Level Of Interobserver Agreement Research Articles

"Non-invasive Follicular Thyroid Neoplasm with Papillary like Nuclear Features": An Institutional Retrospective Study with Re-nomenclature and Re-classification.

The cumulative efforts of pioneers in field of Thyroid pathology have resulted in proposed reclassification of Encapsulated Follicular Variant of Papillary Thyroid Carcinoma (EFVPTC) to "Non-invasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTWP) due to indolent clinical behaviour. To study the spectrum of EFVPTCs in our institute and to reclassify them as NIFTWP using stringent morphological criteria. This is a retrospective study conducted from Jan 2014 to July 2017. Institutional records were accessed and out of 485 thyroidectomy cases, 35 cases of EFVPTC were taken into study and field's kappa was used as a means of statistical analysis. The study conducted on 35 cases of EFVPTCs using strict morphological criteria lead to re-nomenclature and re-classification of 30 out of these 35 cases, with a field's kappa value of 4.3. The present study, lead to re-nomenclature and re-classification of 30 cases of EFVPTC to NIFTWP and proved statistically that there is moderate level of Inter-observer agreement regarding the criteria used for this re-nomenclature and re-classification.

Low-dose (2-mSv) computed tomography for suspected appendicitis: Applicability in an emergency department

ObjectivesTo document the level of interobserver agreement and compare the diagnostic performances of emergency physicians and radiologists at interpreting low radiation CT images of acute appendicitis in adolescents and young adults. MethodsOne hundred and seven adolescents and young adult patients (aged 15 to 44years) that underwent 2-mSv low-dose CT for suspected acute appendicitis between June and December in 2013 were enrolled in this retrospective study. Three emergency physicians and three radiologists with different experiences of low-dose CT independently reviewed CT images. These six physicians rated the likelihood of acute appendicitis using a 5-point Likert scale. We calculated interobserver agreement and compared the diagnostic performances between emergency physicians and radiologists. And diagnostic confidence was also assessed using the likelihood of acute appendicitis. ResultsAcute appendicitis was pathologically confirmed in 42 patients (39%); the remaining 65 patients were considered not to have appendicitis. Fleiss' Kappa for reliability of agreement between emergency physicians and radiologists for the diagnosis of acute appendicitis was 0.720 (95% confidence intervals (CI), 0.685–0.726). Pooled areas under the receiver operating characteristics curve (AUC) for a diagnosis of appendicitis were 0.904 and 0.944 for emergency physicians and radiologists, respectively, and these AUC values were not significantly different (95% confidence interval, −0.087, 0.007; p=0.0855). ConclusionThe emergency physicians and radiologists showed good interobserver agreement and comparable diagnostic performances for appendicitis in adolescents and adults using low-dose CT images. Low-dose CT could be a useful tool for the diagnosis of appendicitis by emergency physicians.

Forensic age assessment by 3.0T MRI of the knee: proposal of a new MRI classification of ossification stages.

To explore the possibility of determining majority via a morphology-based examination of the epiphyseal-diaphyseal fusion by 3.0T magnetic resonance imaging (MRI), a prospective cross-sectional study developing and applying a new stage classification was conducted. 344 male and 350 female volunteers of German nationality between the ages of 12-24 years were scanned between May 2013 and June 2015. A 3.0T MRIscanner was used, acquiring a T1-weighted (T1-w) turbo spin-echo sequence (TSE) and a T2-weighted (T2-w) TSE sequence with fat suppression byspectral pre-saturation with inversion recovery (SPIR). The gathered information was sifted and a five-stage classification was formulatedas a hypothesis. The images were then assessed using this classification. The relevant statistics were defined, the intra- and interobserver agreements were determined, and the differences between the sexes were analysed. The application of the new classification made it possible to correctly assess majority in both sexes by the examination of the epiphyses of the knee joint. The intra- and interobserver agreement levels were very good (κ > 0.80). The Mann-Whitney-U Test implied significant sex-related differences for most stages. Applying the presented MRI classification, it is possible to determine the completion of the 18th year of life in either sex by 3.0T MRI of the knee joint. • Based on prospective referential data a new MRI classification was formulated. • The setting allows assessment of the age of an individual's skeletal development. • The classification scheme allows the reliable determination of majority in both sexes. • The staging shows a high reproducibility for instructed and trained professional personnel. • The proposed classification is likely to be adaptable to other long bone epiphyses.

