Perfect Inter-rater Agreement Research Articles

Ultrafast Brain MRI with Deep Learning Reconstruction for Suspected Acute Ischemic Stroke.

Background Deep learning (DL)-accelerated MRI can substantially reduce examination times. However, studies prospectively evaluating the diagnostic performance of DL-accelerated MRI reconstructions in acute suspected stroke are lacking. Purpose To investigate the interchangeability of DL-accelerated MRI with conventional MRI in patients with suspected acute ischemic stroke at 1.5 T. Materials and Methods In this prospective study, 211 participants with suspected acute stroke underwent clinically indicated MRI at 1.5 T between June 2022 and March 2023. For each participant, conventional MRI (including T1-weighted, T2-weighted, T2*-weighted, T2 fluid-attenuated inversion-recovery, and diffusion-weighted imaging; 14 minutes 18 seconds) and DL-accelerated MRI (same sequences; 3 minutes 4 seconds) were performed. The primary end point was the interchangeability between conventional and DL-accelerated MRI for acute ischemic infarction detection. Secondary end points were interchangeability regarding the affected vascular territory and clinically relevant secondary findings (eg, microbleeds, neoplasm). Three readers evaluated the overall occurrence of acute ischemic stroke, affected vascular territory, clinically relevant secondary findings, overall image quality, and diagnostic confidence. For acute ischemic lesions, size and signal intensities were assessed. The margin for interchangeability was chosen as 5%. For interrater agreement analysis and interrater reliability analysis, multirater Fleiss κ and the intraclass correlation coefficient, respectively, was determined. Results The study sample consisted of 211 participants (mean age, 65 years ± 16 [SD]); 123 male and 88 female). Acute ischemic stroke was confirmed in 79 participants. Interchangeability was demonstrated for all primary and secondary end points. No individual equivalence indexes (IEIs) exceeded the interchangeability margin of 5% (IEI, -0.002 [90% CI: -0.007, 0.004]). Almost perfect interrater agreement was observed (P > .91). DL-accelerated MRI provided higher overall image quality (P < .001) and diagnostic confidence (P < .001). The signal properties of acute ischemic infarctions were similar in both techniques and demonstrated good to excellent interrater reliability (intraclass correlation coefficient, ≥0.8). Conclusion Despite being four times faster, DL-accelerated brain MRI was interchangeable with conventional MRI for acute ischemic lesion detection. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Haller in this issue.

PD-L1 testing in metastatic triple-negative breast cancer: Interobserver and interplatform reproducibility of CE-IVD assays for CPS and IC scores

PD-L1 test is recommended in different types of tumors to select patients eligible for immune checkpoint inhibitors (ICI) therapy. Several factors make this test challenging in metastatic triple-negative breast cancer (mTNBC). Different assays and platforms are available, each associated with distinct scoring systems and threshold values specific to the ICI compound used, i.e. CPS≥10 for pembrolizumab and IC ≥ 1 % for atezolizumab. Our objective was to assess the consistency of PD-L1 testing in mTNBC by examining interobserver and interassay reproducibility.We assessed n = 60 mTNBC samples for PD-L1 testing using 22C3 pharmDx assay on a Dako Autostainer Link 48 and VENTANA PD-L1 (SP263) on a Ventana BenchMark Ultra. Additionally, a subset of n = 19 samples was tested using the SP142 assay, also on the Ventana BenchMark Ultra. CPS with both 22C3 and SP263 was independently evaluated by five pathologists, all certified PD-L1 trainers. The IC with SP142 was assessed by three of these pathologists, who have particular expertise in breast pathology. Following the computation of the intraclass correlation coefficient (ICC) for each assay and their respective thresholds, we assessed the agreement between different raters and assays using Fleiss's κ, with a 95 % confidence interval (CI).Overall, we observed a significant (p < 0.001) ICC with both CPS assays [22C3 = 0.939 (CI:0.913–0.96); SP263 = 0.972 (CI:0.96–0.982); combined 22C3-SP263 = 0.909 (CI:0.874–0.938)]. Fleiss's κ confirmed an almost perfect agreement among pathologists and assays: 22C3 = 0.938 (CI:0.857–1.018); SP263 = 0.972 (CI:0.890–1.052); combined 22C3-SP263 = 0.907 (CI:0.869–0.945). Perfect inter-rater agreement was reached considering IC.This study establishes the reliability of assessing CPS in mTNBC using either the 22C3 pharmDx, as employed in the KEYNOTE studies, or the VENTANA SP263 assay. Each assay must be used on its designated platform, namely the Dako for 22C3 pharmDx and the Ventana for VENTANA SP263. It is important to remark that CPS and IC identify different patient cohorts and, therefore, are not interchangeable.

