Perfect Intraobserver Agreement Research Articles

Influence of intercostal muscles contraction on sonographic evaluation of lung sliding: a physiological study on healthy subjects

ObjectivesTo investigate the following: (a) effects of intercostal muscle contraction on sonographic assessment of lung sliding and (b) inter-rater and intra-observer agreement on sonographic detection of lung sliding and lung pulse.MethodsWe used Valsalva and Muller maneuvers as experimental models in which closed glottis and clipped nose prevent air from entering the lungs, despite sustained intercostal muscles contraction. Twenty-one healthy volunteers underwent bilateral lung ultrasound during tidal breathing, apnea, hyperventilation, and Muller and Valsalva maneuvers. The same expert recorded 420 B-mode clips and 420 M-mode images, independently evaluated for the presence or absence of lung sliding and lung pulse by three raters unaware of the respiratory activity corresponding to each imaging.ResultsDuring Muller and Valsalva maneuvers, lung sliding was certainly recognized in up to 73.0% and up to 68.7% of imaging, respectively, with a slight to fair inter-rater agreement for Muller maneuver and slight to moderate for Valsalva. Lung sliding was unrecognized in up to 42.0% of tidal breathing imaging, and up to 12.5% of hyperventilation imaging, with a slight to fair inter-rater agreement for both. During apnea, interpretation errors for sliding were irrelevant and inter-rater agreement moderate to perfect. Even if intra-observer agreement varied among raters and throughout respiratory patterns, we found it to be higher than inter-rater reliability.ConclusionsIntercostal muscles contraction produces sonographic artifacts that may simulate lung sliding. Clinical studies are needed to confirm this hypothesis. We found slight to moderate inter-rater agreement and globally moderate to almost perfect intra-observer agreement for lung sliding and lung pulse.Trial registrationClinicalTrials.gov registration number.NCT 02386696.

Assessing the reproducibility and predictive value of objective cough measurement for successful withdrawal of invasive ventilatory support in adult patients

BackgroundUtilizing clinical tests, such as objective cough measurement, can assist in predicting the success of the weaning process in critically ill patients.MethodsA multicenter observational analytical study was conducted within a prospective cohort of patients recruited to participate in COBRE-US. We assessed the capability of objective cough measurement to predict the success of the spontaneous breathing trial (SBT) and extubation. Intra- and inter-observer reproducibility of the cough test and was evaluated using the intraclass correlation coefficient (ICC) and Cohen’s weighted kappa. We used receiver operating characteristic curves (ROC-curve) to evaluate the predictive ability of objective cough measurement.ResultsWe recruited 367 subjects who were receiving invasive mechanical ventilation. A total of 451 objective cough measurements and 456 SBTs were conducted. A significant association was found between objective cough measurement and successful SBT (OR: 1.68; 95% CI 1.48–1.90; p = 0.001). The predictive capability of the objective cough test for SBT success had a ROC-curve of 0.58 (95% CI: 0.56–0.61). Objective cough measurement to predict successful extubation had a ROC-curve of 0.61 (95% CI: 0.56–0.66). The intraobserver reproducibility exhibited an ICC of 0.94 (95% CI: 0.89–0.96; p < 0.001), while the interobserver reproducibility demonstrated an ICC of 0.72 (95% CI: 0.51–0.85; p < 0.001). The intraobserver agreement, assessed using Cohen’s weighted kappa was 0.94 (95% CI: 0.93–0.99; p < 0.001), whereas the interobserver agreement was 0.84 (95% CI: 0.67 − 0.10; p < 0.001).ConclusionsThe objective measurement of cough using the method employed in our study demonstrates nearly perfect intra-observer reproducibility and agreement. However, its ability to predict success or failure in the weaning process is limited.

Three-dimensional magnetic resonance cholangiography is superior to two-dimensional single-shot magnetic resonance cholangiography for visualization and image quality of the feline and canine biliary tract: A postmortem study.

