Intraclass Correlation Coefficient Model Research Articles

Intra- and Inter-rater Reliability of the Lumbar-Locked Thoracic Rotation Test in Patients With Neck Pain.

Neck pain is a common musculoskeletal disorder. Therefore, establishing effective physical therapy for neck pain is one of the most important issues. In addition, in physical therapy for neck pain, it is important to evaluate the thoracic spine, which is an adjacent region of the neck. The lumbar-locked rotation test is designed to evaluate the rotational range of the thoracic spine. However, the reliability of the test when performed on patients with neck pain has not been confirmed. We aimed to determine the intra- and inter-rater reliability of the lumbar-locked rotation test in patients with neck pain. In this study involving 43 patients, two separate examiners measured thoracic spine rotation. Both examiners conducted three measurements for each side, before and after a five-minute interval. Reliability was assessed using various intra-class correlation coefficient (ICC) models. The intra-rater reliability showed ICC values of 0.99 for both examiners. The inter-rater reliability showed ICC values of 0.98 for both right and left thoracic rotations. The findings strongly suggest that the lumbar-locked rotation test has high within-session intra- and inter-rater reliability for patients with neck pain. This test can be considered a reliable method of measuring the thoracic spine rotational range of motion in patients with neck pain in clinical practice.

Development and Validation of a Formative Assessment Tool for Nephrology Fellows' Clinical Reasoning.

Diagnostic errors are commonly driven by failures in clinical reasoning. Deficits in clinical reasoning are common among graduate medical learners, including nephrology fellows. We created and validated an instrument to assess clinical reasoning in a national cohort of nephrology fellows and established performance thresholds for remedial coaching. Experts in nephrology education and clinical reasoning remediation designed an instrument to measure clinical reasoning through a written patient encounter note from a web-based, simulated AKI consult. The instrument measured clinical reasoning in three domains: problem representation, differential diagnosis with justification, and diagnostic plan with justification. Inter-rater reliability was established in a pilot cohort ( n =7 raters) of first-year nephrology fellows using a two-way random effects agreement intraclass correlation coefficient model. The instrument was then administered to a larger cohort of first-year fellows to establish performance standards for coaching using the Hofstee method ( n =6 raters). In the pilot cohort, there were 15 fellows from four training program, and in the study cohort, there were 61 fellows from 20 training programs. The intraclass correlation coefficients for problem representation, differential diagnosis, and diagnostic plan were 0.90, 0.70, and 0.50, respectively. Passing thresholds (% total points) in problem representation, differential diagnosis, and diagnostic plan were 59%, 57%, and 62%, respectively. Fifty-nine percent ( n =36) met the threshold for remedial coaching in at least one domain. We provide validity evidence for a simulated AKI consult for formative assessment of clinical reasoning in nephrology fellows. Most fellows met criteria for coaching in at least one of three reasoning domains, demonstrating a need for learner assessment and instruction in clinical reasoning.

Using MRI Radiomics to Predict the Efficacy of Immunotherapy for Brain Metastasis in Patients with Small Cell Lung Cancer

