Two-way Random Effects Model Research Articles

Reliability of self-measured objective functional impairment using the timed up and go test in patients with diseases of the spine.

Accurate assessment of a patient's functional status is crucial for determining the need for treatment and evaluating outcomes. Objective functional impairment (OFI) measures, alongside patient-reported outcome measures (PROMs), have been proposed for spine diseases. The Timed-Up and Go (TUG) test, typically administered by healthcare professionals, is a well-studied OFI measure. This study investigates whether patient self-measurement of TUG is similarly reliable. In a prospective, observational study, patients with spinal diseases underwent two TUG assessments: one measured by a healthcare professional and one self-measured by the patient. Interrater reliability was assessed using the intraclass correlation coefficient (ICC) with a two-way random-effects model, considered excellent between 0.75 - 1.00. Paired t-tests directly compared both measurements. The impact of variables such as age, sex, disease type, symptom severity (via PROMs), comorbidities, and frailty on reliability was also analysed. Seventy-four patients were included, with a mean age of 62.9years (SD 17.8); 29 (39.2%) were female. The majority (64.9%) were treated for degenerative disc disease. The lumbo-sacral region was most affected (71.6%), and 47.3% had previous surgeries. Patient self-measurement reliability was excellent (ICC 0.8740, p < 0.001), and the difference between healthcare professional (19.3 ± 9.4s) and patient measurements (18.4 ± 9.7s) was insignificant (p = 0.116). Interrater reliability remained high in patients > 65years (ICC 0.8584, p < 0.001), patients with ASA grades 3&4 (ICC 0.7066, p < 0.001), patients considered frail (ICC 0.8799, p < 0.001), and in patients not using any walking aid (ICC 0.8012, p < 0.001). High symptom severity still showed strong reliability (ICC 0.8279, p < 0.001 for Oswestry Disability Index > 40; ICC 0.8607, p = 0.011 for Neck Disability Index > 40). Patients with spine diseases can reliably self-measure OFI using the TUG test. The interrater reliability between self-measurements and those by healthcare professionals was excellent across all conditions. These findings could optimize patient assessments, especially in resource-limited settings.

Test-Retest Reliability of the Verran Professional Governance Scale©.

Background and Purpose: Stability testing, conducted using a test-retest protocol, measures an instrument's reliability by evaluating the consistency of participant responses to survey questions with repeated testing within a short interval. No studies have measured the stability of the Verran Professional Governance Scale© (VPGS). The purpose of this study was to evaluate the test-retest reliability of the VPGS. Methods: Volunteers from a parent study using the VPGS were sent a link to a retest version of the survey 14 days after taking the initial survey with a reminder email sent 5 days after the first request. Item-level and subscale comparisons were made between participants' initial and retest responses using intraclass correlation coefficients (ICCs) applying a two-way random-effects model. Results: VPGS subscales had ICC scores of 0.71 for decision-making, 0.73 for collateral relationships, and 0.86 for professional obligation. Conclusions: Findings suggest that the VPGS demonstrates test-retest reliability. Future research should evaluate the instrument's responsiveness.

Self-directed Learning Ability and Shadow Education Expenditures: A Comparison of Impact on Student Achievement in Korea During COVID-19

This study examines the impact of students’ self-directed learning (SDL) ability and parental expenditures for shadow education, and other factors, on academic achievement in South Korea during the pandemic. Busan Education Longitudinal Study panel data for 2019 (pre-COVID) and 2020–2021 (COVID) were utilized. National exam scores of middle and high school students in Korean, English, and math subject areas were analyzed using multiple regression, random effects, and two-way random effects models. The analysis revealed that, during the pandemic, parents’ high expenditures to provide shadow education to complement their children’s public education did not significantly influence academic achievement. In contrast, SDL ability was found to have a significant impact on achievement in all three subject areas during the pandemic. The findings underscore the importance of programs, policies, and teaching strategies that develop students’ SDL skills to enable them to learn on their own when a crisis restricts traditional teacher-guided classroom instruction.

Novel Scoring Scale for Quality Assessment of Lung Ultrasound in the Emergency Department.

The use of a reliable scoring system for quality assessment (QA) is imperative to limit inconsistencies in measuring ultrasound acquisition skills. The current grading scale used for QA endorsed by the American College of Emergency Physicians (ACEP) is non-specific, applies irrespective of the type of study performed, and has not been rigorously validated. Our goal in this study was to determine whether a succinct, organ-specific grading scale designed for lung-specific QA would be more precise with better interobserver agreement. This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems. The ICC between reviewers was 0.552 (95% CI 0.40-0.68) for the ACEP grading scale and 0.703 (95% CI 0.59-0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively). We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

In-person validation of the Ichthyosis Scoring System.