Avaliação da reprodutibilidade intra e interobservadores da classificação AO para fratura do punho

ObjectiveThis study evaluated the intraobserver and interobserver reliability of the AO classification for standard radiographs of wrist fractures. MethodsThirty observers, divided into three groups (orthopedic surgery senior residents, orthopedic surgeons, and hand surgeons) classified 52 wrist fractures, using only simple radiographs. After a period of four weeks, the same observers evaluated the initial 52 radiographs, in a randomized order. The agreement among the observers, the groups, and intraobserver was obtained using the Kappa index. Kappa‐values were interpreted as proposed by Landis and Koch. ResultsThe global interobserver agreement level of the AO classification was considered fair (0.30). The three groups presented fair global interobserver agreement (residents, 0.27; orthopedic surgeons, 0.30; hand surgeons, 0.33). The global intraobserver agreement level was moderated. The hand surgeon group obtained the higher intraobserver agreement level, although only moderate (0.50). The residents group obtained fair levels (0.30), as did the orthopedics surgeon group (0.33). ConclusionThe data obtained suggests fair levels of interobserver agreement and moderate levels of intraobserver agreement for the AO classification for wrist fractures.

Variability of Gross Tumor Volume Delineation for Stereotactic Body Radiotherapy of the Lung With Tri-60Co Magnetic Resonance Image-Guided Radiotherapy System (ViewRay): A Comparative Study With Magnetic Resonance- and Computed Tomography-Based Target Delineation.

Introduction:To evaluate the intra-/interobserver variability of gross target volumes between delineation based on magnetic resonance imaging and computed tomography in patients simulated for stereotactic body radiotherapy for primary lung cancer and lung metastasis.Materials and Methods:Twenty-five patients (27 lesions) who underwent computed tomography and magnetic resonance simulation with the MR-60Co system (ViewRay) were included in the study. Gross target volumes were delineated on the magnetic resonance imaging (GTVMR) and computed tomography (GTVCT) images by 2 radiation oncologists (RO1 and RO2). Volumes of all contours were measured. Levels of intraobserver (GTVMR_RO vs GTVCT_RO) and interobserver (GTVMR_RO1 vs GTVMR_RO2; GTVCT_RO1 vs GTVCT_RO2) agreement were evaluated using the generalized κ statistics and the paired t test.Results:No significant volumetric difference was observed between all 4 comparisons (GTVMR_RO1 vs GTVCT_RO1, GTVMR_RO2 vs GTVCT_RO2, GTVMR_RO1 vs GTVMR_RO2, and GTVCT_RO1 vs GTVCT_RO2; P > .05), with mean volumes of GTVs ranging 5 to 6 cm3. The levels of agreement between those 4 comparisons were all substantial with mean κ values of 0.64, 0.66, 0.74, and 0.63, respectively. However, the interobserver agreement level was significantly higher for GTVCT compared to GTVMR (P <.001). The mean κ values significantly increased in all 4 comparisons for tumors >5 cm3 compared to tumors ≤5 cm3 (all P < .05).Conclusion:No significant differences in volumes between magnetic resonance- and computed tomograpghy-based Gross target volumes were found among 2 ROs. Magnetic resonance-based GTV delineation for lung stereotactic body radiotherapy also demonstrated acceptable interobserver agreement. Tumors >5 cm3 show higher intra-/interobserver agreement compared to tumors <5 cm3. More experience should be accumulated to reduce variability in magnetic resonance-based Gross target volumes delineation in lung stereotactic body radiotherapy.

Reliability and agreement on embryo assessment: 5 years of an external quality control programme.