Immune-checkpoint inhibitors (ICIs) combined with chemotherapy has been widely used in the first-line treatment of small cell lung cancer (SCLC) patients. However, the efficacy of ICIs for patients with brain metastases (BMs) of SCLC is limited. There are no effective factors to predict the efficacy. We developed and validate a model to predict intracranial efficacy for ICIs in patients with BMs from SCLC by using MRI radiomics. In this study, we collected 101 SCLC patients with BMs treated with ICIs. They clinical characteristics and pre-treatment Magnetic Resonance Imaging (MRI) were collected. Seventy cases collected from our hospital as training cohort and 31 cases collected from another hospital as an independent validation cohort. Brain metastatic lesions were contoured on ITK-SNAP software and 3748 radiomic features capturing both intra- and peritumoral texture patterns were extracted. The primary endpoint of this study was intracranial overall response rate (ORR). Intraclass correlation coefficient (ICC) and random forest (RF) model were used to select radiomic features. The top 10 selected radiomic features were adopted to build prognostic models by using logistic regression. Area Under the Curve (AUC) of the Receiver Operating Characteristic (ROC) was chosen as the metric to assess model performances. We also performed a nomogram based on a multivariate logistic regression model includes radiomic and clinical features to predict ICIs intracranial efficacy. The clinical characteristics including number of treatment lines and concurrent brain radiotherapy, ten intratumoral signatures and one peritumoral signatures were found significantly associated with ICIs intracranial efficacy. Predictors contained in the individualized prediction nomogram included the radiomics signature, and clinical features. The model showed favorable discrimination with a C-index of 0.861[95% CI: 0.779-0.943] and AUC of 0.861[95% CI: 0.778- 0.944] in training cohort and with a C-index of 0.812[95% CI: 0.647-0.978] and AUC of 0.812[95% CI:0.646-0.979] in the test cohort. Radiomic features from pre-treatment MRI images were predictive for intracranial efficacy in SCLC patients with BMs. Pre-treatment radiomics may allow early prediction of benefit and expedite more aggressive treatment for high-risk patients and it has to be further explored as predictor of outcome in a larger series of patients.

Reliability and validity testing of the ASSIST functional performance index

ABSTRACT Reliability and validity testing of the ASSIST Functional Performance Index (AFPI) was conducted, focusing on persons with physical disabilities (PwPD). The AFPI was iteratively developed to assess persons’ needs for Mainstream Smart Home Technologies (MSHT) as Assistive Technology (AT) and to measure the impact of a service delivery model for MSHT. The AFPI consists of 46 items organized by functional domains. A total of N = 22 PwPD completed the AFPI twice. The median response time between these two time points was four days. Test-retest reliability of overall scores was assessed using the Intraclass Correlation Coefficient model (ICC, 3.1). The weighted kappa coefficient was applied to conduct an item analysis, demonstrating moderate to substantial agreement in all but one of the items. During the second administration, validity was established by correlating the number of hours of assistance and total AFPI scores with the SCI-FI Self-Care and Basic Mobility Short Form Questionnaires. Results indicate that the AFPI demonstrates good to very good validity as an assessment tool and outcome measure in recommending and evaluating the impact of MSHT for PwPD. Future studies, including more participants and persons with cognitive and sensory disabilities, may further establish the clinical utility of the AFPI.

Reliability of sonographic measurements of the ulnar collateral ligament: a multi-rater prospective study.

The use of sonography is a cost-effective and reliable method to evaluate upper extremity superficial tissue structural integrity and pathology. Establishing the measurement reliability of widely used diagnostic ultrasound evaluation for musculoskeletal assessment is paramount enhance accurate clinical evaluations. The objective of this study was to establish the inter-rater and intra-rater reliability of select ulnar collateral ligament (UCL) thickness measures at two distinct anatomical locations in intercollegiate baseball athletes using ultrasound imaging (USI). This was a prospective cohort study conducted in a university research laboratory and included a total of 17 NCAA Division I baseball athletes (age 20.4 ± 1.43, height = 183.63 cm ± 6.27 cm, mass = 89.28 kg ± 8.24 kg). Two trained clinicians measured UCL mid-substance and apex thickness in the throwing extremity, prospectively, on 5 occasions at 1-month intervals during rest. Intraclass correlation coefficients (ICCs) (model 3,3), associated standard error of measurement, and 95% minimal detectable change in thickness were derived. Intrarater reliability estimates for operator 1 were 0.90-0.98 (mid-substance) and 0.91-0.99 (apex). Operator 2's values were 0.92-0.97 and 0.93-0.99, respectively. The standard error of measurement (SEM) ranged from 0.045-0.071 cm (mid-substance) and 0.023-0.067 cm (apex). The minimal detectable difference (MDD95) was 0.12-0.20 cm (mid-substance) and 0.07-0.19 cm (apex). Interrater reliability was 0.86-0.96 (mid-substance) and 0.79-0.98 (apex); most ICCs were >0.90. Measurement of UCL thickness at two locations demonstrated very good to excellent reliability with high precision. Using this protocol, two evaluators can obtain consistent UCL measurement at two positions. This finding has significant implications for the clinical evaluation of superficial tissue pathology of the same individual by two experienced practitioners.