Magnetic resonance cholangiography (MRC) is an established diagnostic tool for noninvasive assessment of the biliary tract in humans. It has also been found to be feasible in companion animals, but no published studies have compared MRC sequences in veterinary medicine. The present study is part of a prospective, observational, analytical investigation on MR cholangiopancreatography performed on the donated bodies of 12 cats and eight dogs. The main aim of this study was to compare the images of 2D-SSh-TSE-MRC and 3D-TSE-MRC sequences for visualization and image quality of the feline and canine biliary tract. Both sequences are T2-weighted and noncontrast. Three independent readers scored the visibility of four segments of the biliary tract, namely the gallbladder (GB), cystic duct, common bile duct (CBD), and extrahepatic ducts, and the image quality of the two MRC sequences using five-point Likert scales. Wilcoxon signed-rank test was used to compare the scores between the MRC sequences separately for cats and dogs. Inter- and intraobserver agreements were measured using Gwet's AC2 with linear weighting. The 3D-TSE-MRC images were scored significantly higher than the 2D-SSh-TSE-MRC for both visibility and image quality (P<.001-.016 for cats, P=.008-.031 for dogs); the only exception was GB in dogs. In both cats and dogs, interobserver agreement for segment visibility and image quality ranged from slight to substantial in 2D-SSh-TSE-MRC and from poor to almost perfect in 3D-TSE-MRC. Most of the assessments (73% for segment visibility and 66% for image quality) had substantial to almost perfect intraobserver agreement. Findings from the current study support the use of 3D-TSE-MRC over 2D-SSh-TSE-MRC for evaluation of the feline and canine biliary tract, but further studies on live animals are warranted.

A Novel Classification of Intraoperative Ulnar Nerve Instability to Aid Transposition Surgery

The purpose of this study was to compare inter-and intraobserver agreement of a novel intraoperative subluxation classification for patients undergoing ulnar nerve surgery at the elbow. We hypothesize there will be strong inter- and intraobserver agreement of the four-category classification system and reviewers will have substantial confidence while reviewing the classification system. Four blinded fellowship-trained orthopedic hand surgeons reviewed 25 videos in total on two separate viewings, 21 days apart. Variables collected were ulnar subluxation classification (A, B, C or D) and a confidence metric. Subsequent to primary data collection, classification grading was stratified into A/B or C/D subgroups for further analysis. Cohen's kappa scores were used to evaluate all variables collected in this study. The interpretation of kappa scores included ≤0.0 as no agreement, 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.0 as almost perfect agreement. Interobserver agreement of subluxation classification as a four-category scale demonstrated a moderate agreement on first viewing, second viewing, and when both viewings were combined (kappa=0.51, 0.51, and 0.51 respectively). Seventy-five percent (3 out of 4) of reviewers had moderate intraobserver agreement for ulnar nerve subluxation classification while one reviewer had substantial intraobserver classification (kappa= 0.72). Overall, there was high confidence in 65% of classification scores in the second round of viewing, which improved from 58% in the first viewing round. When ulnar subluxation classification selections were regrouped into classes A/B or C/D, 100% of reviewers had substantial interobserver (kappa=0.74 - 0.75) and substantial to almost perfect intraobserver (kappa=0.71 to 0.91) agreement. The four-category classification was reproducible within and between reviewers. Agreement appeared to increase when simplifying the classification to two categories, which may provide guidance to surgical decision making. The validation of a reproducible classification scheme for intraoperative ulnar subluxation may aid with decision making and further postoperative outcomes research.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

A new comprehensive MRI classification and grading system for lumbosacral central and lateral stenosis: clinical application and comparison with previous systems.