An external quality-control programme for morphology-based embryo quality assessment, incorporating a standardized embryo grading scheme, was evaluated over a period of 5 years to determine levels of inter-observer reliability and agreement between practising clinical embryologists at IVF centres and the opinions of a panel of experts. Following Guidelines for Reporting Reliability and Agreement Studies, the Gwet index and proportion of positive (Ppos) and negative agreement were calculated. For embryo morphology assessment, a substantial degree of reliability was measured between the centres and the panel of experts (Gwet index: 0.76; 95% CI 0.70 to 0.84). The agreement was higher for good- versus poor-quality embryos. When multinucleation or vacuoles were observed, low levels of reliability were obtained (Ppos: 0.56 and 0.43, respectively). In blastocysts, the characteristic that presented the largest discrepancy was that related to the inner cell mass. In decisions about the final disposition of the embryo, reliability between centre and the panel of experts was moderate (Gwet index: 0.51; 95% CI 0.41 to 0.60). In conclusion, the ability of clinical embryologists to evaluate the presence of multinucleation and vacuoles in the early cleavage embryo, and to determine the category of the inner cell mass in blastocysts, needs to be improved.

Interobserver agreement on standardized ultrasound and histopathologic signs for the prenatal diagnosis of placenta accreta spectrum disorders.

To evaluate interobserver agreement in assessment of ultrasound signs and histopathologic findings associated with placenta accreta spectrum (PAS) disorders. A retrospective study was conducted using data for patients prenatally diagnosed with PAS disorders at a UK hospital between January 31, 2012, and March 30, 2017. Ultrasound images (including gray-scale and color Doppler imaging [CDI] parameters) and histopathologic slides were reviewed by two observers; the level of agreement was calculated. Among 25 patients, 11 had placenta creta, 10 had placenta increta, and four had placenta percreta. Interobserver agreement for ultrasound imaging in the second and third trimesters and histopathologic diagnosis of PAS was rated as good-to-excellent. The highest level of interobserver agreement for ultrasound signs was found for loss of clear zone (100%) and substantial myometrial thinning (96%-100%) on gray-scale imaging, the presence of lacunar feeder vessels (100%) on two-dimensional CDI, and crossing vessels and lacunae (92%-95%) on three-dimensional CDI. Standardized ultrasound signs might prove useful for prenatal screening of women at risk of PAS disorders and should enable remote evaluation of images when PAS is suspected.

Automated computation of femoral angles in dogs from three-dimensional computed tomography reconstructions: Comparison with manual techniques

The aim of this ex vivo study was to test a novel three-dimensional (3D) automated computer-aided design (CAD) method (aCAD) for the computation of femoral angles in dogs from 3D reconstructions of computed tomography (CT) images. The repeatability and reproducibility of three manual radiography, manual CT reconstructions and the aCAD method for the measurement of three femoral angles were evaluated: (1) anatomical lateral distal femoral angle (aLDFA); (2) femoral neck angle (FNA); and (3) femoral torsion angle (FTA). Femoral angles of 22 femurs obtained from 16 cadavers were measured by three blinded observers. Measurements were repeated three times by each observer for each diagnostic technique. Femoral angle measurements were analysed using a mixed effects linear model for repeated measures to determine the levels of intra-observer agreement (repeatability) and inter-observer agreement (reproducibility). Repeatability and reproducibility of measurements using the aCAD method were excellent (intra-class coefficients, ICCs≥0.98) for all three angles assessed. Manual radiography and CT exhibited excellent agreement for the aLDFA measurement (ICCs≥0.90). However, FNA repeatability and reproducibility were poor (ICCs<0.8), whereas FTA measurement showed slightly higher ICCs values, except for the radiographic reproducibility, which was poor (ICCs<0.8). The computation of the 3D aCAD method provided the highest repeatability and reproducibility among the tested methodologies.

Observer Agreement for Measurements in Videolaryngostroboscopy

This study evaluated the levels of intraobserver and interobserver agreement for measurements of visuoperceptual variables in videolaryngostroboscopic examinations and compared the observers' behavior during independent versus consensus panel rating. This is a retrospective study. This study was conducted in a single-center tertiary care facility. Sixty-four patients with dysphonia of heterogeneous etiology were included. All subjects underwent a standardized videolaryngostroboscopic examination. Two experienced and trained observers scored exactly the same examinations, first independently and then on a consensus panel. Specific visuoperceptual variables and the clinical diagnosis (as recommended by the Committee on Phoniatrics and the Phonosurgery Committee of the European Laryngological Society and advised by the American Speech-Language-Hearing Association) were scored. Descriptive and kappa statistics were used. In general, intraobserver agreement was better than agreement between observers for measurements of several variables. The intrapanel observer agreement levels were slightly higher than the intraobserver agreement levels on the independent rating task. When rating on the consensus panel, the observers deviated considerably from the scores they had previously given on the independent rating task. Observer agreement in videolaryngostroboscopic assessment has important implications not only for the diagnosis and treatment of dysphonic patients but also for the interpretation of the results of scientific studies using videolaryngostroboscopic outcome parameters. The identification of factors that can influence the levels of observer agreement can provide a better understanding of the rating process and its limitations. The results of this study suggest that future research could achieve better agreement levels by rating the visuoperceptual variables in a panel setting.

Accurate Classification of Diminutive Colorectal Polyps Using Computer-Aided Analysis

Narrow-band imaging is an image-enhanced form of endoscopy used to observed microstructures and capillaries of the mucosal epithelium which allows for real-time prediction of histologic features of colorectal polyps. However, narrow-band imaging expertise is required to differentiate hyperplastic from neoplastic polyps with high levels of accuracy. We developed and tested a system of computer-aided diagnosis with a deep neural network (DNN-CAD) to analyze narrow-band images of diminutive colorectal polyps. We collected 1476 images of neoplastic polyps and 681 images of hyperplastic polyps, obtained from the picture archiving and communications system database in a tertiary hospital in Taiwan. Histologic findings from the polyps were also collected and used as the reference standard. The images and data were used to train the DNN. A test set of images (96 hyperplastic and 188 neoplastic polyps, smaller than 5 mm), obtained from patients who underwent colonoscopies from March 2017 through August 2017, was then used to test the diagnostic ability of the DNN-CAD vs endoscopists (2 expert and 4 novice), who were asked to classify the images of the test set as neoplastic or hyperplastic. Their classifications were compared with findings from histologic analysis. The primary outcome measures were diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic time. The accuracy, sensitivity, specificity, PPV, NPV, and diagnostic time were compared among DNN-CAD, the novice endoscopists, and the expert endoscopists. The study was designed to detect a difference of 10% in accuracy by a 2-sided McNemar test. In the test set, the DNN-CAD identified neoplastic or hyperplastic polyps with 96.3% sensitivity, 78.1% specificity, a PPV of 89.6%, and a NPV of 91.5%. Fewer than half of the novice endoscopists classified polyps with a NPV of 90% (their NPVs ranged from 73.9% to 84.0%). DNN-CAD classified polyps as neoplastic or hyperplastic in 0.45 ± 0.07 seconds-shorter than the time required by experts (1.54±1.30 seconds) and nonexperts (1.77 ± 1.37 seconds) (both P < .001). DNN-CAD classified polyps with perfect intra-observer agreement (kappa score of 1). There was a low level of intra-observer and inter-observer agreement in classification among endoscopists. We developed a system called DNN-CAD to identify neoplastic or hyperplastic colorectal polyps less than 5 mm. The system classified polyps with a PPV of 89.6%, and a NPV of 91.5%, and in a shorter time than endoscopists. This deep-learning model has potential for not only endoscopic image recognition but for other forms of medical image analysis, including sonography, computed tomography, and magnetic resonance images.

Vascular Pattern Analysis on Microvascular Sonography for Differentiation of Pleomorphic Adenomas and Warthin Tumors of Salivary Glands.

Pleomorphic adenomas and Warthin tumors are the most common salivary gland tumors. It is important to differentiate between them because at least a partial parotidectomy is necessary for pleomorphic adenomas, whereas enucleation is sufficient for Warthin tumors. This study aimed to evaluate the usefulness of vascular pattern analysis using microvascular sonography to differentiate between the tumors. Sixty-two patients with pathologically proven pleomorphic adenomas (n = 38) and Warthin tumors (n = 24) were included. For all tumors, grayscale, power Doppler, and microvascular sonographic examinations were performed. Differences in vascular patterns (vascular distribution and internal vascularity) on power Doppler and microvascular sonography as well as grayscale sonographic features (size, shape, border, echogenicity, heterogeneity, and cystic change) between pleomorphic adenomas and Warthin tumors were evaluated. A comparison of diagnostic performances of grayscale sonography with power Doppler sonography and grayscale sonography with microvascular sonography was performed. The level of interobserver agreement between 2 reviewers in diagnosing tumors was evaluated. No grayscale sonographic features showed a significant difference between the tumors. Vascular distributions and internal vascularity on power Doppler sonography (P = .01 and .002) and microvascular sonography (both P < .001) were all significantly different. The diagnostic accuracy of grayscale sonography with microvascular sonography (79.0%) was higher than that of grayscale sonography with power Doppler sonography (72.6%). This difference was significant according to the McNemar test (P = .004). Interobserver agreement was excellent in diagnosing tumors on both grayscale sonography with power Doppler sonography (κ = 0.83) and grayscale sonography with microvascular sonography (κ = 0.94). Vascular pattern analysis using microvascular sonography with other sonographic features is helpful for differentiating between pleomorphic adenomas and Warthin tumors.

Interobserver Variability in Scoring Liver Biopsies with a Diagnosis of Alcoholic Hepatitis.

Alcoholic hepatitis (AH) is one of the most severe forms of alcoholic liver disease. Recently, a histologic scoring system for predicting prognosis in this patient cohort was proposed as Alcoholic Hepatitis Histologic Score (AHHS). We aimed to assess interobserver variability in recognizing histologic features of AH and the effect of this variability on the proposed AHHS categories. Hematoxylin-eosin- and trichrome-stained slides from 32 patients diagnosed with AH with liver biopsies within 1month of presentation (2000 to 2015) were reviewed by 5 pathologists including 3 liver pathologists and 2 gastrointestinal (GI) pathologists masked to the clinical findings or outcome. Histologic features of AH were assessed, the AHHS was calculated, and an AHHS category (mild, moderate, severe) was assigned. The Fleiss' kappa coefficient (κ) analysis was performed to determine the interobserver agreement. A slight-to-moderate level of interobserver agreement existed among 5 reviewers on histopathologic features of AH with κ value ranging from 0.20 (95% confidence interval (CI): 0.03 to 0.46, megamitochondria) to 0.52 [95% CI: 0.40 to 0.68, polymorphonuclear leukocyte (PMN) infiltration]. There was only a fair level of agreement in assigning AHHS category (κ=0.33, 95% CI: 0.20 to 0.51). While overall fibrosis and neutrophilic inflammation were comparably evaluated by 3 liver pathologists and 2 GI pathologists, bilirubinostasis and megamitochondria were more consistently diagnosed by liver pathologists. Overall, 18 of 32 (56%) were uniformly assigned to an AHHS category by all liver pathologists with a κ value of 0.40 (95% CI: 0.22 to 0.60). In general, features of AH can be recognized with a slight-to-moderate level of interobserver agreement and there was fair interobserver agreement on assigning an AHHS category. Significant interobserver variability among pathologists revealed by the current study can limit its usefulness in everyday clinical practice.

Evaluating Corneal Fluorescein Staining Using a Novel Automated Method.

To evaluate interobserver concordance in measured corneal fluorescein staining (CFS) using the National Eye Institute/Industry (NEI) grading scale and the Corneal Fluorescein Staining Index (CFSi), a computer-assisted, objective, centesimal scoring system. We conducted a study to evaluate CFS in clinical photographs of patients with corneal epitheliopathy. One group of clinicians graded CFS in the images using the NEI while a second group applied the CFSi. We evaluated the level of interobserver agreement and differences among CFS scores with each method, level of correlation between the two methods, and distribution of cases based on the CFS severity assigned by each method. The level of interobserver agreement was 0.65 (P < 0.001) with the NEI, and 0.99 (P < 0.001) with the CFSi. There were statistically significant differences among clinicians' measurements obtained with the NEI (P < 0.001), but not with the CFSi (P = 0.78). There was a statistically significant correlation between the CFS scores obtained with the two methods (R = 0.72; P < 0.001). The NEI scale allocated the majority of cases (65%) within the higher quartile in the scale's severity (12-15/15). In contrast, the CFSi allocated the majority of cases (61%) within the lower quartile in the scale's severity (0-25/100). The CFSi is easy to implement, provides higher interobserver consistency, and due to its continuous score can discriminate smaller differences in CFS. Reproducibility of the computer-based system is higher and, interestingly, the system allocates cases of epitheliopathy in different severity categories than clinicians do. The CFSi can be an alternative for objective CFS evaluation in the clinic and in clinical trials.

Forensic age estimation by magnetic resonance imaging of the knee: the definite relevance in bony fusion of the distal femoral- and the proximal tibial epiphyses using closest-to-bone T1 TSE sequence.

To clarify the relevance of the bony fusion of the distal femoral and the proximal tibial epiphyses by means of magnetic resonance imaging (MRI), a prospective cross-sectional cohort study was performed with a special focus on a reliable determination of the 14th, 16th and 18th years of life. We scanned 658 German volunteers in the age bracket 12-24 years using a 3.0T MR-scanner and utilising a T1 turbo spin-echo sequence representing true bone anatomy. Minimum, maximum, mean ± standard deviation and median with lower and upper quartiles were defined. Intra- and interobserver agreements were determined (Cohen's kappa). The statistical relevance of sex-related differences was analysed (Mann-Whitney U test, p < 0.05, exact, two-sided). The bony fusion took place before the 18th year of life in both epiphyses. The Mann-Whitney U test results imply significant sex-related differences for most stages. For both epiphyses, the intra observer (κ femur 0.961; tibia 0.971) and interobserver (κ femur 0.941; tibia 0.951) agreement levels were very good. The 14th and the 16th years of life can be determined in both sexes, but the completion of the 18th year of life cannot solely be determined by the bony fusion, as depicted by closest-to-bone MRI. • Forensic age estimation by means of MRI of the knee is feasible. • MRI provides data about the ossification process without using ionising radiation. • The method allows the determination of the 14th and 16th years of life. • The bony fusion is not suitable as the sole indicator of majority. • The chosen classification is easy to use for specially trained professional personnel.

Accuracy of Linear Measurements in Stitched Cone Beam Computed Tomographic Images An In-Vitro Stud

Introduction: Cone Beam Computed Tomography plays a major role in all specialties of maxillofacial region. This variability in applications necessitates variability in the available Field of View (FOV). However, large detector size might not be available in some machines. Stitching allows the fusion of 2 or more small volumes to form larger volumes. For that this study was carried out to evaluate the accuracy of linear measurements obtained from stitched CBCT images compared to direct real measurements.Methodology: Twenty four skulls with mandibles were recruited from Anatomy Department, Faculty of Medicine, Cairo University. Two radiopaque gutta percha markers were glued on each skull and mandible at the nasion and mental ridge (at mid line) respectively. Each skull fixed to its mandible was placed on the CBCT machine Planmeca Pro Max 3D Mid® (Asentajankatu, Helsinki, Finland) in Oral and Maxillofacial Radiology Department at Faculty of Dentistry, Cairo University. For real measurements, the distance between the two markers was measured using digital caliper. The resultant images were evaluated using Planmeca Romexis Viewer version 4.4.0.R (Asentajankatu, Helsinki, Finland) and the CBCT measurements were performed by two blinded observers.Results: The mean real measurement was 96.12 (±11.42) mm which was slightly greater than that of the CBCT measurement which is 95.43 (±11.39) mm. There was a good agreement between CBCT and real measurements. The level of inter-observer and intra-observer agreement is very strong regarding both real and CBCT measurementsConclusion: Linear measurements driven from Stitched CBCT images are accurate and reliable for diagnostic purposes in maxillofacial region.

Reply: ECHM Consensus Conference and levels of evidence

Dr Sherlock asks for clarification on the approach adopted by the European Committee on Hyperbaric Medicine (ECHM) to assessing evidence for establishing indications for hyperbaric oxygen treatment (HBOT). Firstly, regardless of the strict process of editing and proof-reading of tables included in the above-mentioned publication, we received comments from some readers that identified imperfect layout of Table 1 and incorrect layout of Table 2 which significantly changed the conclusions to be drawn from them. This concerned both the details of the methodology used and description of the ECHM recommendations and associated levels of evidence. Therefore, those tables are republished in their correct forms in this issue, hoping that this will explain at least some of the doubts and misunderstandings. Both the Editor and ourselves apologise for these errors of publication. Secondly, in the ECHM Consensus Conference methodology, we scored the evidence for clinical studies requiring double-blind randomised controlled trials (RCT) as Level A and B when, at the same time, some scoring scales require simply 'RCT', as correctly pointed out by Dr Sherlock. Long experience in organising evidence based medicine (EBM) meetings and discussions has taught us that RCTs that are not double blinded are often criticised as having serious potential bias and so are denied as level A evidence. Although we acknowledge that double blinding a clinical study in HBOT is a source of difficulty, we chose a priori to consider only double-blinded RCTs in our grading scale to avoid endless discussions about this potential bias. We are well aware that doing so means that Level A evidence is a difficult target for the hyperbaric community. We agree that many evidence scoring systems have a low level of inter-observer agreement. This is why we treat the Consensus Conference as a valuable tool that provides a better opportunity for discussing the evidence than analysis by a small group of 'experts'. This is because the whole process is transparent and available to all participants' comments and input. The final process of voting by the audience after the general discussion thus truly reflects the position of the professional hyperbaric community in Europe on the issued recommendations. By these two mechanisms, the blind application of disputable evidence scoring systems may be avoided or, at least, decreased. Thirdly, the problem of 'sham' treatments in hyperbaric research has been raised. While this has been discussed many times in the past, hyperbaric research is not the sole field where such sham treatment raises some difficulty. Surgery is probably the best example where RCTs with control arms utilising sham surgical procedures (possibly including the administration of anaesthesia) are rare and can raise major ethical problems. Nevertheless, from an EBM viewpoint, the difficulty of designing a double-blind study is never taken into account during evaluation of clinical studies. Finally, Dr Sherlock pointed out her doubts on the recommendations issued by the ECHM on idiopathic sudden sensorineural hearing loss (ISSHL). While there is no possibility to cite here the full experts' report on that issue presented during the conference, we understand that a detailed report from the Conference is being prepared for publication. In brief, the strength of evidence has been scored as Level B, in general agreement with the last Cochrane review and the UHMS Committee report. Based on this level of evidence, the Type 1 recommendation was issued with the agreement of the large majority of the Consensus Conference participants.

Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study.

Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla. The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience. An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, 'classic appearance'; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists. Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58-0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59-0.72). The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.

Poor inter-observer agreement on the endoscopic diagnosis of eosinophilic esophagitis among Japanese endoscopists

A variety of endoscopic findings are considered useful for the diagnosis of eosinophilic esophagitis (EoE). However, the diagnostic consistency among Japanese endoscopists for those findings has not been fully examined. The aim of this study was to investigate the inter- and intra-observer agreement for endoscopic findings suggesting EoE. Forty endoscopists, including 20 with board certification from the Japan Gastroenterological Endoscopy Society (JGES), participated in this study. Initially, they examined 50 randomized white-light endoscopic images from 30 patients with EoE and 20 without EoE. Four weeks later, the same 50 endoscopic images were re-examined in a different random order. Inter- and intra-observer agreement was calculated using kappa statistics for multiple observers. The kappa coefficient of reliability [95% confidence interval (CI)] for all 40 endoscopists for diagnosis of EoE was 0.34 (0.33–0.35), indicating poor level of inter-observer agreement, while intra-observer agreement showed a moderate value of 0.52 (0.47–0.57). Among 4 possible endoscopic findings (linear furrows, concentric rings, edema, white exudates) for EoE, acceptable levels (kappa value >0.4) of inter- and intra-observer agreement were seen only for linear furrows. When the JGES board-certified and non-certified endoscopists were compared for successful diagnosis of EoE, the value was significantly higher for the board-certified group. However, the level of inter-observer agreement remained poor level. We concluded that inter-observer agreement on the endoscopic diagnosis of EoE among Japanese endoscopists did not reach a clinically acceptable level.

Application of Prostate Imaging Reporting and Data System Version 2 (PI-RADS v2): Interobserver Agreement and Positive Predictive Value for Localization of Intermediate- and High-Grade Prostate Cancers on Multiparametric Magnetic Resonance Imaging

To evaluate interobserver agreement with the use of and the positive predictive value (PPV) of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) for the localization of intermediate- and high-grade prostate cancers on multiparametric magnetic resonance imaging (mpMRI). In this retrospective, institutional review board-approved study, 131 consecutive patients who had mpMRI followed by transrectal ultrasound-MR imaging fusion-guided biopsy of the prostate were included. Two readers who were blinded to initial mpMRI reports, clinical data, and pathologic outcomes reviewed the MR images, identified all prostate lesions, and scored each lesion based on the PI-RADS v2. Interobserver agreement was assessed by intraclass correlation coefficient (ICC), and PPV was calculated for each PI-RADS category. PI-RADS v2 was found to have a moderate level of interobserver agreement between two readers of varying experience, with ICC of 0.74, 0.72, and 0.67 for all lesions, peripheral zone lesions, and transitional zone lesions, respectively. Despite only moderate interobserver agreement, the calculated PPV in the detection of intermediate- and high-grade prostate cancers for each PI-RADS category was very similar between the two readers, with approximate PPV of 0%, 12%, 64%, and 87% for PI-RADS categories 2, 3, 4, and 5, respectively. In our study, PI-RADS v2 has only moderate interobserver agreement, a similar finding in studies of the original PI-RADS and in initial studies of PI-RADS v2. Despite this, PI-RADS v2 appears to be a useful system to predict significant prostate cancer, with PI-RADS scores correlating well with the likelihood of intermediate- and high-grade cancers.

Multidisciplinary evaluation of interstitial lung diseases: current insights: Number 1 in the Series "Radiology" Edited by Nicola Sverzellati and Sujal Desai.

Multidisciplinary team (MDT) diagnosis is regarded as the diagnostic reference standard for interstitial lung disease (ILD). Several studies have reported that MDT diagnosis is associated with higher levels of diagnostic confidence and better interobserver agreement when compared to the individual components of the MDT in isolation. Although this recommendation is widely accepted, no guideline statement specifies what constitutes an MDT meeting and how its participants should govern it. Furthermore, the precise role of an MDT meeting in the setting of ILD may vary from one group to another. For example, in some cases, the meeting will confine its discussion to characterising the disease and formulating diagnosis. In others, management decisions may also be part of the discussion. Surprisingly, there is no consensus on how MDT diagnosis is validated. As multidisciplinary evaluation contains all the available clinical information on an individual patient, there is no reference standard against which the veracity of MDT diagnosis can be tested. Finally, many of these uncertainties surrounding MDT meeting practice are unlikely to be answered by traditional evidence-based studies, which create difficulties when generating guideline recommendations. There is clearly a need for expert consensus on what constitutes acceptable MDT meeting practice. This consensus will need to be flexible to accommodate the variability in resources available to fledgling MDT groups and the variable nature of patients requiring discussion.