Homogeneity Test of Many-to-One Relative Risk Ratios in Unilateral and Bilateral Data with Multiple Groups

In medical clinical studies, we often encounter paired organs’ unilateral or bilateral data. For bilateral data, there exists an intraclass correlation between paired organs. Under an intraclass correlation model, this paper proposes asymptotic statistics for testing the equality of many-to-one relative risk ratios in combined unilateral and bilateral data. Furthermore, we calculate the explicit expressions of these statistics. Moreover, these procedures are adequate to solve the hypothesis problems of unilateral or bilateral data. Through comparison, the simulation results show that the score test has a robust empirical type-I error rate and sufficient power. We provide a clinical trial of acute otitis media to illustrate our proposed methods.

Validity, Intra-Rater Reliability and Normative Data of the Neuroflexor™ Device to Measure Spasticity of the Ankle Plantar Flexors after Stroke.

Quantification of lower limb spasticity after stroke and the differentiation of neural from passive muscle resistance remain key clinical challenges. The aim of this study was to validate the novel NeuroFlexor foot module, to assess the intrarater reliability of measurements and to identify normative cut-off values. Fifteen patients with chronic stroke with clinical history of spasticity and 18 healthy subjects were examined with the NeuroFlexor foot module at controlled velocities. Elastic, viscous and neural components of passive dorsiflexion resistance were quantified (in Newton, N). The neural component, reflecting stretch reflex mediated resistance, was validated against electromyography activity. A test-retest design with a 2-way random effects model permitted study of intra-rater reliability. Finally, data from 73 healthy subjects were used to establish cutoff values according to mean + 3 standard deviations and receiver operating characteristic curve analysis. The neural component was higher in stroke patients, increased with stretch velocity and correlated with electromyography amplitude. Reliability was high for the neural component (intraclass correlation coefficient model 2.1 (ICC2,1) ≥ 0.903) and good for the elastic component (ICC2,1 ≥ 0.898). Cutoff values were identified, and all patients with neural component above the limit presented pathological electromyography amplitude (area under the curve (AUC) = 1.00, sensitivity = 100%, specificity = 100%). The NeuroFlexor may offer a clinically feasible and non-invasive way to objectively quantify lower limb spasticity.

Can Patients Accurately Recall their Preoperative Pain and Functional Scores Following Rotator Cuff Repair and Total Shoulder Arthroplasty?

Accurate analysis of preoperative shoulder pain and function is important for understanding treatment efficacy and producing high-quality research. Oftentimes, preoperative patient-reported outcomes (PROs) are missing. Therefore the accuracy of recalled preoperative PROs may be important. We investigate the ability of patients who underwent rotator cuff repair (RCR) or shoulder arthroplasty (TSA) to recall their preoperative PROs. We identified 145 patients who underwent either RCR or TSA and had preoperative PROs. All patients completed the ASES, SANE, SST, and VAS surveys within 3 months prior to surgery. Patients were contacted between one and four years after surgery and asked to recall their baseline pain and shoulder function prior to surgery. The mean difference was calculated by determining the difference between the mean recalled score and the mean actual score. Intraobserver reliability analysis was performed, comparing recall and actual score for each using the 2-way mixed-effects intraclass correlation coefficient (ICC) model. The ICC values > 0.75 were considered excellent, values between 0.4 and 0.75 were considered moderate, and values of < 0.4 demonstrated a weak agreement. For patients who underwent RCR, the mean differences between actual and recalled ASES, SANE, SST and VAS pain were 6.3 (P=0.004), 2.0 (P=0.155), -0.04 (P=0.625) and - 1.0 (P<0.001), respectively. In patients who underwent TSA, the mean differences between actual and recalled ASES, SANE, SST and VAS pain were 4.5 (P =0.038), -3.9 (P=0.262), -1.2 (P=0.001) and -1.5 (P<0.001), respectively. ASES, SST, and VAS show moderate reliability, and SANE reliability was weak in both RCR and TSA populations. Patients had a tendency to recall higher pain scores than actual preoperative pain scores. In patients who underwent RCR or TSA, there was too much variability between individual patient's ability to accurately recall preoperative pain and function to reliably use recall data for research purposes.