Interrater reliability of the ovarian–adnexal reporting and data system magnetic resonance imaging (O‑RADS MRI)

Abstract Aim The current study aims to evaluate interrater reliability of ovarian–adnexal reporting and data system (O-RADS) magnetic resonance imaging (MRI) in interpretation of adnexal and ovarian lesions. Material and methods Retrospective analysis of 131 ovarian lesions was as done for 106 consecutive female patients with adnexal and/or ovarian lesions that underwent MR imaging of the pelvis. Images interpretation was accomplished by two-blinded independent raters for cystic and solid parts of ovarian lesions. The score was 5 types classified pursuant to O-RADS. Results A perfect interrater agreement regarding overall O-RADS [Kappa: 0.874, P: 0.001]. There was a perfect interrater agreement of the solid component (Kappa: 0.979, 95% confidence interval (CI) 0.938–1.0, P: 0.001), enhancement degree relative to myometrium (Kappa: 0.876, 95% CI 0.781–0.971, P: 0.001) and entirely solid lesions (Kappa: 1.0, 95% CI 1.0–1.0, P: 0.001). A perfect interrater agreement for ORADS 1 (Kappa: 0.937, P: 0.001), ORADS 2 (Kappa: 0.983, P: 0.001), ORADS 3 (Kappa: 0.834, P: 0.001), ORADS 4 (Kappa: 0.827, P: 0.001) and ORADS 5 (Kappa: 0.963, P: 0.001) was present. Conclusions The O-RADS MRI scoring system has better characterization of adnexal masses with high interrater agreement. Overcoming limitations of this study, O-RADS, may be suggested as a basic system in assessment of adnexal masses.

Modified PROMISE criteria for standardized interpretation of gastrin-releasing peptide receptor (GRPR)-targeted PET.

There are image interpretation criteria to standardize reporting prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET). As up to 10% of prostate cancer (PC) do not express PSMA, other targets such as gastrin-releasing peptide receptor (GRPR) are evaluated. Research on GRPR-targeted imaging has been slowly increasing in usage at staging and biochemical recurrence (BCR) of PC. We therefore propose a modification of the Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) criteria (mPROMISE) for GRPR-targeted PET. [68Ga]Ga-RM2 PET data from initially prospective studies performed at our institution were retrospectively reviewed: 44 patients were imaged for staging and 100 patients for BCR PC. Two nuclear medicine physicians independently evaluated PET according to the mPROMISE criteria. A third expert reader served as standard reference. Interreader reliability was computed for GRPR expression, prostate bed (T), lymph node (N), skeleton (Mb), organ (Mc) metastases, and final judgment of the scan. The interrater reliability for GRPR PET at staging was moderate for GRPR expression (0.59; 95% confidence interval [CI] 0.40, 0.78), substantial for T-stage (0.78; 95% CI 0.63, 0.94), and almost perfect for N-stage (0.97; 95% CI 0.92, 1.00) and final judgment (0.92; 95% CI 0.82, 1.00). The interreader agreement at BCR showed substantial agreement for GRPR expression (0.70; 95% CI 0.59, 0.81) and final judgment (0.65; 95% CI 0.53, 0.78), while almost perfect agreement was seen across the major categories (T, N, Mb, Mc). Acceptable performance of the mPROMISE criteria was found for all subsets when compared to the standard reference. Interpreting GRPR-targeted PET using the mPROMISE criteria showed its reliability with substantial or almost perfect interrater agreement across all major categories. The proposed modification of the PROMISE criteria will aid clinicians in decreasing the level of uncertainty, and clinical trials to achieve uniform evaluation, reporting, and comparability of GRPR-targeted PET. Clinicaltrials.gov Identifier: NCT03113617 and NCT02624518.