The purpose of our study was to provide a novel schematized and comprehensive classification of causes and severity grading system for lumbosacral stenosis. The MRI system proposed consisted of a severity grading scale for central and lateral (recess and foramen) stenosis, together with a schematized indication of the main causes of the disease (disc, arthritis, epidural lipomatosis, and their combinations). The system was applied to a cohort of patients from a single Institution in the last 2-years. Two radiologists evaluated all the MRIs to determine intra- and inter-observer reliability according to Cohen Kappa (Kc, for non-ordered categorical variables) and weighted Kappa (Kw, for ordered variables). Two orthopaedic surgeons clinically evaluated all patients and provided a schematic grading system with a central and lateral stenosis clinical score (CS-CS and LS-CS). Associations between ordinals were tested with chi-square test and measured with the Goodman and Kruskal's gamma index (Gi, with 95% confidence interval [95% CI]). Lastly, the most used previous MRI systems were applied, and their performances were compared to the new system proposed. One hundred and twelve patients were included (55 females-mean age 63.3 ± 10.7years). An almost perfect intra-observer agreement for the assessment of central stenosis, foramen stenosis, and lateral recess stenosis was found (Kw = 0.929, 0.928, and 0.924, respectively). The inter-observer agreement was almost perfect for central stenosis and foramen stenosis and substantial for lateral recess stenosis (Kw = 0.863, 0.834, and 0.633, respectively). Whatever the aetiologies involved in central and lateral stenosis, the intra-observer agreement was perfect (all Kc = 1), whereas the inter-observer agreements were almost perfect for arthritis (Kc = 0.838) and lipomatosis (Kc = 0.955) and substantial for disc (Kc = 0.691) regarding central stenosis. The inter-observer agreement for the causes of lateral stenosis was lower and variable, ranging from perfect (lipomatosis) to fair (disc, Kc = 0.224). The grading system revealed a strong association with CS-CS for both readers, with GI = 0.671 (95% CI 0.535-0.807) and 0.603 (95% CI = 0.457-0.749), respectively. The association with MRI grading and LS-CS was moderate for foraminal stenosis and for the concomitant presence of foraminal and lateral recess stenosis, with Gi = 0.337 (95% CI 0.121-0.554) and Gi = 0.299 (95% CI 0.098-0.500), respectively. A weak association was found between lateral recess grading alone and LS-CS with Gi = 0.102 (95% CI 0.193-0.397). The new grading systems showed higher Gi for associations with clinical symptoms, compared with previous ones, both for CS-CS and LS-CS. A standardized visual grading system for lumbar spinal stenosis that takes into account all of the major contributing factors-including disc, arthritis, and lipomatosis, for the central canal, lateral recess, and neural foramina could be a useful and practical tool for defining the stenosis, lowering inter-observer variability, and directing the various treatment options.

Markedly hypoechoic: a new definition improves the diagnostic performance of thyroid ultrasound.

To determine the contribution of a modified definition of markedly hypoechoic in the differential diagnosis of thyroid nodules. A total of 1031 thyroid nodules were included in this retrospective multicenter study. All of the nodules were examined with US before surgery. The US features of the nodules were evaluated, in particular, the classical markedly hypoechoic and modified markedly hypoechoic (decreased or similar echogenicity relative to the adjacent strap muscles). The sensitivity, specificity, and AUC of classical/modified markedly hypoechoic and the corresponding ACR-TIRADS, EU-TIRADS, and C-TIRADS categories were calculated and compared. The inter- and intraobserver variability in the evaluation of the main US features of the nodules was assessed. There were 264 malignant nodules and 767 benign nodules. Compared with classical markedly hypoechoic as a diagnostic criterion for malignancy, using modified markedly hypoechoic as the criterion resulted in a significant increase in sensitivity (28.03% vs. 63.26%) and AUC (0.598 vs. 0.741), despite a significant decrease in specificity (91.53% vs. 84.88%) (p < 0.001 for all). Compared to the AUC of the C-TIRADS with the classical markedly hypoechoic, the AUC of the C-TIRADS with the modified markedly hypoechoic increased from 0.878 to 0.888 (p = 0.01); however, the AUCs of the ACR-TIRADS and EU-TIRADS did not change significantly (p > 0.05 for both). There was substantial interobserver agreement (κ = 0.624) and perfect intraobserver agreement (κ = 0.828) for the modified markedly hypoechoic. The modified definition of markedly hypoechoic resulted in a significantly improved diagnostic efficacy in determining malignant thyroid nodules and may improve the diagnostic performance of the C-TIRADS. Our study found that, compared with the original definition, modified markedly hypoechoic significantly improved the diagnostic performance in differentiating malignant from benign thyroid nodules and the predictive efficacy of the risk stratification systems. • Compared with the classical markedly hypoechoic as a diagnostic criterion for malignancy, the modified markedly hypoechoic resulted in a significant increase in sensitivity and AUC. • The C-TIRADS with the modified markedly hypoechoic achieved higher AUC and specificity than that with the classical markedly hypoechoic (p = 0.01 and < 0.001, respectively).