Validation of bladder health scales and function indices for women’s research

Existing bladder-specific measures lack the ability to assess the full range of bladder health, from poor to optimal health. This study aimed to report evidence of validity of the self-administered, multidimensional bladder health scales and function indices for research in adult women. A cross-sectional population-based validation study with random assignment to paper or electronic administration was conducted using national address-based probability sampling supplemented by purposive sampling of women with lower urinary tract symptoms in 7 clinical research centers. Construct validity of the bladder health scales and function indices was guided by a multitrait-multimethod approach using health and condition-specific questionnaires, bladder diaries, expert ratings of bladder health, and noninvasive bladder function testing. Internal dimensional validity was evaluated using factor analysis; internal reliability was assessed using paired t-tests and 2-way mixed-effects intraclass correlation coefficient models. Chi-square, Fisher exact, or t-tests were used for mode comparisons. Convergent validity was evaluated using Pearson correlations with the external construct measures, and known-group validity was established with comparison of women known and unknown to be symptomatic of urinary conditions. The sample included 1072 participants. Factor analysis identified 10 scales, with Cronbach's alpha ranging from 0.74 to 0.94. Intraclass correlation coefficients of scales ranged from 0.55 to 0.94. Convergent validity of the 10 scales and 6 indices ranged from 0.52 to 0.83. Known-group validity was confirmed for all scales and indices. Item distribution was similar by mode of administration. The paper and electronic forms of the bladder health scales and function indices are reliable and valid measures of bladder health for use in women's health research.

The Spatial Orientation of the Foot: A Critical Step in Hindfoot Alignment Evaluation on Weight Bearing CT

Category: Hindfoot; Ankle Introduction/Purpose: Weight Bearing CT (WBCT) has been proven to be effective in hindfoot alignment assessment. However, we have noted that in both WBCT examination and evaluation, positioning of the foot has not been sufficiently prioritized. We hypothesized that changing the foot orientation will significantly affect the measurement of the hindfoot, which will in turn affect further clinical decision making. Methods: WBCT scans of ten feet without any foot and ankle deformity were loaded in CubeVue software. The foot was aligned to a neutral (0°) position based on the 2nd ray and the heel, and was then rotated 5°, 10°, 15° and 20° both externally and internally to simulate malposition. The 'semi' three dimensional hindfoot Moment Arm (HMA) was evaluated with the foot in these different positions. For measured parameters, varus alignment was recorded as a negative value, and valgus alignment was recorded as a positive value. Each measurement was repeated twice to minimize bias. A linear regression model was used to analyze the relationship of the HMA value and the rotation angles. An intraclass correlation coefficient (ICC) model was used to assess the intra- and interobserver reliability. Statistical analysis was completed using SAS 9.4. Results: When rotating the foot from external 20° to internal 20°, the HMA demonstrated a linear change in hindfoot alignment from varus to valgus. A 1° increase in the rotation angle caused 0.52 (±0.03) mm increase in the HMA value (Figure 1). The HMA measurements had excellent inter- and intra-observer reliability (ICC &gt;= 0.9) (Table 1). Both CT images and measured values confirmed that internal rotation changed a neutral into a valgus hindfoot, and external rotation changed a neutral hindfoot into varus (Figure 2). Conclusion: When using current two or 'semi' three-dimensional methods to evaluate hindfoot alignment on WBCT scans, positioning the foot in the correct orientation is critical. Malrotation and malposition of the foot will cause significant impact on measurements and generate false data as well as misdiagnoses. This study was performed on normal feet but is clinically relevant when applied to deformities, particularly those associated with abduction or adduction of the midfoot and forefoot while current knowledge about deformed foot positioning is limited. This is an important topic for future investigation.

