. The variability of the placement of MCL, LCL and the clinical parameter medial arch were determined. For assessing the inter- and intra-rater reliability, intraclass correlation coefficient (ICC) and the standard error of measurement (SEM) were calculated. ResultsRigid segment residuals of the hindfoot could be reduced by 70 % by using the HiAD. Largest inter-rater variability in the MCL and LCL placement was found in z-direction with less than 3.2 ± 2.7 mm and 3.8 ± 2.8 mm, respectively. Correspondingly, largest intra-rater variability was 3.4 ± 2.3 mm for LCL and 2.4 ± 1.9 mm for MCL, respectively. Regarding reliability ICC showed good to excellent results for the medial arch (interrater ICC 0.471–0.811). SignificanceThe application of HiAD to place MCL and LCL appear to be a reliable method with robust marker positions and could be implemented in any multi segment foot model. However, further investigation would be helpful to determine the sensitivity of the marker positions in detecting hindfoot deformities.