Cone beam computed tomography in the assessment of TMJ deformity in children with JIA: repeatability of a novel scoring system

BackgroundThe temporomandibular joint (TMJ) is frequently involved in juvenile idiopathic arthritis (JIA). Diagnostic imaging is necessary to correctly diagnose and evaluate TMJ involvement, however, hitherto little has been published on the accuracy of the applied scoring systems and measurements. The present study aims to investigate the precision of 20 imaging features and five measurements based on cone beam computed tomography (CBCT).MethodsImaging and clinical data from 84 participants in the Norwegian study on juvenile idiopathic arthritis, the NorJIA study, were collected. Altogether 20 imaging features and five measurements were evaluated independently by three experienced radiologists for intra- and interobserver agreement. Agreement of categorical variables was assessed by Fleiss’, Cohen’s simple or weighted Kappa as appropriate. Agreement of continuous variables was assessed with 95% limits of agreement as advised by Bland and Altman.Results“Overall impression of TMJ deformity” showed almost perfect intraobserver agreement with a kappa coefficient of 0.81 (95% CI 0.69–0.92), and substantial interobserver agreement (Fleiss’ kappa 0.70 (0.61–0.78)). Moreover, both “flattening” and “irregularities” of the eminence/fossa and condyle performed well, with intra- and interobserver agreements of 0.66–0.82 and 0.55–0.76, respectively. “Reduced condylar volume” and “continuity” of the fossa/eminence had moderate intra- and interobserver Kappa values, whereas continuity of the condyle had Kappa values above 0.55. Measurements of distances and angles had limits of agreement of more than 15% of the sample mean.ConclusionsWe propose a CBCT-based scoring system of nine precise imaging features suggestive of TMJ deformity in JIA. Their clinical validity must be tested.

AGREEMENT ON MRI DIAGNOSIS IN COMPRESSIVE MALIGNANT VERTEBRAL FRACTURES.

Verify interobserver and intraobserver agreement of malignant compressive vertebral fractures (MCVF) diagnosis using magnetic resonance imaging (MRI). We retrospectively included a lumbar spine MRI of 63 patients with non-traumatic compressive vertebral fracture diagnoses. Each lumbar vertebra was classified as: without fracture, with fracture of benign characteristics, or with fracture of malignant characteristics. Two medical residents in radiology, one musculoskeletal radiologist fellow, one musculoskeletal radiologist, and two spine surgeons evaluated MRI exams, independently and blindly. Each observer performed two readings, with a 15-day interval between evaluations. A simple Kappa coefficient was used to calculate the intra and interobserver agreement. The reference standard classification was based on bone biopsy or clinical, and imaging follow-up of at least two years, for diagnostic performance analysis. Diagnostic performance was assessed by calculating sensitivity, specificity, accuracy, and positive and negative predictive values with a 95% confidence interval (CI). We observed substantial to perfect intraobserver agreement (kappa: 0.80 to 1.00) and substantial interobserver agreement (kappa 0.64 to 0.77). In general, the sensitivity for the detection of MCVF was moderate, except for the second-year radiology resident that achieved a lower sensitivity. The specificity, accuracy, and negative predictive value were high for all observers. MCVF diagnosis using MRI showed substantial interobserver agreement. The second-year medical resident achieved lower sensitivity but high specificity for MCVF. Regarding the seniors, there was no statistical significance between spine surgeons and the musculoskeletal radiologist. Level of Evidence III; Diagnostic.

A novel algorithm for classification of interatrial communications within the oval fossa in the newborn.