A Comparison of Different Techniques for Measuring the Hindfoot Moment Arm on Weight-Bearing CT: An Inter and Intra-Observer Reliability Study

Category: Hindfoot; Ankle Introduction/Purpose: The Hindfoot Moment Arm (HMA) has been used to evaluate the hindfoot alignment with the Saltzman weightbearing XRay images (1), and was recently introduced into the field of weightbearing CT (WBCT) by Saltzman et al (2). The authors of this study have noticed that when using the Saltzman WBCT HMA technique, it is very difficult to determine the specific 'one' image in coronal plane scans with the widest tibial diaphyseal to draw the long axis of the tibia. The purpose of this study was to introduce a modified technique of measuring HMA in WBCT scans and compare the inter and intra-observer reliabilities between the modified and the Saltzman WBCT HMA techniques. Methods: WBCT scans of ten healthy limbs were loaded in CubeVue software. The foot was aligned in the correct orientation in the transverse plane based on the 2nd ray and the heel and the HMA was evaluated using the modified and Saltzman techniques. Using the modified technique, the sagittal plane thickness of one scan cut was increased to include the full width and length of the tibia and the axis of the distal tibia was identified by connecting two circles tangential to both cortices of the tibia. The weightbearing point of the calcaneus was located and the HMA was evaluated by measuring the perpendicular distance of the calcaneus weightbearing point to the axis of the distal tibia with varus a negative and valgus alignment a positive value. Intraclass correlation coefficient (ICC) model was used to assess the intra- and interobserver reliability of the two HMA techniques in SAS 9.4. Results: Both techniques had excellent intra- and interobserver reliability (Saltzman WBCT HMA intra-observer ICC=0.97, Saltzman WBCT HMA inter-observer ICC=0.94, the modified WBCT HMA intra-observer ICC=0.99, the modified WBCT HMA inter-observer ICC=0.91) (Table 1). Conclusion: The modified WBCT HMA was equivalent to the Saltzman technique in both inter and intra-observer reliabilities. The authors found that the modified technique was easier and less time consuming to perform in identifying the axis of the tibia since the modified technique uses multiple cuts to restore the full thickness of tibia, which not only reduces potential error, but also saves time during measurements. Compared with a relatively shorter tibia in one cut, the reconstructed tibia provides a longer and clearer shaft to work with, which allows both proximal and distal circles to be drawn with higher precision (Figure 1). 1. Saltzman, C. L., &amp; El-Khoury, G. Y. (1995). The hindfoot alignment view. Foot &amp; Ankle International, 16(9), 572-576. 2. Arena, C. B., Sripanich, Y., Leake, R., Saltzman, C. L., &amp; Barg, A. (2021). Assessment of hindfoot alignment comparing weightbearing radiography to weightbearing computed tomography. Foot &amp; Ankle International, 42(11), 1482-1490.

Testing the Equality of Proportions for Combined Unilateral and Bilateral Data Under Equal Intraclass Correlation Model

ABSTRACT In clinical studies, data can be collected either unilaterally or bilaterally in each subject. Especially in bilateral cases, the correlation between responses of a paired organs is non-negligible if we would like to formulate a homogeneity test among groups. In this article, we investigated and derived three test methods based on an equal intraclass correlation model aiming to exploit such combined data samples. The performance of each test method is examined by simulation under various parameter configurations, which suggests the Score test usually has the properties of satisfactory Type I error control and great power performance, and therefore, is recommended among these three proposed and existing methods. A real work example in the otolaryngologic study is analyzed to illustrate the practical application of our proposed test.

Intraoperative Fluoroscopy Allows the Reliable Assessment of Deformity Correction during Periacetabular Osteotomy.

We aimed to determine the accuracy and reliability of measures characterizing anterior, lateral, and posterior acetabular coverage on intraoperative fluoroscopic images compared to postoperative radiographs when performing periacetabular osteotomies (PAOs). A study involving 100 PAOs was initiated applying a standardized intraoperative imaging protocol. Coverage was determined by the lateral center edge angle (LCEA), the Tönnis angle (TA), and the anterior and posterior wall index (AWI, PWI). An intraclass correlation coefficient (ICC) model was used to assess interrater (ICC (3,2)) and intrarater (ICC (2,1)) reliability. The ICC (2,2) between analyses obtained from intraoperative fluoroscopy and postoperative radiographs and the corresponding 95% confidence interval (CI) were determined and complemented by Bland–Altman analysis, the mean difference, and 95% limits of agreement (LOA). The ICCs were 0.849 for the LCEA (95% CI 0.783–0.896), 0.897 for the TA (95% CI 0.851–0.930), 0.864 for the AWI (95% CI 0.804–0.907), and 0.804 for the PWI (0.722–0.864). The assessed interrater reliability was excellent except for the AWI, which was graded good (ICC = 0.857, 95% CI 0.794–0.902). Interrater agreement was generally good and fair for the AWI (ICC = 0.715, 95% CI 0.603–0.780). For each postoperative radiograph, interrater reliability was good with ICCs ranging from 0.813 (TA) to 0.881 (PWI). Intrarater reliability was good for all measurements and excellent for the preoperative TA (ICC = 0.993, 95% CI 0.984–0.997) and PWI (ICC = 0.954, 95% CI 0.919–0.97). In summary, we confirm the validity and reliability of intraoperative fluoroscopy as an alternative imaging modality to radiography to evaluate acetabular fragment orientation during PAO. We affirm the LCEA and TA as precise measures for lateral head coverage, and show the suitability of the AWI and PWI to steadily assess acetabular version.

Validation of a new assessment tool for chest tube insertion on Thiel embalmed human cadavers: a feasibility study

IntroThiel embalmed human cadavers are considered as high‐fidelity simulator for several surgical procedures, including Chest Tube Insertion (CTI). In proficiency‐based education, targeted feedback is essential in order to improve learners’ technical skills. Assessments must be validated prior to their use. Validity can be established using Messick’s framework, which collects evidence from five sources. The ACTION tool is a new assessment tool, and consists of a procedure‐specific Rating Scale and an error checklist. It has been developed by a Delphi panel, which ensures content evidence. This study evaluates the feasibility of a validation study for the ACTION tool on Thiel embalmed human cadavers.MethodsA convenience sample of three medical undergraduates and one PhD candidate was recruited. All provided informed consent and demographic information. Each participant was scored and recorded while performing a CTI. Each recording was later scored by three raters. Rater agreement was evaluated by calculating a two‐way mixed effects, absolute agreement, single unit of measurement intraclass correlation coefficient (ICC) model. Internal consistency of the assessment was evaluated using Cronbach Alfa. Feasibility was evaluated using structured questions regarding recruitment and data outcomes.ResultsRecruitment capability and data collection procedures were evaluated as being feasible and suitable for the target study participants. All necessary resources are available and data analysis can be carried out.Preliminary results for the procedural steps indicate an ICC of 0.62, indicating moderate rater agreement, and a Cronbach Alfa of 0.94, indicating excellent internal consistency. For the errors, an ICC of 0.63, and a Cronbach Alfa of 0.68 was observed.ConclusionValidation of the ACTION tool following Messick’s framework is feasible. A rater training session can increase reliability. After validation, the assessment tool can be used to evaluate learners’ proficiency in CTI on Thiel embalmed human cadavers, prior to patient contact.

Validity and reliability of performance tests as balance measures in patients with total knee arthroplasty

PurposeThis study aimed to investigate validity and reliability of the Timed Up and Go Test (TUG), 10 Meter Walk Test (10MWT), Single Leg Stance Test (SLST), 2 Minute Walk Test (2MWT), and Five Times Sit-to-Stand Test (5xSST) for evaluating balance in patients with total knee arthroplasty (TKA).Materials and MethodsThis cross-sectional study included 41 participants who had undergone TKA 6 months before the study due to osteoarthritis. Participants performed the TUG, 10MWT, SLST, 5xSST, and 2MWT. Each of the tests was performed twice, with a 1-day interval between tests. Intraclass correlation coefficient (ICC) models were used to determine the test–retest reliability. The level of correlations between performance tests and Berg Balance Scale and Fall Efficacy Scale-International were used to establish concurrent and convergent validity of the performance tests, respectively.ResultsThe mean age of the subjects was 64.07 ± 10.57 years. All tests showed excellent reliability (ICC > 0.94), excluding SLST that demonstrated good test–retest reliability (ICC = 0.72). All of the tests (SLST, 10MWT, 5xSST, 2MWT, TUG) were found to have good validity (rho > 0.704).ConclusionsAccording to these results, TUG, 10MWT, SLST, 5xSST, and 2MWT are reliable and valid outcome measures in patients with TKA, and could be used to assess balance after TKA surgery.

Normalized hand-behind-back for the measurement of shoulder internal rotation

BackgroundThe hand-behind-back (HBB) is a method for measuring the range of shoulder internal rotation; here, the highest vertebral level reached by the thumb is recorded. Alternatively, other specific landmarks may be used to measure its distance with the thumb. When the records of distance are adopted, it becomes difficult to compare individuals of different physiques, that is, comparing adults and children. In this study, we proposed a modified HBB method that attempts to normalize body size disparity and examined its reliability.MethodsThree raters measured the modified HBB in 60 healthy subjects. A test-retest design was used, wherein each rater measured one trial, for a total of three trials each subject. The subject's thumb was actively and passively ascended along the spinal column as high as possible; subsequently, the distance between the C7 spinous process and tip of the thumb (C7-thumb) was measured with a tape. The HBB ratio (HBBR) was used as the parameter of shoulder internal rotation. It was defined as the ratio between the C7-thumb and the distance between the C7 spinous process and midpoint of the line connecting the posterior superior iliac spines (C7-posterior superior iliac spine).ResultsIntraclass correlation coefficients (model 2.1) ranged from 0.73 to 0.89, indicating that the reliability of the active and passive HBBR had moderate or good and good reliability, respectively. Bland-Altman analysis revealed that the values of minimal detectable changes were 0.053 and 0.036 for the active and passive measurements, respectively.ConclusionThe proposed method was confirmed to have sufficient reliability for clinical use. The HBBR may be used as a parameter of the shoulder internal rotation, which enables the comparison between individuals of different physiques.

Testing parallelism and confidence intervals of level difference in an intraclass correlation model with monotone missing data

In this article, we consider a parallelism test and confidence interval of level difference with uniform covariance structure wherein each dataset has a monotone missing data. A likelihood ratio test statistic is derived using the maximum likelihood estimators of the parameters for the transformed dataset of a contrast matrix. Furthermore, its exact null distribution is presented using a contrast transformation matrix. Moreover, an approximate confidence interval of level difference in two sample problem is presented under parallelism using the upper percentiles of Student’s t-distribution. Finally, a Monte Carlo simulation and a numerical example are given.

Electromyographic analysis of maximal voluntary contraction of female pelvic floor muscles: Intrarater and interrater reliability study.

To investigate the intrarater and interrater reliability of the surface electromyography (sEMG) of female pelvic floor muscles (PFM) by visual determination of the onset-offset during maximal voluntary contraction (MVC). Intrarater and interrater reliability study. Three MVC, recorded for 5 s (s) each and separated by intervals of 60 s, were requested. Two independent raters visually determined the onset and offset of each MVC. The agreement between raters on the quality of the signals was analyzed both qualitatively (visual inspection) and quantitatively (signal-to-noise ratio, SNR). The reliability of integral and median frequency (MDF) of sEMG signals during MVC was analyzed using intraclass correlation coefficient (ICC) models (ICC2,1 , ICC2,3 ) and repeated measures analysis of variance. A total of 58 women (mean age of 54 years) and two independent raters participated in the analyses. Of the total, 22 (37.9%) were considered of high quality by both raters and the SNR ranged 34.3-22.2 decibels (dB). The agreement of qualitative visual evaluation of the sEMG signal was fair (Cohen's κ = 0.306 [0.148; 0.463]). Intrarater and interrater reliability were excellent for the average of the three MVC, both for integral (ICC2,3 = 0.884 [0.821; 0.925]; ω2 = -0.006, p = 0.558) and MDF (ICC2,3 = 0.998 [0.998; 0.999]; ω2 = -0.009, p = 0.992). Qualitative visual analysis of the sEMG signal presents fair interrater agreement and reflects the SNR. Visual determination of the onset and offset of the MVC of PFM using the standard interface of the sEMG software has excellent reliability for determination of muscle activation variables.