Feasibility of software-based assessment for automated evaluation of tooth preparation for dental crown by using a computational geometric algorithm

The purpose of this study was to propose the concept of software-based automated evaluation (SAE) of tooth preparation quality using computational geometric algorithms, and evaluate the feasibility of SAE in the assessment of abutment tooth preparation for single-unit anatomic contour crowns by comparing it with a human-based digitally assisted evaluation (DAE) by trained human evaluators. Thirty-five mandibular first molars were prepared for anatomical contour crown restoration by graduate students. Each prepared tooth was digitized and evaluated in terms of occlusal reduction and total occlusal convergence using SAE and DAE. Intra-rater agreement for the scores graded by the SAE and DAE and inter-rater agreement between the SAE and DAE were analyzed with the significance level (α) of 0.05. The evaluation using the SAE protocol demonstrated perfect intra-rater agreement, whereas the evaluation using the DAE protocol showed moderate-to-good intra-rater agreement. The evaluation values of the SAE and DAE protocols showed almost perfect inter-rater agreement. The SAE developed for tooth preparation evaluation can be used for dental education and clinical skill feedback. SAE may minimize possible errors in the conventional rating and provide more reliable and precise assessments than the human-based DAE.

Novel, Validated 5-Point Photonumeric Scales for Assessment of the Neck and Décolleté.

There is a scarcity of scales that assess platysmal bands, wrinkles in the décolleté, and horizontal neck lines in the digital and live setting. The objective of this investigation was to create and validate 5-point photonumeric scales that assess horizontal neck lines, platysmal bands, and wrinkles in the décolleté. A medical team created 3 different novel 5-point photonumeric scales for the assessment of horizontal neck lines, platysmal bands, and décolleté wrinkling. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation. The Croma (Leobendorf, Austria) Horizontal Neck Lines Assessment Scale showed substantial interrater agreement and almost perfect intrarater agreement in the digital and live validations, respectively. The Croma Platysmal Bands Assessment Scale showed substantial intrarater agreement in both digital and live validations. For the décolleté, a static scale and a dynamic scale were created and validated. The Croma Static Décolleté Wrinkles Assessment Scale showed substantial and almost perfect interrater agreement in the digital and live validations, respectively, and the intrarater agreement in both was almost perfect. The Croma Dynamic Décolleté Wrinkles Assessment Scale showed almost perfect agreement in both validation settings for both interrater and intrarater measures. The Croma Horizontal Neck Lines Assessment Scale and the Croma Static and Dynamic Décolleté Wrinkles Assessment Scales have sufficient interrater and intrarater agreement for justifiable use in clinical and research settings.

COVID-19-related cardiomyopathy: Can dual-energy computed tomography be a diagnostic tool?

No study on dual energy computed tomography (DECT) has been found in the literature to evaluate possibly fatal cardiac/myocardial problems in corona virus disease 2019 (COVID-19) patients. Myocardial perfusion deficits can be found in COVID-19 patients even without any significant coronary artery occlusion, and these deficits can be shown via DECT with a perfect interrater agreement. To assess lung perfusion alterations in COVID-19 patients. To our knowledge, no study using DECT has been performed to evaluate possibly fatal cardiac/ myocardial problems in COVID-19 patients. The purpose of this study is to evaluate the role of DECT in the detection of COVID-19-related cardiac diseases. Two blinded independent examiners evaluated CT images using the 17-segment model according to the American Heart Association's classification of the segmentation of the left ventricular myocardium. Additionally, intraluminal diseases and abnormalities in the main coronary arteries and branches were investigated. Following segment-by-segment analysis, perfusion deficiencies identified on the iodine map pictures on DECT were identified. The study enrolled a total of 87 patients. Forty-two of these individuals were classified as COVID-19 positive, and 45 were classified as controls. Perfusion deficits were identified in 66.6% (n = 30) of the cases. All control patients had a normal iodine distribution map. Perfusion deficits were found on DECT iodine map images with subepicardial (n = 12, 40%), intramyocardial (n = 8, 26.6%), or transmural (n = 10, 33.3%) anatomical locations within the left ventricular wall. There was no subendocardial involvement in any of the patients. Myocardial perfusion deficits can be found in COVID-19 patients even without any significant coronary artery occlusion. These deficits can be shown via DECT with a perfect interrater agreement. Additionally, the presence of perfusion deficit is positively correlated with D-dimer levels.