An interatrial communication is present in most neonates. The majority are considered the "normal" patency of the oval foramen, while a minority are abnormal atrial septal defects. Differentiation between the two with transthoracic echocardiography may be challenging, and no generally accepted method of classification is presently available. We aimed to develop and determine the reliability of a new classification of interatrial communications in newborns. An algorithm was developed based on echocardiographic criteria from 495 newborns (median age 11[8;13] days, 51.5% females). The algorithm defines three main categories: patency of the oval foramen, atrial septal defect, and no interatrial communication as well as several subtypes. We found an interatrial communication in 414 (83.6%) newborns. Of these, 386 (93.2%) were categorised as patency of the oval foramen and 28 (6.8%) as atrial septal defects.Echocardiograms from another 50 newborns (median age 11[8;13] days, 36.0% female), reviewed by eight experts in paediatric echocardiography, were used to assess the inter- and intraobserver variation of classification of interatrial communications into patency of the oval foramen and atrial septal defect, with and without the use of the algorithm. Review with the algorithm gave a substantial interobserver agreement (kappa = 0.66), and an almost perfect intraobserver agreement (kappa = 0.82). Without the use of the algorithm, the interobserver agreement between experienced paediatric cardiologists was low (kappa = 0.20). A new algorithm for echocardiographic classification of interatrial communications in newborns produced almost perfect intraobserver and substantial interobserver agreement. The algorithm may prove useful in both research and clinical practice.

Methods of Radiographic Measurements of Heart and Left Atrial Size in Dogs with and without Myxomatous Mitral Valve Disease: Intra- and Interobserver Agreement and Practicability of Different Methods

Simple SummaryIn the present study, different radiographic measurements for evaluating the cardiac size and left atrial size in dogs with and without myxomatous mitral valve disease were evaluated. Veterinarians applied these measurements with different levels of experience to identify heart enlargement in conventional and inverted radiographs. The repeatability and ease of application were evaluated. It was shown that radiographic measurements can identify cardiac enlargement reliably and even potentially stage dogs with myxomatous mitral valve disease if echocardiography is unavailable. The measurements can be performed in conventional and inverted radiographs with reliable results by veterinarians with different degrees of experience.Dogs suffering from Myxomatous Mitral Valve Disease (MMVD) show a potential heart enlargement, especially in the left atrium, detectable by radiography. Due to digital radiography, different radiographic measurements estimate cardiac size quite uncomplicatedly. The Vertebral Heart Size (VHS), Radiographic Left Atrial Dimension (RLAD), Left Atrial Width (LAWidth), and the Vertebral Left Atrial Size (VLAS) used anatomical landmarks for measuring cardiac size in relation to the vertebral column. This study aimed to compare VHS, RLAD, LAWidth, and VLAS measured in conventional and inverted radiographs by veterinarians with different levels of experience in healthy dogs and dogs with MMVD. The reliability and user-friendliness of these measurements were evaluated, and the staging was compared to the echocardiography staging. A total of 50 unaffected dogs and 150 dogs with MMVD in stages B1, B2, and C were assessed. Three veterinarians with different levels of experience examined 200 conventional radiographs and their corresponding inverted radiographs blinded to the echocardiographic and clinical examination results. Analyses were performed to compare the measurements’ grading and determine anatomical landmarks with measurement difficulties. Additionally, inter- and intraobserver agreement was assessed using intraclass correlation coefficient, and the agreement between radiographic and echocardiographic staging was compared using the kappa coefficient. The VHS, LAWidth, and VLAS were easier to define than the RLAD. The interobserver agreement was almost perfect for VHS (0.962) and good for the other radiographic measurements (RLAD: 0.778, LAWidth: 0.772, VLAS: 0.858). The VHS assigned the most dogs to the correct stage. However, VHS, RLAD, LAWidth, and VLAS presented an almost perfect intraobserver agreement. The dorsal left atrial margin of the RLAD was the most difficult measurement point to identify. The VHS is the most reproducible radiographic method for measuring the canine heart size and shows the highest agreement with echocardiography. An observer-related influence could be detected for RLAD, LAWidth, and VLAS.

Inter and Intraobserver Agreement of the IOOG SAMEO ATO Classification for Tympanomastoid Surgery.