Convergent Validity and Test-Retest Reliability of Multimodal Ultrasonography and Related Clinical Measures in People With Chronic Stroke

ObjectiveTo assess the test-retest reliability of diagnostic ultrasonography measurements of the bilateral biceps brachii (BB), brachial artery, medial gastrocnemius (MG), and popliteal artery in survivors of stroke and their convergent validity with related clinical comparators. DesignCross-sectional study. SettingAll procedures were conducted in a university laboratory. ParticipantsSixty-five community dwelling adults (N=65; 26 women, 39 men) with an average age of 60.9±7.7 years and stroke duration of 5.7±3.9 years participated in this study. InterventionsNot applicable. Main Outcome MeasuresMeasures of muscle structure (ie, thickness, cross-sectional area, fascicle length, pennation angle), stiffness, and intramuscular blood perfusion were conducted using B-mode, elastography and color flow Doppler ultrasonography modes, respectively. Convergent validity was assessed by examining correlations between ultrasonography measures and assessments of related constructs (ie, dynamic stiffness, isometric peak torque, spasticity, and systemic vascular function using myotonometry, dynamometry, the Composite Spasticity Scale, and the Ankle-Brachial Index, respectively). A 2-way random-effects intraclass correlation coefficient (ICC) model (ICC2,3) was used to determine agreement between intersession measures among a smaller cohort of participants with stroke (n=20). ResultsICC estimates ranged from moderate to excellent for muscle stiffness (paretic: ICC=0.74-0.89; nonparetic: ICC=0.66-0.88), structure (paretic: ICC=0.87-0.99; nonparetic: ICC=0.81-0.98), and blood perfusion measures (paretic: ICC=0.74-0.84; nonparetic: ICC=0.73-0.88). Weak to moderate associations were found between myotonometry and elastography measures of the bilateral BB (r=0.29-0.52, P≤.05) and MG muscles (r=0.31-0.69, P≤.05). The correlations between elastography measures and spasticity scores for the paretic upper (r=0.35-0.63, P≤.05) and lower limbs (r=0.25-0.37, P≤.05) were also weak to moderate. ConclusionsElastography demonstrated mostly weak to moderate correlation with measures of stiffness using myotonometry as well as scores of paretic upper and lower limb spasticity. The results also indicate acceptable intersession reliability for muscle and vascular measures using several ultrasonography modalities among individuals with chronic stroke.

Interobserver concordance in visual assessment of Ki67 immunohistochemistry in surgical excision specimens from patients with lymph node-negative breast cancer.

This study aimed to determine the interobserver concordance of two methods for proliferation assessment in breast cancer using Ki67 immunohistochemistry. Ki67 was independently assessed in randomly selected tumour samples from patients with lymph node-negative breast cancer using two different methods: either cell counting or visual estimation of hot spot areas. For hot spot cell counting, positive and negative cell numbers were recorded for total cell counts of 300-500, 500-800 and 800-1000 cells. Visual estimation involved allocation of a score from 1 to 5 using a visual scale to estimate percentage positivity. Interobserver agreement for hot spot counting was calculated using a two-way fixed effects intraclass correlation model, and by using Cohen's kappa measure for visual assessment. Prognostic concordance between the two methods was also calculated using Cohen's kappa. Samples from 96 patients were included in this analysis. Interobserver agreement for hot spot cell counting was excellent (> 0.75) across all three cell count ranges, with correlation coefficients of 0.88 (95% CI 0.84-0.92), 0.87 (95% CI 0.82-0.91) and 0.89 (95% CI 0.85-0.92), respectively. Interobserver agreement with visual estimation was greatest for hot spots compared with areas of intermediate or low proliferation, with kappa scores of 0.49, 0.42 and 0.40, respectively. Both assessment methods demonstrated excellent prognostic agreement. Interobserver and prognostic concordance in Ki67 immunohistochemistry assessments was high using either hot spot cell counting or visual estimation, further supporting the utility and reproducibility of these cost-efficient methods to assess proliferation.