Ichthyoses are a heterogeneous group of skin disorders characterized by scaling and erythema. Recognizing the variability of scale and erythema by region and ichthyosis subtype, we developed the Ichthyosis Scoring System (ISS) to quantify severity. We previously found ISS to have high inter- and intrarater reliability in evaluating photographic images. To confirm ISS clinical utility, we examined its performance at the 2022 Foundation for Ichthyosis and Related Skin Types conference. Sixty-five participants were evaluated by 3 of 9 medical professionals trained to score ichthyosis scale and erythema using ISS. Intrarater and interrater intraclass correlation coefficients (ICC) were analyzed using one-way and two-way random effects models, respectively. Intrarater reliability was excellent (ICC = 0.931, 95% CI, 0.921-0.940) for scale and good (ICC = 0.876, 95% CI, 0.853-0.899) for erythema scoring. Compared to photo validation with excellent intrarater reliability ratings for both scale (ICC = 0.956, 95% CI, 0.925-0.974) and erythema (ICC = 0.913, 95% CI, 0.855-0.949), ISS demonstrated equivalent reliability for live use. Overall interrater reliability for 10 body sites showed excellent (ICC >0.9) and good (ICC >0.75) agreement and consistency for both scale and erythema. Palms were an exception, demonstrating moderate (ICC >0.5) interrater agreement and consistency for erythema evaluation. ISS is a reliable measure of global and regional ichthyosis severity during in-person evaluations. Ease-of-use, accessibility, and content validity in both live and photographic evaluation endorse ISS as a standard for ichthyosis severity analysis.

Mapping of the PROMIS global health measure to the PROPr in the United States

BackgroundThe Patient-Reported Outcomes Measurement and Information System (PROMIS®) global health items (global-10) yield physical and mental health scale scores and the PROMIS-Preference (PROPr) scoring system estimated from PROMIS domain scores (e.g., PROMIS-29 + 2) produces a single score anchored by 0 (dead or as bad as being dead) to 1 (full health). A link between the PROMIS global-10 and the PROPr is needed.MethodsThe PROMIS-29 + 2 and the PROMIS global-10 were administered to 4102 adults in the Ipsos KnowledgePanel in 2022. The median age was 52 (range 18–94), 50% were female, 70% were non-Hispanic White, and 64% were married or living with a partner. The highest level of education completed for 26% of the sample was a high school degree or general education diploma and 44% worked full-time. We estimated correlations of the PROPr with the PROMIS global health items and the global physical and mental health scales. We examined the adjusted R2 and estimated correlations between predicted and observed PROPr scores.ResultsProduct-moment correlations between the PROMIS global health items and the PROPr ranged from 0.50 to 0.63. The PROMIS global physical health and mental health scale scores correlated 0.74 and 0.60, respectively, with the PROPr. The adjusted R2 in the regression of the PROPr on the PROMIS global health items was 64%. The equated PROPr preference scores correlated (product-moment) 0.80 (n = 4043; p < 0.0001) with the observed PROPr preference scores, and the intra-class correlation (two-way random effects model) was 0.80. The normalized mean absolute error (NMAE) was 0.45 (SD = 0.43). The adjusted R2 in the OLS regression of the PROPr on the PROMIS global health scales was 59%. The equated PROPr preference scores correlated (product-moment) was 0.77 (n = 4046; p < 0.0001) with the observed PROPr preference scores, and the intra-class correlation was 0.77. The NMAE was 0.49 (SD = 0.45).ConclusionsRegression equations provide a reasonably accurate estimate of the PROPr preference-based score from the PROMIS global health items or scales for group-level comparisons. These estimates facilitate cost-effectiveness research and meta-analyses. The estimated PROPr scores are not accurate enough for individual-level applications. Future evaluations of the prediction equations are needed.

The inter- and intra-rater reliability of the manual diaphragm assessment scale in healthy participants

ObjectiveThe main aim of this study was to test the inter and intra-rater reliability of the Manual Diaphragm Assessment (MED) scale and compared with chest expansion (CE) in healthy participants. MethodsA reliability study, with a sample of 45 healthy participants, composed of 30 women and 15 men. Participants were evaluated by two raters. The MED assesses seven different points on the diaphragm and rates its degree of restriction on a scale of 1–5. Upper and lower CE were measured in centimeters with a measuring tape, which is a valid and reliable method. The intraclass coefficients (ICC) for inter and intra-rater reliability for CE and MED were calculated for mean measurement consistency using a two-way random effects model. ResultsThe intra- and inter-rater reliability of MEDs ranged from low to moderate. The majority of the ICC values in intra-rater reliability were greater than in inter-rater reliability, and the majority of the ICC values in both were higher at the left assessment point. CE inter- and intra-reliability ICC varied from moderate to good. For the upper and lower CE, the inter-rater reliability ICC values were greater than 0.74, and the intra-rater reliability was greater than 0.71. ConclusionThe manual evaluation diaphragm scale had poor to moderate intra and inter-reliability. The chest expansion's intra and inter-reliability ranged from moderate to good, which was consistent with previous studies. Measuring chest expansion with a tape is a reliable method of evaluating the diaphragm in a clinical setting.