In 2018 the International Otology Outcome Group (IOOG) introduced the stage of surgery, approach, mastoidectomy, external ear canal reconstruction, obliteration of mastoid cavity, access to middle ear, tympanic membrane, ossicular chain (SAMEO ATO) categorization framework for tympanomastoid surgery to develop a classification system that encompasses all aspects of surgical technique that are likely to influence the outcome of tympanomastoid surgery. To date there is no study that examines inter or intraobserver reliability of this classification system. To assess inter and intraobserver reliability of the SAMEO ATO classification. Retrospective single center study. Two observers independently categorized 167 tympanomastoid surgeries using the SAMEO-ATO system to allow for interobserver analysis. Categorization was performed retrospectively from operation notes. Intraobserver reliability was evaluated for one observer. One hundred sixty seven tympanomastoid surgeries performed by a single surgeon between 2018 and 2021. Inter and intraobserver reliability calculated using Cohen's kappa. Almost perfect interobserver agreement was seen for stage of surgery ( S ), approach ( A ), mastoidectomy ( M ), and ossicular chain ( O ) with kappa scores ranging from of 0.957 to 0.848.Almost perfect intraobserver agreement was seen for approach ( A ), mastoidectomy ( M ), external ear reconstruction ( E ), obliteration of mastoid cavity ( O ), access to middle ear ( A ), and ossicular chain ( O ) with kappa ranging from 0.929 to 08.21. The SAMEO ATO classification is a reliable system for recording surgical procedures. Given the complexity of the SAMEO ATO classification it is vital that those using it have a thorough knowledge of the classification.

Revising the modified Neer classification for distal clavicle fractures: Description and reliability

BackgroundThe modified Neer classification is the most widely used classification system for distal clavicle fractures. However, it provides limited information for treatment decisions. The objective of this study was to revise the modified Neer classification to make it more suitable for treatment decision-making. HypothesisThe revised version of the modified Neer classification has good intra- and interobserver agreements and provides an instructive treating algorithm. Study designCohort study MethodsSix observers, including three experienced shoulder specialists and three junior orthopaedic residents, independently reviewed plain radiographs of 52 patients with distal clavicle fractures. They were asked to classify the fracture types according to the modified Neer classification and our revised new classification separately to determine treatment approaches for each patient. Images were mirrored and randomized to verify the intraobserver agreement. Reliabilities were measured using the Fleiss kappa values. ResultsBoth the modified Neer classification and our revised version had near perfect intraobserver agreement (κ values: 0.87–1.00), whereas our revised Neer classification had a better interobserver agreement (κ values: 0.78 vs. 0.70, z = 4.70, p < 0.01) and stronger relevance to treatment decisions (coefficient of contingency: 0.70 vs. 0.44). ConclusionOur study demonstrated a near-perfect intraobserver and substantial interobserver agreement of the revised new classification, indicating that our revised new classification was better than the modified Neer classification. Meanwhile, our revised classification brought few disputes in treatment selection. Clinical relevanceThe modified Neer classification was revised to make it more accurate and suitable for guiding treatment. Type of studyStudy of diagnostic test Level of studyLevel II

Vertebral heart size and vertebral left atrial size reference ranges in healthy Maltese dogs

The most common cardiac measurements on thoracic radiography in veterinary medicine are vertebral heart size (VHS) and vertebral left atrial size (VLAS). Previously published studies have demonstrated evidence that reference ranges for these measures vary among different dog breeds, however reference ranges for Maltese breed dogs are currently lacking. We hypothesized that VHS and VLAS in healthy Maltese dogs would not be influenced by sex, age, or bodyweight. This retrospective, reference interval study aimed to describe reference intervals for VHS and VLAS in a sample of clinically healthy Maltese dogs and assess the intra- and interobserver variabilities for VLAS and VHS measurements. A total of 81 clinically healthy Maltese dogs were included, with healthy status being based on a complete cardiologic examination. Thoracic radiography in right lateral recumbency was performed for all dogs. The intra- and interobserver variability assessments of VHS and VLAS were based on measurements independently performed by three observers. The mean VHS was 9.53 ± 0.46 vertebrae (v). The median and interquartile range (IQR) for VLAS was 2 v (IQR, 1.8-2.1v). A statistically significant moderate positive correlation was observed between VHS and VLAS (P<.01, r=0.416). Both VHS and VLAS showed an almost perfect intraobserver agreement. Interobserver agreement was almost perfect for VHS and substantial for VLAS. Findings supported previous studies recommending the use of breed-specific reference values for VHS and VLAS, and provided background data for future radiographic evaluations of Maltese dogs with clinical signs of cardiac disease.

Accuracy of the Light-induced Fluorescent Intraoral Camera in Occlusal Caries Detection

This study was conducted to evaluate the accuracy of a light-induced fluorescence intraoral camera vs the visual-tactile assessment method according to the modified International caries detection and assessment system-II (ICDAS-II) criteria clinically in the detection of initial occlusal caries. Occlusal surfaces of 260 molar and premolar teeth from 52 adult participants were examined by two calibrated observers, using two diagnostic methods. Teeth were initially assessed visually according to the criteria of the ICDAS-II, and then by fluorescence camera (Soprolife®). Inter- and intraobserver agreements were measured using Cohen's kappa test. Correlation between methods was calculated using Wilcoxon signed-rank test, and effect size for comparison between the two modalities. The sensitivity, specificity, predictive values, diagnostic accuracy, likelihood ratios (LRs), area under the receiver operating characteristic (ROC) curve (AUC), and 95% confidence interval (95% CI) of the AUC for caries detection by Soprolife® were evaluated. A significant positive correlation was found between the ICDAS-II and camera measurements (p-value <0.001, effect size = 0.572). The sensitivity of Soprolife® was 94.2%, specificity 84.2%, positive predictive value 87.1%, negative predictive value 92.8%, positive LR 6%, negative LR 0.07%, and the diagnostic accuracy 89.5%. AUC was 0.909 with 95% CI (0.863-0.955). There was a perfect intraobserver agreement (kappa = 1.00) for both testing modalities. There was moderate interobserver agreement (kappa = 0.520) with regards to ICDAS, while for Soprolife®, there was substantial interobserver agreement (kappa = 0.798). Soprolife® can be used as a valid and reliable assessment tool for occlusal caries detection. Light-induced fluorescence intraoral camera is an efficient tool in the detection of initial occlusal caries.

Mobility Assessment of the Supraspinatus in a Porcine Cadaver Model Using a Sensor-Enhanced, Arthroscopic Grasper

Tendon mobility is highly relevant in rotator cuff surgery. Objective data about rotator cuff mobility is rare. Tendon mobility still needs to be evaluated subjectively by the surgeon. This study aims to establish a porcine animal model for mobility analysis of the supraspinatus. In this context, we introduce a sensor-enhanced, arthroscopic grasper (SEAG) suitable for objective intraoperative measurements of tendon mobility in clinical praxis. Tendon mobility of 15 fresh porcine cadaver shoulders with artificial rotator cuff tears was evaluated using the SEAG. Mobility characteristics (load–displacement curves, maximum load, stiffness) were studied and inter- and intraobserver agreement (intraclass correlation coefficient (ICC)) were tested. Factors with a potential adverse effect (plastic deformation and rigor mortis) were also evaluated. All shoulders showed characteristic reproducible load–displacement curves with a nonlinear part at the start, followed by a linear part. Mean maximum load was 28.6 N ± 12.5. Mean stiffness was 6.0 N/mm ± 2.6. We found substantial interobserver agreement (ICC 0.672) and nearly perfect intraobserver agreement (0.944) for maximum load measurement. Inter- (0.021) and intraobserver (0.774) agreement for stiffness was lower. Plastic deformation and rigor mortis were excluded. The animal model demonstrates reliable and in vivo-like measurements of tendon mobility. The SEAG is a reliable tool for tendon mobility assessment.

Reliability of cephalograms derived of cone beam computed tomography versus lateral cephalograms to estimate cervical vertebrae maturity in a Peruvian population: A retrospective study

Cone beam computed tomography (CBCT) images can be useful for estimating cervical vertebrae maturity (CVM). The aim of this study was to evaluate the reliability of cephalograms derived from CBCT versus lateral cephalograms (LC) to estimate the CVM in a Peruvian population. The sample evaluated consisted of 40 cephalograms derived from CBCT and 40 LC images from individuals aged 10-19 years. One trained and calibrated observer (Kappa scores≥0.90) interpreted the CBCT and LC images twice. Intra-observer reliability of each maturation stage on CBCT sagittal slices and LC images were analysed using the weighted kappa statistics (α=0.05). Comparison of CVM stages between CBCT slices and LC images were analysed by the Spearman rank correlation coefficient, p<0.05. The weighted kappa test showed almost perfect intra-observer agreement for the CVM stages using the CBCT sagittal slices (0.873). Considering the LC images, the weighted kappa test showed almost perfect intra-observer agreement too (0.937). In both intra-observer agreement, the difference was limited to one maturation stage of the CVM method. The first and second intra-observer agreement for the CVM stages between the CBCT sagittal slices and LC images were almost perfect (0.937 and 0.874). High correlation values at the first (0.975) and second (0.976) intra-observer agreement for the CVM stages between CBCT sagittal slices and LC images were also found. CBCT is a reliable method for CVM assessment and can be used as an alternative method for this purpose. The orthodontists might use the CBCT scans as a valuable tool for CVM method estimation.

Doppler Color Scoring System in Women With an Incomplete Miscarriage: Interobserver and Intraobserver Reproducibility Study.

Doppler Color Scoring (DCS) has been used to predict successful expectant management of incomplete miscarriage. The aim of this study was to assess inter- and intraobserver reproducibility of the DCS system in women with incomplete miscarriage noted on transvaginal sonography. This was a prospective reproducibility study involving offline analysis of 32 prerecorded video sets on transvaginal sonography in real time of women with incomplete miscarriage. Vascularization of retained products of conception was recorded using the DCS system adopted from the International Ovarian Tumor Analysis group. Five gynecologic sonologists of varying experience assigned a DCS classification to each video in the analysis. The same videos were reanalyzed, in a different order, at least 7 days later, to assess intraobserver agreement. Inter- and intraobserver correlations were performed to determine agreement. Interobserver agreement was also measured between each observer and the reference standard (G.C.). A Cohen's κ coefficient value less than 0 suggests poor agreement, 0.01 to 0.20 slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 and 0.99 almost perfect. Interobserver agreement for all observers for DCS allocation ranged from 0.480 to 0.751. Overall interobserver agreement for 5 observers was substantial (κ, 0.626). Overall interobserver agreements for the 2 inexperienced and 3 experienced observers compared to G.C. were 0.521 and 0.618, respectively. Experienced observers achieved overall almost perfect intraobserver agreement, compared to substantial agreement for inexperienced sonologists. DCS interobserver reproducibility between all observers and GC ranged from moderate to substantial. DCS intraobserver reproducibility was substantial to almost perfect. The DCS system appears to be a reproducible tool in evaluating women with incomplete miscarriage.

Interobserver and intraobserver comparison of imaging glenoid morphology, glenoid version and humeral head subluxation.

Glenoid morphology, glenoid version and humeral head subluxation represent important parameters for the treating physician. The most common method of assessing glenoid morphology is the Walch classification which has only been validated with computed tomography (CT). CT images and magnetic resonance imaging (MRI) images of 25 patients were de-identified and randomized. Three reviewers assessed the images for each parameter twice. The Walch classification was assessed with a weighted kappa value. Glenoid version and humeral head subluxation were comparted with a reproducibility coefficient. The Walch classification demonstrated almost perfect intraobserver agreement for MRI and CT images (k = 0.87). Weighted interobserver agreement values for the Walch classification were fair for CT and MRI (k = 0.34). The weighted reproducibility coefficient for glenoid version measured 9.13 (CI 7.16-12.60) degrees for CT and 13.44 (CI 10.54-18.55) degrees for MRI images. The weighted reproducibility coefficient for percentage of humeral head subluxation was 17.43% (CI 13.67-24.06) for CT and 18.49% (CI 14.5-25.52) for MRI images. CT and MRI images demonstrated similar efficacy in classifying glenoid morphology, measuring glenoid version and measuring posterior humeral head subluxation. MRI can be used as an alternative to CT for measuring these parameters.

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.