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification

The aim of this study was to propose computed tomography angiography (CTA) based anatomical segmentation of the superior mesenteric artery (SMA), in order to standardise the reporting of occlusive lesions in acute mesenteric ischaemia (AMI). A retrospective CTA evaluation of patients with occlusive AMI admitted between 2016 and 2021. After the screening of 468 patients, 95 were included. The SMA was segmented into proximal (S1, ostium to the inferior pancreaticoduodenal artery), middle (S2, from the inferior pancreaticoduodenal to the ileocolic artery), and distal (S3, downstream the ileocolic artery) sections. The jejunal arteries were labelled J1 to J6, and the middle, right, and ileocolic arteries C1, C2, and C3. Two radiologists independently applied the proposed segmentation to a cohort of patients with occlusive AMI to describe occlusive lesions. Intra- and inter-rater agreement was assessed with kappa statistics. Occlusions involved one segment in 50 (53%) patients (S1, n= 27 [28%]; S2, n= 12 [13%]; S3, n= 11 [12%]); two segments in 37 (39%) patients (S2/S3, n= 31 [33%]; S1/S2, n= 3 [3%]; S1/S3, n= 3 [3%]); and all three segments in eight patients (S1/S2/S3, 8%). The median number of jejunal arteries was four (interquartile range 3, 4.5). C1 and C2 were present in 93 (98%) and 23 patients (24%), respectively. Almost perfect intra-rater agreement was obtained for S1 (91% agreement, κ= 0.82, 95% confidence interval [CI] 0.72 - 0.92); substantial agreement was obtained for S2 (90% agreement, κ= 0.80, 95% CI 0.68 - 0.92) and S3 (86% agreement, κ= 0.72, 95% CI 0.58 - 0.86). Almost perfect inter-rater agreement (with the second junior reading) was obtained for S1 (97% agreement, κ= 0.95, 95% CI 0.89 - 1.0), S2 (91% agreement, κ= 0.82, 95% CI 0.72 - 0.92), and S3 (agreement 96%, κ= 0.91, 95% CI 0.83 - 0.99). A standardised CTA based anatomical segmental description of SMA occlusive lesions in AMI is proposed; it provided substantial to almost perfect intra- and inter-rater agreement for most anatomical segments.

Inter-Rater Agreement of the Classification of Intraoperative Adverse Events (ClassIntra) in Abdominal Surgery.

Adverse events in surgical patients can occur preoperatively, intraoperatively, and postoperatively. Universally accepted classification systems are not yet available for intraoperative adverse events (iAEs). ClassIntra has recently been developed and validated as a tool for grading iAEs that occur between skin incision and skin closure irrespective of the origin, that is, surgery, anesthesia, or organizational. The aim of this study is to assess the inter-rater agreement of ClassIntra and assess its predictive value for postoperative complications in elective abdominal surgery. This study is a secondary use of data from the LAParotomy or LAParoscopy and ADhesiolysis (LAPAD) study, with detailed data on incidence and management of intra-operative and post-operative complications. Data were collected in a cohort of elective abdominal surgeries. Two teams graded all recorded events in the LAPAD study according to ClassIntra. Cohen Kappa coefficient was calculated to determine inter-rater agreement. Uni- and multivariable linear regression was used to assess the predictive value of the ClassIntra grades for postoperative complications. IAEs were rated in 333 of 755 (44%) surgeries by team 1, and in 324 of 755 (43%) surgeries by team 2. Cohen kappa coefficient for ClassIntra grades was 0.87 [95% confidence interval (CI) 0.84-0.90]. Discrepancies in grading were most frequent for intraoperative bleeding and adhesions' associated injuries. At least 1 postoperative complication was observed in 278 (37%) patients. The risk of a postoperative complications increased with every increase in severity grade of ClassIntra. Intraoperative hypotension [mean difference (MD) 23.41, 95% CI 12.93-33.90] and other organ injuries (MD 18.90, 95% CI -4.22 - 42.02) were the strongest predictors for postoperative complications. ClassIntra has an almost perfect inter-rater agreement for the classification of iAEs. An increasing grade of ClassIntra was associated with a higher incidence of postoperative complications. Discrepancies in grading related to common complications in abdominal procedures mostly consisted of intraoperative bleeding and adhesion-related injuries. Grading of interoperative events in abdominal surgery might further improve by consensus regarding the definitions of a number of frequent events.

Performance of Deauville Criteria in [18F]FDG-PET/CT Diagnostics of Giant Cell Arteritis.

In this retrospective study, PET/CT data from 59 patients with suspected giant cell arteritis (GCA) were reviewed using the Deauville criteria to determine an optimal cut-off between PET positivity and negativity. Seventeen standardised vascular regions were analysed per patient by three investigators blinded to clinical information. Statistical analysis included ROC curves with areas under the curve (AUC), Cohen's and Fleiss' kappa (κ) to calculate sensitivity, specificity, accuracy, and agreement. According to final clinician's diagnosis and the revised 2017 ACR criteria GCA was confirmed in 29 of 59 (49.2 %) patients. With a diagnostic cut-off ≥ 4 (highest tracer uptake of a vessel wall exceeds liver uptake) for PET positivity, all investigators achieved high accuracy (range, 89.8-93.2%) and AUC (range, 0.94-0.97). Sensitivity and specificity ranged from 89.7-96.6% and 83.3-96.7%, respectively. Agreement between the three investigators suggested 'almost perfect agreement' (Fleiss' κ = 0.84) A Deauville score of ≥4 as threshold for PET positivity yielded excellent results with high accuracy and almost perfect inter-rater agreement, suggesting a standardized, reproducible, and reliable score in diagnosing GCA. However, the small sample size and reference standard could lead to biases. Therefore, verification in a multicentre study with a larger patient cohort and prospective setting is needed.

Hyperkalemia Detection in Emergency Departments Using Initial ECGs: A Smartphone AI ECG Analyzer vs. Board-Certified Physicians.

Hyperkalemia is a potentially fatal condition that mandates rapid identification in emergency departments (EDs). Although a 12-lead electrocardiogram (ECG) can indicate hyperkalemia, subtle changes in the ECG often pose detection challenges. An artificial intelligence application that accurately assesses hyperkalemia risk from ECGs could revolutionize patient screening and treatment. We aimed to evaluate the efficacy and reliability of a smartphone application, which utilizes camera-captured ECG images, in quantifying hyperkalemia risk compared to human experts. We performed a retrospective analysis of ED hyperkalemic patients (serum potassium ≥ 6 mmol/L) and their age- and sex-matched non-hyperkalemic controls. The application was tested by five users and its performance was compared to five board-certified emergency physicians (EPs). Our study included 125 patients. The area under the curve (AUC)-receiver operating characteristic of the application's output was nearly identical among the users, ranging from 0.898 to 0.904 (median: 0.902), indicating almost perfect interrater agreement (Fleiss' kappa 0.948). The application demonstrated high sensitivity (0.797), specificity (0.934), negative predictive value (NPV) (0.815), and positive predictive value (PPV) (0.927). In contrast, the EPs showed moderate interrater agreement (Fleiss' kappa 0.551), and their consensus score had a significantly lower AUC of 0.662. The physicians' consensus demonstrated a sensitivity of 0.203, specificity of 0.934, NPV of 0.527, and PPV of 0.765. Notably, this performance difference remained significant regardless of patients' sex and age (P < 0.001 for both). Our findings suggest that a smartphone application can accurately and reliably quantify hyperkalemia risk using initial ECGs in the ED.

Pediatric Interfacility Transport Curriculum: Its Impact on the Pediatric Intensive Care and Emergency Medicine Fellows’ Performance and Confidence

ObjectivePediatric interfacility transports are frequent. Despite the absence of a formal pediatric transport curriculum in eastern Canada, directly managing patients during transport and medical direction of the referring center and transport team are part of the pediatric critical care medicine (PCCM) and pediatric emergency medicine (PEM) program requirements. The authors developed a pediatric interfacility transport curriculum and measured its impact on fellows’ confidence and performance. MethodsThis was a pilot interventional prospective study in Montreal, Canada. Postcurriculum surveys were used to measure confidence, and high-fidelity simulations were used to measure performance. A target threshold for confidence was defined before implementation, and pre- and post values were compared. The simulation scenario and assessment checklist were locally developed. ResultsThe participants were 11 PCCM and 3 PEM fellows. The content of the curriculum and educational methods were selected based on the literature and a needs assessment survey. All participants rated themselves as confident at the end of the curriculum. Eighty-three percent of the participants were deemed proficient with a perfect interrater agreement. ConclusionThe pediatric transport curriculum had a positive impact on PEM and PCCM fellows’ confidence and performance in transport. Further studies should look at the impact of such a curriculum on participants’ real-life performance and patient care.

Non-contrast CT markers of intracerebral hematoma expansion: a reliability study.

We evaluated whether clinicians agree in the detection of non-contrast CT markers of intracerebral hemorrhage (ICH) expansion. From our local dataset, we randomly sampled 60 patients diagnosed with spontaneous ICH. Fifteen physicians and trainees (Stroke Neurology, Interventional and Diagnostic Neuroradiology) were trained to identify six density (Barras density, black hole, blend, hypodensity, fluid level, swirl) and three shape (Barras shape, island, satellite) expansion markers, using standardized definitions. Thirteen raters performed a second assessment. Inter- and intra-rater agreement were measured using Gwet's AC1, with a coefficient > 0.60 indicating substantial to almost perfect agreement. Almost perfect inter-rater agreement was observed for the swirl (0.85, 95% CI: 0.78-0.90) and fluid level (0.84, 95% CI: 0.76-0.90) markers, while the hypodensity (0.67, 95% CI: 0.56-0.76) and blend (0.62, 95% CI: 0.51-0.71) markers showed substantial agreement. Inter-rater agreement was otherwise moderate, and comparable between density and shape markers. Inter-rater agreement was lower for the three markers that require the rater to identify one specific axial slice (Barras density, Barras shape, island: 0.46, 95% CI: 0.40-0.52 versus others: 0.60, 95% CI: 0.56-0.63). Inter-observer agreement did not differ when stratified for raters' experience, hematoma location, volume, or anticoagulation status. Intra-rater agreement was substantial to almost perfect for all but the black hole marker. In a large sample of raters with different backgrounds and expertise levels, only four of nine non-contrast CT markers of ICH expansion showed substantial to almost perfect inter-rater agreement. • In a sample of 15 raters and 60 patients, only four of nine non-contrast CT markers of ICH expansion showed substantial to almost perfect inter-rater agreement (Gwet's AC1> 0.60). • Intra-rater agreement was substantial to almost perfect for eight of nine hematoma expansion markers. • Only the blend, fluid level, and swirl markers achieved substantial to almost perfect agreement across all three measures of reliability (inter-rater agreement, intra-rater agreement, agreement with the results of a reference reading).

Considerations on Baseline Generation for Imaging AI Studies Illustrated on the CT-Based Prediction of Empyema and Outcome Assessment.

For AI-based classification tasks in computed tomography (CT), a reference standard for evaluating the clinical diagnostic accuracy of individual classes is essential. To enable the implementation of an AI tool in clinical practice, the raw data should be drawn from clinical routine data using state-of-the-art scanners, evaluated in a blinded manner and verified with a reference test. Three hundred and thirty-five consecutive CTs, performed between 1 January 2016 and 1 January 2021 with reported pleural effusion and pathology reports from thoracocentesis or biopsy within 7 days of the CT were retrospectively included. Two radiologists (4 and 10 PGY) blindly assessed the chest CTs for pleural CT features. If needed, consensus was achieved using an experienced radiologist’s opinion (29 PGY). In addition, diagnoses were extracted from written radiological reports. We analyzed these findings for a possible correlation with the following patient outcomes: mortality and median hospital stay. For AI prediction, we used an approach consisting of nnU-Net segmentation, PyRadiomics features and a random forest model. Specificity and sensitivity for CT-based detection of empyema (n = 81 of n = 335 patients) were 90.94 (95%-CI: 86.55–94.05) and 72.84 (95%-CI: 61.63–81.85%) in all effusions, with moderate to almost perfect interrater agreement for all pleural findings associated with empyema (Cohen’s kappa = 0.41–0.82). Highest accuracies were found for pleural enhancement or thickening with 87.02% and 81.49%, respectively. For empyema prediction, AI achieved a specificity and sensitivity of 74.41% (95% CI: 68.50–79.57) and 77.78% (95% CI: 66.91–85.96), respectively. Empyema was associated with a longer hospital stay (median = 20 versus 14 days), and findings consistent with pleural carcinomatosis impacted mortality.

Grading Pancreatic Neuroendocrine Tumors via Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Multi-Institutional Study

Introduction: World Health Organization (WHO) grading system is prognostic in pancreatic neuroendocrine tumors (PanNETs). Concordance between WHO-grade on cytology (c-grade) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and histopathological analysis (h-grade) of surgical specimen is reported between 60% and 80%. Factors associated with concordance and trends of utilization of EUS-FNA remain poorly understood. Methods: A multicenter retrospective study was performed on patients undergoing resection for PanNETs at four high-volume centers. Patients with functional or syndrome-associated tumors, and those receiving neoadjuvant therapy were excluded. Factors associated with concordance and trends of utilization of EUS-FNA were assessed. Results: Of 1,329 patients, 682 (51.1%) underwent EUS-FNA; 567(83.1%) were diagnostic of PanNETs and WHO-grade was reported for 293 (51.7%) patients. The concordance between c-grade and h-grade was 78.2% with moderate inter-rater agreement (Kc=0.48,p<0.001). Significantly higher rates of concordance were observed in patients with smaller tumors (<2 vs. ≥2 cm, 88.9% vs. 72.7%,p=0.001). The highest concordance of 97.9% was observed in patients with small tumors undergoing assessment between 2015-2019 with near perfect inter-rater agreement (Kc=0.88, p<0.001) An increase in utilization of EUS-FNA (46.7% to 62.1%) was observed over the last 2 decades (p<0.001). EUS-FNA was more frequently diagnostic of PanNETs (p<0.001), and WHO-grade was more frequently reported (<0.001). Concordance between c-grade and h-grade did not change significantly (p=0.056). Conclusion: Recently, a trend towards increasing utilization and improved diagnostic accuracy of EUS-FNA has been observed in PanNETs. Concordance between c-grade and h-grade is associated with tumor size with strong agreement when assessing PanNETs >2cm in size.

Nurse-led cardiovascular diseases risk assessment and communication using WHO/ISH risk prediction chart in a tertiary care hospital of North India.

Cardiovascular diseases (CVDs) contribute to most of the potentially preventable burden through early risk assessment. Nurse-led CVD risk assessment is an effective strategy to address the human resource crisis for CVD prevention. An interventional study was conducted in medicine wards of a tertiary care hospital in North India to train nurses in CVD risk assessment and its communication. All bedside nurses (n = 30) of selected wards were enrolled and trained in CVD risk assessment and communication using WHO/ISH risk prediction charts. Once fully trained, each nurse enrolled patients (>40 years of age) from their respective wards to assess and communicate CVD risk. To calculate the reliability of risk assessment, investigator simultaneously assessed CVD risk with nurses. The mean age of nurses was 32.07 ± 6.31 years. The results revealed that training significantly increased the knowledge of nursing personnel (P < 0.001). There was perfect inter-rater reliability agreement (Cohen's k = 0.929) between nurses and investigators while assessing CVD risk. Nurses demonstrated good communication skills. The study concluded that nurses can be trained successfully in CVD risk assessment and communication. The study recommends the task shifting of CVD risk assessment to nurses after providing proper training.

The impact of the field of view (FOV) on image quality in MDCT angiography of the lower extremities

ObjectivesTo evaluate the impact of the reconstructed field-of-view (FOV) on image quality in computed-tomography angiography (CTA) of the lower extremities.MethodsA total of 100 CTA examinations of the lower extremities were acquired on a 2 × 192-slice multidetector CT (MDCT) scanner. Three different datasets were reconstructed covering both legs (standard FOV size) as well as each leg separately (reduced FOV size). The subjective image quality was evaluated for the different vessel segments (femoral, popliteal, crural, pedal) by three readers using a semi-quantitative Likert scale. Additionally, objective image quality was assessed using an automated image quality metric on a per-slice basis.ResultsThe subjective assessment of the image quality showed an almost perfect interrater agreement. The image quality of the small FOV datasets was rated significantly higher as compared to the large datasets for all patients and vessel segments (p < 0.05) with a tendency towards a higher effect in smaller vessels. The difference of the mean scores between the group with the large FOV and small FOV was 0.68 for the femoral level, 0.83 for the popliteal level, 1.12 for the crural level, and 1.08 for the pedal level. The objective image quality metric also demonstrated a significant improvement of image quality in the small FOV datasets.ConclusionsSide-separated reconstruction of each leg in CTA of the lower extremities using a small reconstruction FOV significantly improves image quality as compared to a standard reconstruction with a large FOV covering both legs.Key Points• In CT angiography of the lower legs, the side-separated reconstruction of each leg using a small field-of-views improves image quality as compared to a standard reconstruction covering both legs.• The side-separated reconstruction can be readily implemented at every commercially available CT scanner.• There is no need for additional hardware or software and no additional burden to the patient.

P.146 Non-contrast CT markers of intracerebral hemorrhage expansion: a predictive accuracy and reliability study

Background: We evaluated (1) the predictive accuracy and (2) multi-observer reliability of non-contrast CT markers of hematoma expansion (HE). Methods: In 124 patients with spontaneous intracerebral hemorrhage, two investigators documented the presence of six density (Barras density, hypodensity, black hole, swirl, blend, fluid level) and three shape (Barras shape, island, satellite) expansion markers, with discrepancies resolved by a third rater. We defined HE as any one of (1) &gt;6 mL absolute or &gt;33% relative growth of the intraparenchymal hematoma or (2) an absolute growth of &gt;1 mL or new development of intraventricular hematoma. A subsample of 60 patients was used for the inter-observer reliability study in 13 raters. Seven raters participated in the intra-rater study. Results: The sensitivity of markers for HE varied between 4% (fluid level) and 78% (satellite), while specificity ranged from 37% (swirl) to 97% (black hole). Almost perfect inter-rater agreement was observed for the swirl (0.89) and fluid level (0.83) markers, while hypodensity (0.65) showed substantial agreement. Only the blend and fluid level markers achieved substantial intra-rater agreement (&gt; 0.6) in all raters. Conclusions: Non-contrast CT markers of HE showed lower reliability and predictive accuracy than previously reported. Future studies should address means to improve NCCT-based HE prediction.

Arterial Spin Labeling for the Etiological Workup of Intracerebral Hemorrhage in Children.

Pediatric nontraumatic intracerebral hemorrhage accounts for half of stroke in children. Early diagnostic of the causative underlying lesion is the first step toward prevention of hemorrhagic recurrence. We aimed to investigate the performance of arterial spin labeling sequence (ASL) in the acute phase etiological workup for the detection of an arteriovenous shunt (AVS: including malformation and fistula), the most frequent cause of pediatric nontraumatic intracerebral hemorrhage. Children with a pediatric nontraumatic intracerebral hemorrhage between 2011 and 2019 enrolled in a prospective registry were retrospectively included if they had undergone ASL-magnetic resonance imaging before any etiological treatment. ASL sequences were reviewed using cerebral blood flow maps by 2 raters for the presence of an AVS. The diagnostic performance of ASL was compared with admission computed tomography angiography, other magnetic resonance imaging sequences including contrast-enhanced sequences and subsequent digital subtraction angiography. A total of 121 patients with pediatric nontraumatic intracerebral hemorrhage were included (median age, 9.9 [interquartile range, 5.8-13]; male sex 48.8%) of whom 76 (63%) had a final diagnosis of AVS. Using digital subtraction angiography as an intermediate reference, visual ASL inspection had a sensitivity and a specificity of, respectively, 95.9% (95% CI, 88.5%-99.1%) and 79.0% (95% CI, 54.4%-94.0%). ASL had a sensitivity, specificity, and accuracy of 90.2%, 97.2%, and 92.5%, respectively for the detection of the presence of an AVS, with near perfect interrater agreement (κ=0.963 [95% CI, 0.912-1.0]). The performance of ASL alone was higher than that of other magnetic resonance imaging sequences, individually or combined, and higher than that of computed tomography angiography. ASL has strong diagnostic performance for the detection of AVS in the initial workup of intracerebral hemorrhage in children. If our findings are confirmed in other settings, ASL may be a helpful diagnostic imaging modality for patients with pediatric nontraumatic intracerebral hemorrhage. URL: https://www.clinicaltrials.gov; Unique identifiers: 3618210420, 2217698.

Validation of a Chin Retrusion Scale for Chinese Subjects.

Chin augmentation procedures are gaining in popularity. The purpose of this study was to validate the China (Allergan) Chin Retrusion Scale (CACRS) and to evaluate the reliability of the scale. A team of 10 physicians based in Beijing, China, consisting of 1 principal investigator and 9 independent raters, assessed a pool of subject images. Using standardized equipment to capture 2-dimensional images, 100 subjects were photographed from a left, lateral, 90° view. Two measures were used to assess the validity of the scale: rater evaluations of clinically significant differences in 52 pairs of images and rater assessment of chin retrusion using the CACRS to grade the 100 images. The CACRS demonstrated almost perfect inter-rater agreement during 2 validation sessions, with intraclass correlation coefficients of 0.89 and 0.90 at sessions 1 and 2, respectively. Overall inter-rater agreement for all 9 raters was almost perfect, with a weighted kappa of 0.82. Based on inter- and intra-rater agreement, the CACRS was validated for physician ratings of chin retrusion in Chinese subjects. Results from clinical significance evaluations indicated that a 1-grade difference between image pairs was considered clinically meaningful for the CACRS. The CACRS is a validated and reliable photonumeric scale for the assessment of chin retrusion in Chinese men and women. The scale is a clinically significant reference tool for evaluating the effect of chin augmentation.