Assessing lower limb angles from sagittal plane images captured with a smartphone for post-stroke gait

BACKGROUND: Clinical gait analysis of sagittal plane lower-limb kinematics using video images is a quantitative tool for clinicians. However, the reliability and validity of limb kinematics after stroke using video images has not been fully investigated. OBJECTIVE: This study aimed to examine the within-session inter-rater reliability and criterion-related validity of lower limb angles measured in sagittal plane images captured using a smartphone for assessing post-stroke gait and to determine which asymmetric parameters are associated with faster gait velocity. METHODS: Thirty-two patients with stroke were included; video images were recorded as they walked at their preferred pace for 1–3 cycles. Lower limb angles (contact, push-off, and excursion angles) and degree of asymmetry were determined based on video images using markers of acromion, greater trochanter, and fifth metatarsal head. Measurement reliability was calculated using the two-way random effects model of intraclass correlation coefficients and minimal detectable change. The criterion validity investigated Pearson’s correlation between lower limb angles and their asymmetry and gait velocity. RESULTS: The lower value of the 95% confidence interval of intraclass correlation coefficients (2.3) of the lower limb was 0.891, and the maximum minimal detectable change was 9.6 degrees. Push-off angle showed a moderate-to-strong correlation with gait velocity, whereas the asymmetry of the push-off angle showed a weak correlation with gait velocity. CONCLUSIONS: Assessing post-stroke gait utilizing video images using a smartphone is feasible. The push-off angle, in particular, may provide insight into the clinical assessment of post-stroke gait.

Influence of Joint Line Level on Clinical Outcomes and Range of Motion in Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Restoring the native joint line correlates with better clinical outcomes in total knee arthroplasty. Yet, the effect of joint line elevation on clinical outcomes after total ankle arthroplasty (TAA) remains unclear. A previous study reported that pre- and post-TAA joint line heights, as measured by the joint line height ratio (JLHR), were elevated compared to non- arthritic ankles. However, the clinical impact of this has yet to be determined. Therefore, this study assessed the relationship between the TAA joint line level with post-TAA range of motion (ROM) and PROMIS scores. We hypothesized that an elevated joint line would be associated with restricted post-TAA dorsiflexion and worse postoperative PROMIS scores. Methods: This is a single-center review of 150 patients who underwent primary TAA. Patients with (1)fibular or medial malleolar osteotomy, (2) component subsidence, and (3) incomplete radiographs or outcome scores were excluded. Demographic data, surgical protocol, pre- and postoperative radiographs, and 1-year postoperative PROMIS scores were reviewed. Radiographic measurements included JLHR, pre- and post-TAA tibiotalar dorsiflexion and plantarflexion, and tibial component sagittal alignment. Two graders measured post-TAA JLHRs, and the average of the two graders was used for the analysis. Rater agreement was assessed using intraclass correlation coefficients (two-way random effects model). Relationships between JLHR, post-TAA tibiotalar ROM, and PROMIS scores were investigated using Pearson correlation. Multiple linear regression models were used to investigate the association of JLHR with post-TAA tibiotalar total ROM, dorsiflexion, and plantarflexion, after adjusting for pre- TAA ROM, tibial component sagittal alignment, gastrocnemius release (GR), Tendo-Achilles lengthening (TAL), and polyethylene size. Results: The interobserver reliability of the JLHR was excellent (r=0.98). Mean JLHR decreased from 1.66 pre-TAA to 1.55 post- TAA (P &lt; 0.001), indicating the joint line was significantly lowered postoperatively. Greater elevation of the post-TAA JLHR was associated with significantly decreased post-TAA dorsiflexion (r=-0.26, P&lt; 0.001) and worse 1-year PROMIS physical function (r=- 0.22, P=0.046), pain intensity (r=0.22,P=0.042), and pain interference scores (r=0.29,P=0.007). There was no correlation between JLHR and post-TAA plantarflexion (P=0.76). Regression analysis identified a 5º reduction in post-TAA dorsiflexion with each 1.0 unit increase in JLHR (Coef=-5.13, P=0.005). Post-TAA total ROM (Coef=-3.6,P=0.21) and plantarflexion (Coef=0.91, P=0.67) were not associated with JLHR. Additionally, there was no association between post-TAA total ROM and tibial component sagittal alignment, GR, TAL, or polyethylene size. Conclusion: In this study, the joint line of the ankle was lowered after TAA, and the JLHR was a reliable and clinically applicable method for assessing it. An elevated joint line significantly correlated with restricted post-TAA dorsiflexion, but this may only be clinically relevant for patients with significant (&gt;1.0 unit) changes in the joint line level. In addition, a higher joint line was correlated with worse 1-year PROMIS scores. These results suggest that surgeons should consider the joint line level during TAA preoperative planning to obtain improved clinical outcomes and ankle dorsiflexion.

Establishment of reference intervals for ultrasonographically derived caudal vena cava parameters from 110 healthy, lightly sedated cats

Objectives The present study aimed to establish reference intervals (RIs) for ultrasonographically derived caudal vena cava (CVC) parameters in healthy cats. Methods A prospective, observational, experimental single-centre study involving 110 cats was conducted. Two trained operators scanned all cats in a randomised order. Two sets of cine loops per cat were conducted by each operator from the subxiphoid view with cats in lateral recumbency. Two blinded raters measured the narrowest inspiratory (CVCinsp) and widest expiratory (CVCexp) diameter over two separate respiratory cycles for each operator (four measurements in total for each rater) at the point the CVC crosses the diaphragm. The CVC collapsibility index (CVCCI) was calculated. Reference intervals and limits were calculated for CVC parameters with outliers removed to include the central 95% of CVC values and the non-parametric 90% confidence intervals (90% CIs). The CVCCI interval included the central 95th (2.5th and 97.5th) centiles bounded by the 90% CI. Intra- and inter-rater and intra- and inter-operator reliabilities were calculated for each parameter using a two-way random-effects model. A Bland–Altman plot was used to visualise the CVCCI between the two raters. Results In total, 880 measurements were included for each diameter and 440 CVCCI values were calculated. The CVC diameters were normally distributed, whereas the CVCCI was not. The calculated RIs were 1.4–6.1 mm for CVCinsp and 2.2–6.7 mm for CVCexp. The median (range) CVCCI was 23% (11–36%) with 2.5th and 97.5th centiles of 2% and 67%, respectively. There was a moderate to good intra-rater and intra-operator reliability for CVC diameter. The intra-rater reliability for the CVCCI was moderate. The inter-rater and inter-operator reliabilities for the CVCCI were poor. Conclusions and relevance The CVC RIs determined from the subxiphoid site in cats appear to be wider than those reported in dogs, and rater and operator variability is present. Whether precise measurements of CVC parameters are suitable to guide clinical decisions remains to be determined.

Determining State Expenditures in India: Relative Role of Own Revenues, Central Transfers and Fiscal Deficit

This article analyses the relative role of state’s own revenues, tax and non-tax, central transfers, and borrowing in determining state expenditures. We have examined the prevailing hypotheses regarding explaining determinants of government expenditures such as the Wagner, Wiseman-Peacock and Clark’s Critical Limit hypotheses in the context of state governments in India. We have also looked at Revenue and Spend, Tax and Spend, and the Fiscal Synchronization hypotheses. We have quantified the relative magnitudes of the differential effects of these sources of financing state-level primary expenditures for two groups of states namely, medium and large states (ML) and small and hilly states (SH) in a panel data framework. In addition to the variables reflecting financing sources, this study also examines other prevailing hypotheses affecting state expenditures such as those relating to cyclical increases emanating from election years and years of economic slowdown. Based on results of the Hausman test, we have estimated a two-way random effects model. Our findings indicate that with respect to own tax revenues, the magnitude of responsiveness of primary expenditure is 0.22 for the ML group and 0.10 for the SH group of states. For fiscal transfers, these magnitudes are 0.29 for ML states and 0.20 for SH states. For borrowing, the relevant coefficients are 0.33 for ML states and 0.13 for SH states. Thus, for the ML group, the maximum responsiveness is with respect to borrowing, followed by fiscal transfers and own tax revenues. In the case of the SH group, central transfers explain the largest variation in state-level primary expenditure, followed by borrowing and own tax revenues. We also find that for two out of three general elections in the sample period namely, 2009 and 2014, there was a positive and significant response of primary expenditures. Further, in years of economic slowdown, there is a positive response except in one case where the income effect was dominant and primary expenditure also fell along with the slowdown.

Affective responses to stretching exercises: Exploring the timing of assessments

Affective responses during exercise have been identified as a predictor of exercise adherence. However, research has been mostly limited to aerobic and resistance exercise. Considering that stretching activities are also an important component of physical fitness, this quasi-experimental study was designed to: 1) compare affective responses during and immediately after stretching exercises in apparently healthy adults, and 2) assess the consistency and repeatability of affect ratings obtained one week apart. For this purpose, we analyzed the Feeling Scale (FS) and Felt Arousal Scale (FAS) ratings using Time (during and after stretching) x Intensity (light, moderate, vigorous) x Stretched Muscle Group (quadriceps, hamstrings, glutes, latissimus dorsi, triceps) with repeated measures analysis of variance (ANCOVA) in 34 participants (21 males; aged 32.8 ± 8.6 years). The repeatability of FS and FAS ratings was assessed using two-way random-effects models, Intraclass Correlation Coefficients (ICC), and Bland-Altman plots. FS scores were higher following the stretching exercises, whereas FAS scores were lower, particularly in the vigorous intensity. In general, the inter-day repeatability for FS and FAS measurements was good across muscle groups. ICC tended to be higher at vigorous intensities. Ratings of core affect can be collected during static passive stretches using the FAS and FAS in ecologically valid settings. These results suggest that an adequate assessment of core affective responses to stretching activities should be performed during the exercises.

Poster 303: Radiographs Demonstrate Poor Interrater Reliability and Accuracy for Evaluation of Postoperative Healing for Osteochondral Allograft Transplants of the Knee

Objectives: To evaluate the reliability of radiographs to evaluate healing of osteochondral allografts in the knee compared to CT scans as gold standard imaging. Methods: A retrospective review of prospectively enrolled patients who underwent osteochondral allograft transplantation for focal chondral defects of the knee was performed. At 6 months, all patients prospectively underwent CT scan of the knee. A retrospective review was performed to assess knee radiographs obtained in clinic at 3 and 6 months postoperatively. Three board-eligible orthopaedic sports fellows independently graded available radiographs while remaining blinded to the CT scan results. Separately, two board-eligible orthopaedic sports fellows graded CT scans utilizing the ACTOCA system, and their consensus measurements served as the gold standard for this study. Intraclass correlation (ICC) with a two-way random effects model and kappa coefficients were calculated for grades between the three raters. Results: Among the 44 grafts prospectively imaged, 13 (29.5%) grafts had radiographs at 3 months and 28 (63.6%) grafts had radiographs available for evaluation at 6 months. Among three graders, assessment of integration demonstrated low to moderate reliability (ICC: 0.25-0.41). Contrary to this, assessment of qualities such as graft sclerosis and cyst formation on radiographs demonstrated poor interrater reliability with inability to reject the null hypothesis that all grades were assigned randomly (p&gt;0.05) (Table 1). At 6 months, in patients with large cysts (&gt; 3 mm) on CT, only 2/18 (11%) were accurately detected on radiographs and 5/18 (27.8%) were underestimated as small cysts. In patients with small cysts (&lt; 3 mm) on CT, only 4/42 grafts (9.5%) were accurately graded, and 3/42 (7.1%) evaluated grafts were overestimated to have large cysts (Figure 1). Among patients who had small or large cysts at 6 months, only 1/21 (4.8%) and 1/3 (33.3%) radiographic assessments detected this cystic change at 3 months, respectively. Patients with crossing trabeculae on CT were associated with a mean radiographic integration score of 81.0 ± 15.7, which was significantly greater than those with a discernible cleft &lt; 3 mm (mean 68.7 ± 19.3, p=0.01). However, these groups were not significantly different than radiographic scores for grafts that had discernible clefts &gt; 3 mm (80.0 ± 19.7, p&gt;0.05). Among the 23 patients with a 6-month radiograph available, 4 required subsequent surgery for symptomatic failure. Three (75%) of these patients demonstrated large cyst formation on CT scan at 6 months. Conclusions: Evaluation of osteochondral allograft healing by radiographs alone may be inaccurate and associated with missed abnormalities such as cyst formation. [Table: see text]

Poster 136: Augmented Meniscus Radial Tear Healing via Local Transforming Growth Factor-beta 1 (TGF- β1) Gene Therapy in a Rat Model

Objectives: Meniscus tears cause significant musculoskeletal impairment and are among the most common knee injuries. Tears in the inner third of the meniscus have intrinsically poor healing capacity due to insufficient blood supply. In an effort to improve healing, use of biologic augments is a promising area of investigation. Tissue engineering strategies, such as growth factor gene therapy, have emerged as encouraging approaches to improving meniscal healing. Transforming Growth Factor-Beta 1 (TGF-β1) gene therapy has shown promise in vitro and ex vivo as a therapeutic strategy, but its effects on meniscus healing in vivo remain unknown. This study aimed to determine whether local delivery of viral vectors carrying the TGF-β1 gene could improve the healing of a meniscus tear involving the avascular zone in vivo in a rat model. Methods: Recombinant adenoviruses were generated using the AdEasy system. Briefly, the coding regions of mouse TGFβ1 were PCR amplified and cloned into an adenoviral shuttle vector and subsequently used to generate recombinant adenoviruses in HEK293 cells. The resulting adenoviruses were designated as Adv-TGF-β1. An analogous adenovirus expressing only GFP (Adv-GFP) was used as mock virus controls. To achieve local delivery of viral vectors to the injury site, we utilized a thermoresponsive biodegradable polydiolcitrate-gelatin delivery scaffold (PPCNg). A full-thickness radial tear was made in the medial meniscus of the left hind leg of twelve Wistar rats. Rats were divided into two groups: one receiving a mixture of PPCNg+TGF-β1 (n = 3) and the other receiving PPCNg+GFP (n = 3). A 4ºC pre-chilled solution of PPCNg seeded with Adv-TGF-β1 or Adv-GFP at 1011 infectious viral particles/injection was administered at the site of the induced meniscus tear. After 3 weeks, rats were euthanized, and the menisci were histologically evaluated by hematoxylin and eosin (H&amp;E) staining. The histologic assessment and scoring of meniscus tissue wound healing were done by one blinded and one unblinded observer, each using selected wound healing parameters as described in Table 1, and the results were averaged. The intra-class correlation coefficient (ICC) was computed based on a mean rating (k=2), absolute agreement, and two-way random effects model to assess the agreement between the wound healing score rating of the two observers. Statistical significance between groups was determined using the Mann-Whitney Wilcoxon rank sum test. A value of p &lt; 0.05 was considered statistically significant. All animal procedures were performed according to an Institutional Animal Care and Use Committee protocol at the home institution. Results: Immediately after and 3 weeks post-surgery, there was no evidence of infection, dehiscence, or functional deficit. Histologic evaluation of the sections (n = 8/group) of harvested rat menisci (n = 2/group) revealed improved healing of tears in the PPCNg+TGF-β1 group compared to the control group (5.7 ± 0.48 vs. 5.0 ± 0.89, p = 0.011) (Figure 1B). The lesion area demonstrated significantly greater neovascularization (2.75 ± 0.45 vs. 2.06 ± 0.68, p = 0.004), better collagen organization (1.94 ± 0.25 vs. 1.62 ± 0.50, p = 0.038), and increased hypercellularity (1.0 ± 0.00 vs. 1.3 ± 0.48, p = 0.018) in the PPCNg+TGF-β1 group compared to the controls (Figure 1C). Moderate absolute agreement between the two raters was observed in their wound healing score ratings (ICC = 0.615). Conclusions: Our results indicate that PPCNg-mediated delivery of Adv-TGF-β1 enhanced the early (3 weeks) healing of the meniscus lesion in rats compared with control (Adv-GFP) gene therapy. Further, localized administration of Adv-TGF-β1 induced greater neovascularization, better organization of collagen fibers, and increased hypercellularity at the injury site in the Adv-TGFβ-1 rat group compared with controls at 3 weeks post-injury. These results together suggest that TGF-β1 gene therapy may enhance meniscus healing by inducing more cellular proliferation and infiltration and greater neovascularization at the injury site to serve as nourishment for the establishment of new wound matrix, leading to more significant deposition and remodeling of mature collagen matrix. Further study that includes larger sample sizes, confirmation of successful gene transfer to meniscal cells around the tear site, and investigations of both later time points of wound healing and the mechanisms by which local TGF-β1 gene therapy may modulate augmented meniscus healing in this rat model of meniscal defect is necessary to better determine the potential future clinical utility of local TGF-β1 gene therapy to treat of meniscus tears with poor healing capacity. [Table: see text]

Learning Effects in Air Displacement Plethysmography.

Air displacement plethysmography (ADP) is a widespread technique for assessing global obesity in both health and disease. The reliability of ADP has been demonstrated by studies focused on duplicate trials. The present study was purported to evaluate learning effects on the reliability of body composition assessment using the BOD POD system, the sole commercially available ADP instrument. To this end, quadruplicate trials were performed on a group of 105 subjects (51 women and 54 men). We estimated measurement error from pairs of consecutive trials-(1,2), (2,3), and (3,4)-to test the hypothesis that early measurements are subject to larger errors. Indeed, statistical analysis revealed that measures of reliability inferred from the first two trials were inferior to those computed for the other pairs of contiguous trials: for percent body fat (%BF), the standard error of measurement (SEM) was 1.04% for pair (1,2), 0.71% for pair (2,3), and 0.66% for pair (3,4); the two-way random effects model intraclass correlation coefficient (ICC) was 0.991 for pair (1,2), and 0.996 for pairs (2,3) and (3,4). Our findings suggest that, at least for novice subjects, the first ADP test should be regarded as a practice trial. When the remaining trials were pooled together, the reliability indices of single ADP tests were the following: ICC = 0.996, SEM = 0.70%, and minimum detectable change (MDC) = 1.93% for %BF, and ICC = 0.999, SEM = 0.49 kg, and MDC = 1.35 kg for fat-free mass (FFM). Thus, the present study pleads for eliminating learning effects to further increase the reliability of ADP.

THE LONG-TERM REPRODUCIBILITY OF THE WHITE-COAT EFFECT ON BLOOD PRESSURE AS A CONTINUOUS VARIABLE: THE OHASAMA STUDY

Objective: White coat hypertension is defined as a condition in which office blood pressure (BP), but not out-of-office BP, is elevated. However, the hypertension phenotype categorized by a determined threshold is generally fluctuant in individuals with BP readings close to the hypertension threshold. Furthermore, there is little information about the reproducibility of the white coat effect, which was a continuous variable, over more than a 1-year interval. The present study investigated the long-term interval reproducibility of the white coat effect. Design and method: We used the repeatedly measured white coat effect (office BP and home BP) at a 4-year interval in 153 participants not undergoing antihypertensive treatment (men, 22.9%; mean age, 64.4 years) from the general population of Ohasama, Japan. The reproducibility of the white coat effect as a continuous variable was assessed by testing the Bland–Altman plot and intraclass correlation coefficient (two-way random effect model single measures). Results: At baseline, the mean values were 127.5±15.8 mmHg for office systolic BP, 120.3±11.3 mmHg for home systolic BP, and 7.2±12.8 mmHg for the white coat effect based on systolic BP. The white coat effect for systolic BP decreased by 0.17±14.53 mmHg at the 4-year visit. The Bland–Altman plots showed no significant systemic error for the white coat effect (P &gt; = 0.24) (Figure). The intraclass correlation coefficient (95% confidence interval) of the white coat effect for systolic BP, office systolic BP, and home systolic BP were 0.41 (0.27–0.53), 0.64 (0.52–0.74), and 0.74 (0.47–0.86), respectively. The difference in office systolic BP strongly contributed to the large change in the white coat effect. The agreements between hypertension phenotypes at baseline and the 4-year visit were minimal (kappa = 0.36; 95% confidence interval, 0.25–0.48). Conclusions: Long-term reproducibility of the white coat effect is limited in the general population not undergoing antihypertensive treatment. The change in the white coat effect is mainly caused by office BP variation.

Poor Association between Facial Expression and Mild Lameness in Thoroughbred Trot-Up Examinations.

Musculoskeletal injuries in racehorses are difficult to detect prior to catastrophic breakdown. Lameness is commonly attributed to orthopaedic pain in horses, therefore, subtle lameness may be a pre-clinical sign of injury and, if identified early, could allow for preventative intervention. Our objective was to determine if facial expressions could be used to detect mild lameness as an indicator of orthopaedic pain in 'fit to race' horses. The Horse Grimace Scale (HGS) and the facial expressions in ridden horses (FEReq), were used to score images (n = 380) of mildly lame (n = 21) and non-lame (n = 17) Thoroughbred horses by two independent observers. Using an Equinosis Lameness Locator®, the lameness status of each horse was determined according to published thresholds [forelimb lameness (>|14.5 mm|) and hindlimb lameness (>|7.5 mm|)]. Inter and intraobserver reliability were assessed using two-way random-effects models. Univariable associations between lameness and facial expression parameters were identified using logistic and linear regression. Interobserver reliability was moderate (κ 0.45; 95% CI 0.36, 0.55). Horses with moderate mouth strain (HGS) and tense and extended upper lip (FEReq) were less likely to be lame (p = 0.042 and p = 0.027, respectively). Exposed sclera was associated with lameness (p = 0.045). Higher orbital tightening (HGS) scores were associated with a lower degree of maximum head amplitude (HDmax) lameness (p = 0.044). Tension and moderate tension above the eye, for the HGS and FEReq scores, were associated with increasing amplitude of HDmax (p = 0.048 and p = 0.034, respectively). Inconsistent associations between lameness status and HGS and FEReq scores may limit the potential use of the facial expression for the prediction of mild orthopaedic pain during pre-race lameness examinations. More objective parameters associated with mild orthopaedic pain should be explored.

Quantitative and qualitative image quality assessment in shoulder examinations with a first-generation photon-counting detector CT

Photon-counting detector (PCD) CT allows for ultra-high-resolution (UHR) examinations of the shoulder without requiring an additional post-patient comb filter to narrow the detector aperture. This study was designed to compare the PCD performance with a high-end energy-integrating detector (EID) CT. Sixteen cadaveric shoulders were examined with both scanners using dose-matched 120 kVp acquisition protocols (low-dose/full-dose: CTDIvol = 5.0/10.0 mGy). Specimens were scanned in UHR mode with the PCD-CT, whereas EID-CT examinations were conducted in accordance with the clinical standard as “non-UHR”. Reconstruction of EID data employed the sharpest kernel available for standard-resolution scans (ρ50 = 12.3 lp/cm), while PCD data were reconstructed with both a comparable kernel (11.8 lp/cm) and a sharper dedicated bone kernel (16.5 lp/cm). Six radiologists with 2–9 years of experience in musculoskeletal imaging rated image quality subjectively. Interrater agreement was analyzed by calculation of the intraclass correlation coefficient in a two-way random effects model. Quantitative analyses comprised noise recording and calculating signal-to-noise ratios based on attenuation measurements in bone and soft tissue. Subjective image quality was higher in UHR-PCD-CT than in EID-CT and non-UHR-PCD-CT datasets (all p < 0.001). While low-dose UHR-PCD-CT was considered superior to full-dose non-UHR studies on either scanner (all p < 0.001), ratings of low-dose non-UHR-PCD-CT and full-dose EID-CT examinations did not differ (p > 0.99). Interrater reliability was moderate, indicated by a single measures intraclass correlation coefficient of 0.66 (95% confidence interval: 0.58–0.73; p < 0.001). Image noise was lowest and signal-to-noise ratios were highest in non-UHR-PCD-CT reconstructions at either dose level (p < 0.001). This investigation demonstrates that superior depiction of trabecular microstructure and considerable denoising can be realized without additional radiation dose by employing a PCD for shoulder CT imaging. Allowing for UHR scans without dose penalty, PCD-CT appears as a promising alternative to EID-CT for shoulder trauma assessment in clinical routine.

Reliability of the Non-contact TONO-i Tonometer Compared with the Goldmann Applanation Tonometer

Purpose: The accuracy and agreement of intraocular pressure (IOP) measurements using a noncontact self-measuring tonometer, TONO-i, compared with the Goldmann applanation tonometer (GAT).Methods: A total of 35 healthy participants and 42 primary open angle or normal tension glaucoma patients were enrolled in this study. TONO-i and GAT measurements were obtained and the mean difference in IOPs was analyzed using a paired &lt;i&gt;t&lt;/i&gt;-test. IOP agreement was calculated using the two-way random effects model. Bland-Altman analysis and simple linear regression were used to estimate the disagreement between IOP measurements.Results: The mean IOPs measured using the TONO-i and GAT were 15.9 ± 3.3 mmHg and 16.4 ± 5.1 mmHg, respectively. In glaucoma patients, the mean values measured using the TONO-i (16.7 ± 4.1 mmHg) were lower than those measured using the GAT (17.9 ± 6.1 mmHg; &lt;i&gt;p&lt;/i&gt; &lt; 0.001). However, there was no significant difference among the healthy participants (&lt;i&gt;p&lt;/i&gt; = 0.273). The intraclass coefficients (95% confidence interval) for all participants, normal participants, and glaucoma patients were 0.847 (0.702-0.920), 0.882 (0.804-0.941), and 0.828 (0.742-0.887), respectively, indicating good agreement between the IOP measurements. The mean difference and limits of agreement were not statistically significant. As IOP increased, the absolute difference between the GAT and TONO-i measurements also increased.Conclusions: The TONO-i, a novel tonometer, may be used reliably for IOP self-measurement and detecting IOP elevations. However, caution must be exercised because of the possibility of underestimating high IOPs.

Reliability of an AI-Powered Application Across Different Mobile Devices for Assessment of Chronic Wounds.

Objective: Evaluate the inter- and intrarater reliability of a wound assessment tool in iPhone 12 and 13 mini modalities against a validated iPad mini/Structure Sensor configuration. Approach: We assessed a wound measurement application (eKare inSight®) for result consistency in patients presenting with wounds. Assessments were analyzed using a two-way analysis of variance. