Interobserver Kappa Research Articles

A Classification-System Improves the Intra- and Interobserver Reliability of Radiographic Diagnosis of “Pistol-Grip-Deformity”

Early detection of pistol-grip-deformity may be beneficial in optimising the outcome and the cost effectiveness of surgery. It is important to identify reliable radiographic parameters in assessing femoro-acetabular impingement (FAI) to develop a treatment algorithm. Radiographs of 47 patients ranging from "pistol grip deformity" to a normal head-neck-junction were measured for alpha angle and head ratio, and then classified by two different observers. The Bland-Altman plot was used for inter- and intraobserver agreement of alpha angle and head ratio. Inter- and intraobserver agreement for classification of "pistol grip deformity" was determined using weighted Cohen's kappa coefficient. Observer I achieved a kappa coefficient of 0.97. Observer II achieved a kappa coefficient of 0.92. An interobserver kappa coefficient between 0.87 and 0.92 was achieved by using a classification system. By testing for interobserver agreement, a bias of -0.004 with an upper limit of 0.461 and a lower limit of -0.47 was seen for the ratio and a bias of -3.7 with an upper limit of 17.2 and a lower limit of -24.6 for the alpha angle. Therefore, poor results were seen for intra- and interobserver reliability by using only a single plane for classification of "pistol grip deformity". The strength of agreement could be improved by using a classification system (based on two planes).

Preoperative MDCT Evaluation of Congenital Lung Anomalies in Children: Comparison of Axial, Multiplanar, and 3D Images

The objective of our study was to compare the preoperative diagnostic accuracy of axial, multiplanar, and 3D MDCT images for evaluating congenital lung anomalies in pediatric patients and to assess the potential added diagnostic value of multiplanar and 3D MDCT images in this setting. We used our hospital information system to identify all consecutive pediatric patients younger than 18 years who had undergone preoperative MDCT angiography and had a pathologically proven congenital lung anomaly between June 2005 and February 2010. Each MDCT examination was reviewed independently by two experienced pediatric radiologists for the types, location, associated mass effect, and associated anomalous vessels of congenital lung anomalies on axial, multiplanar, and 3D MDCT images. The final diagnosis was determined by surgical and pathologic findings. Diagnostic accuracy, confidence level of diagnosis (scale of 1-3: 1 = highest confidence and 3 = lowest), perceived added diagnostic value of multiplanar or 3D MDCT images (scale of 1-5: 5 = highest added diagnostic value and 1 = lowest), and interobserver kappa agreement were evaluated. The final study cohort consisted of 46 pediatric patients (28 males and 18 females; mean age, 5.6 ± 6 [SD] months; range, 1 day-50 months). Histopathologic diagnoses included congenital pulmonary airway malformation (n = 19, 41%), sequestration (n = 15, 33%), congenital lobar emphysema (n = 7, 15%), and bronchogenic cyst (n = 5, 11%). Both independent reviewers correctly diagnosed types, location, associated mass effect, and associated anomalous arteries of all congenital lung anomalies with high accuracy (100%) and confidence level (mean confidence level < 1.2) on each type of image display (axial, multiplanar, and 3D). However, for the detection of anomalous veins, multiplanar and 3D images were associated with greater diagnostic accuracy and higher confidence level than axial images alone. Specifically, diagnostic accuracy for the detection of anomalous veins (n = 15; 33%) was 60% (9/15 cases) for axial MDCT images, 80% (12/15) for multiplanar MDCT images, and 100% (15/15) for 3D MDCT images (Friedman test, p = 0.011). Confidence levels for the detection of anomalous veins were significantly higher with 3D MDCT images (mean level = 1.0) and multiplanar MDCT images (mean level = 1.5) compared with axial MDCT images alone (mean level = 2.6) (Friedman test, p < 0.01). Both multiplanar and 3D MDCT images were found to provide added diagnostic value for accurately detecting anomalous veins associated with congenial lung anomalies (paired Student t tests, p < 0.012). Axial MDCT images allow accurate diagnosis of the types, location, associated mass effect, and anomalous arteries of congenital lung anomalies, but supplemental multiplanar and 3D MDCT images add diagnostic value for the evaluation of congenital lung lesions associated with anomalous veins.

Hepatocellular adenomas: Accuracy of magnetic resonance imaging and liver biopsy in subtype classification

Hepatocellular adenomas (HCAs) are divided into genotype/phenotype subgroups associated with different evolutive profiles. Therefore, recognition of subtype is of clinical importance in patient management. Magnetic resonance imaging (MRI) is considered the most informative imaging modality and liver biopsy a key diagnostic tool whose role in HCA subtyping has never been extensively studied. The purpose of our study was to evaluate the diagnostic performance of MRI and liver biopsy with and without immunohistochemistry and to assess the interobserver agreement for MR classification in a consecutive series of resected HCAs. Forty-seven HCAs with preoperative MRI and biopsy were retrospectively included. MRI data were reviewed independently by two abdominal radiologists blind to the pathological results and classification. Subtyping of HCAs on liver biopsy was made blindly to clinical, biological, and imaging data and to final classification. Routine histological analysis was based on morphological criteria and immunohistochemistry was systematically performed when enough tissue was available. Final subtyping of HCA was based on the examination of the surgical specimen. Radiologists correctly classified HCAs in 85%. The interobserver kappa correlation coefficient was 0.86. Routine histological analysis led to 76.6% of correct classification and 81.6% when immunophenotypical characteristics were available. The additional value of immunophenotypical markers is best in HCAs containing steatosis. Agreement between MRI findings and routine histological analysis was observed in 74.5%, leading to a likelihood ratio of subtype diagnosis higher than 20. MRI and biopsy analysis are two efficient methods in subtyping HCAs and their association increases the diagnosis confidence. Interobserver variability in MRI criteria is very low.

Implantable Cardioverter Defibrillator Electrogram Adjudication for Device Registries: Methodology and Observations from ALTITUDE

The increasing use of remote monitoring with the associated large retrievable databases provides a unique opportunity to analyze observations on implantable cardioverter-defibrillator (ICD) therapies. Adjudication of a large number of stored ICD electrograms (EGMs) presents a unique challenge. The ALTITUDE study group was designed to use the LATITUDE remote monitoring system to evaluate ICD patient outcomes across the United States. Of 81,081 patients on remote monitoring, a random sample of 2,000 patients having 5,279 shock episodes was selected. The ALTITUDE EGM review committee was comprised of seven electrophysiologists from four institutions. An online EGM adjudication system was designed. Episodes were classified as appropriate (70% of shock episodes) or inappropriate ICD therapies (30%). Light's Kappa was used to assess agreement. Interobserver and intraobserver Kappa scores for dual-chamber ICDs were 0.84 (0.71-0.91) and 0.89 (0.82-0.95), consistent with substantial agreement. Interobserver and intraobserver Kappa scores for single-chamber ICDs were 0.61 (0.54-0.67) and 0.69 (0.59-0.79). The rhythm categories of "nonsustained arrhythmia" and "polymorphic and monomorphic ventricular tachycardia" resulted in the greatest degree of discordant adjudication between reviewers. This method of adjudication of a large volume of stored EGM data prior to device therapies will allow new observations in regards to device performance and has the potential to improve device programming and design. There was substantial interreviewer agreement for rhythm classification. Agreement was greater for dual-chamber compared to single-chamber devices, indicating the atrial lead adds diagnostic value in rhythm interpretation.

Apport de deux techniques d’analyse automatisées des examens [ 18F] FDG TEP dans la discrimination des patients déments frontotemporaux et malades d’Alzheimer

Introduction In younger patients, the in vivo clinical diagnosis of Alzheimer's disease (AD) and of the frontotemporal type (FTD) may be cumbersome. The gold standard diagnostic proof is currently still based upon pathology examination. It is crucial to find reliable techniques to make an accurate in vivo diagnosis and to differentiate the etiology of the dementia. Patients and method Twenty-four patients bearing clinically diagnosed AD ( n = 16) and FTD ( n = 8) underwent [ 18F] FDG-PET/CT brain scan. Four nuclear medicine physicians with varying expertise in neuroimaging read each scan according to: visual analysis; automated analysis computed by BRASS ® Hermes ® software; automated analysis computed by Cortex ID ® General Electric ® software. Interpretation aimed at assessing the global scan aspect, the cerebral metabolism per hemisphere (in five relevant regions) and the diagnostic degree of confidence. Diagnostic interpretations derived from visual and automated analyses were compared to clinical diagnosis. Inter-observer agreement and Kappa scores were calculated. Results Kappa analyses showed a gain in diagnostic accuracy for a nonexpert physician, a gain in diagnostic confidence with Cortex ID ® and a gain in interobserver diagnostic agreement with BRASS ®. Conclusion Using automated software such as Cortex ID ® or BRASS ® helps standardizing the interpretation of [ 18F] FDG distribution pattern in AD or FTD.

Observer Ability to Detect Ex Vivo Simulated Internal or External Cervical Root Resorption

Introduction The objective of this study was to assess observer ability to detect ex vivo simulated internal and external cervical root resorption. Methods A total of 90 single-rooted mandibular anterior teeth were split along the coronal plane. By using a 0.5-mm diameter round bur, 50 of the teeth were drilled to simulate resorptive cavities (25 internal and 25 external cervical resorption), and the remaining 40 teeth were left without surface defects. The sectioned teeth were rejoined and placed in the alveolar sockets of a dry human mandible in groups of 6 and imaged with intraoral film by using 3 different angulations and with a cone-beam computed tomography (CBCT) unit. Film and CBCT image sets were evaluated twice by 3 separate observers. Teeth were scored for the presence and location of resorption by using a 5-point scale. Intraobserver and interobserver kappa coefficients and Az values were calculated for each observer and image set. Differences between modalities were compared by using z statistics, with the significance level set at α = 0.05. Results Both intraobserver and interobserver agreements were statistically higher ( p < .05) for the Iluma CBCT images than for the intraoral images. Az values for CBCT images were also statistically higher ( p < .05) than for film images for all observers and readings. In addition, kappa and Az values of external cervical resorption cavities were statistically higher ( p < .05) than those of internal cervical resorption cavities for all observers, image types, and readings. Conclusions High-resolution Iluma CBCT images performed better than film in the ex vivo detection and localization of simulated internal and external cervical root resorption.

Intra- and inter-observer agreement when using a descriptive classification scale for clinical assessment of faecal consistency in growing pigs

The objective of the current study was to evaluate intra- and inter-observer agreement using a descriptive classification scale with four categories, descriptive text and pictures for assessment of consistency in faecal samples from pigs post weaning. The four consistency categories were score one = firm and shaped, score two = soft and shaped, score three = loose and score four = watery. Five observers from the same veterinary practice examined 100 faecal samples using the scale with four categories. Four of the observers examined the 100 faecal samples twice within the same day. Within observers the difference in proportions for the individual consistency categories between two examinations was on average 0.04 (range: 0–0.10). The mean intra-observer agreement was 0.82 (range: 0.72–0.91) with a mean kappa value of 0.76 (range: 0.61–0.88). For inter-observer agreement overall kappa was 0.64. For the 10 pair-wise comparisons the mean inter-observer agreement was 0.73 (range: 0.61–0.90) with a mean kappa value of 0.64 (range: 0.48–0.87). The difference in proportions for the individual consistency categories was on average 0.08 (range: 0–0.17). In conclusion, the agreement observed for the descriptive classification scale with four categories, descriptive text and pictures may be categorized as a substantial to almost perfect intra-observer agreement and a moderate to almost perfect inter-observer agreement. However, more objective measures than clinical scales may still be needed to improve intra- and inter-observer agreement in research studies.

Agreement and Accuracy of Non-Expert Ophthalmologists in Assessing Glaucomatous Changes in Serial Stereo Optic Disc Photographs

To compare the interobserver agreement in detecting glaucomatous optic disc changes using serial stereophotography between a large group of non-expert ophthalmologists and glaucoma specialists; to assess the accuracy of non-experts; to investigate whether the interobserver agreement and the accuracy of non-experts changed after a training session. Masked interobserver agreement study. Serial optic disc stereophotos from 40 patients with glaucoma. Three independent experienced glaucoma specialists (readers of the European Glaucoma Prevention Study) evaluated a set of 2 serial optic disc color stereo-slides for glaucomatous change, obtained with a delay varying from 2 to 7 years of 40 patients, masked from the temporal sequence of the slides. Each patient was graded as changed or stable by agreement of 2 of 3 of the experts (the reference standard). Thirty-seven non-expert ophthalmologists independently evaluated the same set of serial optic disc stereo-slides twice, with the second evaluation on the same day, masked from the results of the previous evaluation, after a training session on a separate slide set. Interobserver agreement of non-experts and experts in detecting glaucomatous optic disc changes (expressed as kappa coefficient); agreement of non-experts with the reference standard (accuracy) before and after a training session. The interobserver kappa coefficient (κ) of the non-experts and experts was 0.20 (95% confidence interval [CI], 0.19-0.21) and 0.51 (95% CI, 0.33-0.69), respectively (P<0.0001). The mean κ of the non-experts with the reference standard was 0.33 (95% CI, 0.27-0.39). After a training session, the interobserver agreement of the non-experts increased from 0.20 to 0.27 (95% CI, 0.26-0.28) (P<0.0001). The percentage agreement of the non-experts with the reference standard improved from 68.5% before to 71.4% after the training session (Wilcoxon signed-rank test, P=0.034). The interobserver agreement of non-expert ophthalmologists in detecting glaucomatous optic disc changes using serial stereophotos was significantly lower than that of experts, which was moderate. After a training session, the interobserver agreement and the accuracy of the non-experts showed a small but statistically significant improvement.

Achieving High Research Reporting Quality Through the Use of Computational Ontologies

Systematic reviews and meta-analyses constitute one of the central pillars of evidence-based medicine. However, clinical trials are poorly reported which delays meta-analyses and consequently the translation of clinical research findings to clinical practice. We propose a Center of Excellence in Research Reporting in Neurosurgery (CERR-N) and the creation of a clinically significant computational ontology to encode Randomized Controlled Trials (RCT) studies in neurosurgery. A 128 element strong computational ontology was derived from the Trial Bank ontology by omitting classes which were not required to perform meta-analysis. Three researchers from our team tagged five randomly selected RCT's each, published in the last 5 years (2004-2008), in the Journal of Neurosurgery (JoN), Neurosurgery Journal (NJ) and Journal of Neurotrauma (JoNT). We evaluated inter and intra observer reliability for the ontology using percent agreement and kappa coefficient. The inter-observer agreement was 76.4%, 75.97% and 74.9% and intra-observer agreement was 89.8%, 80.8% and 86.56% for JoN, NJ and JoNT respectively. The inter-observer kappa coefficient was 0.60, 0.54 and 0.53 and the intra-observer kappa coefficient was 0.79, 0.82 and 0.79 for JoN, NJ and JoNT journals respectively. The high degree of inter and intra-observer agreement confirms tagging consistency in sections of a given scientific manuscript. Standardizing reporting for neurosurgery articles can be reliably achieved through the integration of a computational ontology within the context of a CERR-N. This approach holds potential for the overall improvement in the quality of reporting of RCTs in neurosurgery, ultimately streamlining the translation of clinical research findings to improvement in patient care.

The inter-observer reliability is very low at clinical examination of parastomal hernia

Parastomal hernia in patients with a permanent colostomy is common. The aim of this study was to evaluate the reliability of the diagnosis based on clinical examination and to compare this examination with the result of a specially designed questionnaire and computerised tomography (CT) scan. Forty-one patients operated upon with an abdominoperineal resection due to rectal cancer at three hospitals between 1996 and 2002 were included. At minimum of 4 years after the operation, they underwent clinical examination by two or three independent surgeons, answered a colostomy questionnaire and were offered a CT scan of the abdominal wall. At Hospital I, 17 patients were examined by three surgeons, with inter-observer kappa values between 0.35 and 0.64. At Hospital II, 13 patients were examined by three surgeons, the kappa values ranged between 0.29 and 0.43. At Hospital III, 11 patients were examined by two surgeons, with kappa value of 0.73. The kappa value between CT scan and the colostomy questionnaire was 0.45. The inter-observer reliability was low, indicating that parastomal hernia is difficult to diagnose by patient history and clinical examination. Some herniae may not be detected by CT scan, and the correlation to patient-reported complaints is low. A more sensitive radiological method to detect parastomal hernia is needed.

Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard

To assess the intra- and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard. Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI. The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant. Overall agreements between gray-scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.

The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis

ObjectiveThe optimal MRI scan planes of collateral ligaments of the ankle have been described extensively, with the exception of the syndesmotic ligaments. We assessed the optimal scan plane for depicting the distal tibiofibular syndesmosis.Materials and MethodsIn order to determine the optimal oblique caudal-cranial and lateral-medial MRI scan plane, two fresh frozen cadaveric ankles were used. The angle of the scan plane that demonstrated the anterior and posterior distal tibiofibular ligament uninterrupted in their full length was determined. In a prospective study this oblique scan plane was then used in addition to the axial and coronal planes, for MRI scans of both ankles in 21 healthy volunteers. Two observers independently evaluated the anterior tibiofibular ligament (ATIFL) and posterior tibiofibular ligament (PTIFL) regarding the continuity of the individual fascicles, thickness and wavy contour of the ligaments in both the axial and the oblique plane. Kappa was calculated to determine the interobserver agreement. McNemar’s test was used to statistically quantify the significance of the two scan planes.ResultsIn the axial plane the ATIFL was in 31% (13/42) partly and in 69% (29/42) completely discontinuous; in the oblique plane the ATIFL was continuous in 88% (37/42) and partly discontinuous in 12% (5/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p < 0.001), but not significantly less thickening (p = 1.00) or less wavy contour (p = 0.06) of the ATIFL. In the axial scan plane the PTIFL was continuous in 76% (32/42), partially discontinuous in 19% (8/42) and completely discontinuous in 5% (2/42); in the oblique plane the PTIFL was continuous in 100% (42/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p = 0.002), but not significantly less thickening (p = 1.00) or less wavy contour (p = 0.50) of the PTIFL. The interobserver agreement score and kappa (κ) regarding the continuity for the ATIFL in the axial and oblique planes was 91% (κ = 0.79) and 91% (κ = 0.55) respectively; for the PTIFL it was 86% (κ = 0.65) and 100% (κ = not defined).ConclusionThe ATIFL and PTIFL are routinuely scanned in the orthogonal planes. The advantage of MRI scanning in an oblique image plane of about 45 degrees permits a better evaluation of the ligaments compared with the axial plane, particularly a better interpretation of ligament continuity, thickening and wavy contour. This may lead to a reduction in false-positive results, especially regarding partial or complete ligament ruptures. This can be of considerable aid in therapeutic management.Electronic supplementary materialThe online version of this article (doi:10.1007/s00256-010-0938-9) contains supplementary material, which is available to authorized users

Examination of musculoskeletal chest pain—An inter-observer reliability study

Background and purpose The musculoskeletal system is recognized as a possible source of pain in patients with chest pain. The objectives of the present study were (1) to investigate the interobserver reliability of an overall diagnosis of musculoskeletal chest pain using a standardized examination protocol in a cohort of patients with chest pain suspected to be of non-cardiac origin, (2) to investigate the interobserver reliability of the single components of the protocol, and finally, (3) to investigate the importance of clinical experience on the level of interobserver reliability. Methods and results Eighty patients with acute chest pain were recruited from a cardiology department. Four observers (two chiropractors and two chiropractic students) performed a physical examination and an extended manual examination of the spine and chest wall. Percentage agreement, Cohen9s Kappa and ICC were calculated for observer pairs and overall. Musculoskeletal chest pain was diagnosed in 44.0 % of patients. Interobserver kappa values were substantial for the chiropractors and overall, and moderate for the students. For single items of the protocol, both pairs showed fair to substantial agreement regarding pain provocation tests and poor to fair agreement regarding spinal segmental dysfunction tests. Conclusions Suspected musculoskeletal chest pain can be identified with substantial interobserver reliability using this standardized protocol if used by experienced and trained observers. Agreement for individual components of the protocol showed, however, considerable variation. Provided training of observers, the examination protocol can be used in selected patients and can be implemented in pre- and post-graduate clinical training.

A specific scoliosis classification correlating with brace treatment: description and reliability

BackgroundSpinal classification systems for scoliosis which were developed to correlate with surgical treatment historically have been used in brace treatment as well. Previously, there had not been a scoliosis classification system developed specifically to correlate with brace design and treatment. The purpose of this study is to show the intra- and inter- observer reliability of a new scoliosis classification system correlating with brace treatment.MethodsAn original classification system ("Rigo Classification") was developed in order to define specific principles of correction required for efficacious brace design and fabrication. The classification includes radiological as well as clinical criteria. The radiological criteria are utilized to differentiate five basic types of curvatures including: (I) imbalanced thoracic (or three curves pattern), (II) true double (or four curve pattern), (III) balanced thoracic and false double (non 3 non 4), (IV) single lumbar and (V) single thoracolumbar. In addition to the radiological criteria, the Rigo Classification incorporates the curve pattern according to SRS terminology, the balance/imbalance at the transitional point, and L4-5 counter-tilting. To test the intra-and inter-observer reliability of the Rigo Classification, three observers (1 MD, 1 PT and 1 CPO) measured (and one of them, the MD, re-measured) 51 AP radiographs including all curvature types.ResultsThe intra-observer Kappa value was 0.87 (acceptance >0.70). The inter-observer Kappa values fluctuated from 0.61 to 0.81 with an average of 0.71 (acceptance > 0.70).ConclusionsA specific scoliosis classification which correlates with brace treatment has been proposed with an acceptable intra-and inter-observer reliability.

The effects of digital image enhancement on the detection of vertical root fracture

To determine the effects of digital image enhancement on observer ability to detect experimentally induced vertical root fractures (VRF). A total of 64 extracted human mandibular premolar teeth were used in this study. In 32 teeth, VRFs were created in the bucco-lingual planes by gently tapping with screw-type root-canal pins. The remaining 32 intact teeth served as a control group. Digital images were obtained using a charge coupled device sensor. Three observers separately examined the original and four types of digitally enhanced images (enhanced using sharpness, zoom-in, reverse-contrast, and pseudo-3D functions) at 1-week intervals. All teeth were evaluated using a 5-point scale for the presence/absence of VRF. Evaluations of each image set were repeated 1 month after the initial viewings. Kappa coefficients were calculated to investigate the degree of intra- and inter-observer agreement. The areas under the receiver operating characteristic (ROC) curves (Az values) were calculated using the MedCalc statistical software. ROC values for each image type, observer and viewing were compared using t-tests. A level of alpha = 0.05 was considered significant. Kappa coefficients for intra-observer agreement ranged from 0.304 to 0.679. Inter-observer agreement kappa values ranged from 0.109 to 0.399 for the first reading and from 0.106 to 0.380 for the second reading. Statistical comparisons between Az values for each observer showed no significant differences (P > 0.05) among image types. There were no differences in diagnostic outcomes among differently enhanced images in the in vitro detection of VRF.

Examination of musculoskeletal chest pain – An inter-observer reliability study

Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis ‘musculoskeletal chest pain’ in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.

Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction

Bone tunnel widening poses a problem for graft fixation during revision anterior cruciate ligament (ACL) reconstruction. Large variability exists in the utilization of imaging modalities for evaluating bone tunnels in pre-operative planning for revision ACL reconstruction. The purpose of this study was to identify the most reliable imaging modality for identifying bone tunnels and assessing tunnel widening, and specifically, to validate the reliability of radiographs, MRI, and CT using intra- and inter-observer testing. Data was retrospectively collected from twelve patients presenting for revision ACL surgery. Five observers twice measured femoral and tibial tunnels at their widest point using digital calipers in coronal and sagittal planes. Measurements were corrected for magnification. Tunnel identification, diameter measurements, and cross-sectional area (CSA) calculations were recorded. A categorical classification of tunnel measurements was created to apply clinical significance to the measurements. Using kappa statistics, intra- and inter-observer reliability testing was performed. CT demonstrated excellent intra- and inter-observer reliability for tunnel identification. Intra- and inter-observer reliability was significantly less for MRI and radiographs. CT revealed superior reliability versus either radiographs or MRI for CSA analysis. Intra-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.66, 0.5, and 0.37, respectively. Inter-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.65, 0.39, and 0.32, respectively. Our results demonstrate CT is the most reliable imaging modality for evaluation of ACL bone tunnels as proven by superior intra- and inter-observer testing results when compared to MRI and radiographs. Radiographs and MRI were not reliable, even for simply identifying the presence of a bone tunnel.

Intraobserver and Interobserver Variability of Fuhrman and Modified Fuhrman Grading Systems for Conventional Renal Cell Carcinoma

The Fuhrman nuclear grade is the most widely used grading system for renal cell carcinoma. The aim of this study was to evaluate the intraobserver and interobserver variability of the Fuhrman and modified Fuhrman grading systems for conventional renal cell carcinoma. In this study, five pathologists independently classified 110 cases of conventional renal cell carcinoma according to the Fuhrman and modified (three- and two-tiered) Fuhrman grading systems. The intraobserver and interobserver variability of these systems were assessed using kappa statistics. The associations between the Fuhrman and modified Fuhrman grades, pathologic stage and tumor size were determined by correlation analysis. The intraobserver and interobserver combined mean kappa values for four-tiered Fuhrman grading were 0.48 and 0.41, respectively. The highest agreement was detected in two-tiered modification (including grades 1 + 2 and 3 + 4); the intraobserver and interobserver combined mean kappa values were 0.67 and 0.62, respectively. Correlations between pathologic stage and tumor size with two-tiered modification (including grades 1 + 2 and 3 + 4) were greater than those in three- and four-tiered Fuhrman grading. Collapsing the Fuhrman grading into a two-tiered scheme improved the intraobserver and interobserver reproducibility.

Reliability of Real-Time Ultrasound to Detect Pelvic Floor Muscle Contraction in Urinary Incontinent Women

We determined the reliability of real-time ultrasound for detecting involuntary or reflex pelvic floor muscle contraction. A total of 118 women with the symptomatic and urodynamic evidence of stress urinary incontinence were recruited in a 3-year period from tertiary referral urogynecology clinics. Under the oral instruction of strong coughing involuntary pelvic floor muscle contraction was detected using introital ultrasound in real-time and cine loop modes. Two dynamic imaging features were considered involuntary pelvic floor muscle contraction, including an inward clitoral motion and a superior-anterior anorectal lift before or during coughing. Real-time ultrasound had good reliability to detect involuntary pelvic floor muscle contraction. For interobserver and intra-observer reliability Cohen's kappa was 0.645 to 0.679. Of the 118 women real-time ultrasound before or during coughing showed an inward clitoral motion in 100 (93%) and an anorectal lift in 108 (92%). Neither type of contraction during coughing was identified in 2 women. Although the 2 contraction patterns were synchronized in 88% of women, for this synchronization kappa was only 0.159, indicating poor coordination between these 2 involuntary activities. Real-time ultrasound is a reliable tool for detecting involuntary pelvic floor muscle contraction.

Concordancia entre observadores con distinta experiencia en interpretación de electrocardiograma de esfuerzo en SPECT de perfusión miocárdica

Coronary artery disease (CAD) is the leading cause of death in many countries. Stress electrocardiogram (ECG) is able to detect myocardial ischemia and also has prognostic value, which may be impaired in presence of electrical baseline abnormalities. Stress myocardial single photon emission tomography (SPECT) has recognized utility yield in assessment of CAD, requiring independent interpretation of ECG and myocardial images. Purpose To analyze stress ECG interpretation reproducibility among observers with different training level, including pre- and post-graduate medical students, compared to an experienced cardiologist and also with SPECT. Method We studied 95 patients under CAD evaluation, mean age 61±9.3 years (range: 42–85), 56% male. Interobserver correlation kappa (k) between perfusion gated 99mTc-Sestamibi SPECT and exercise ECG were calculated as normal/abnormal, presence of necrosis, ischemia or mixed pattern. Interobserver kappa (k) analysis was made. Results 49.5% stress ECG and 45% SPECT studies were abnormal at the initial report with 62.1% concordance (k: 0.24) for normal/abnormal and 58.9% for ischemia (k: 0.14). Agreement between stress ECG initial report and independent cardiologist was 89.5% (k: 0.78). The correlation between independent observers and the initial report ranged between 62.1% and 48.4%, for baseline ECG between 41.1% and 90.5% considering normal/abnormal, and between 80% and 93.7% (k: 0.59–0.87) for the presence of ischemia. Conclusion Stress ECG interpretation presented adequate interobserver reproducibility with greater agreement in the most experienced observers, confirming the importance of training.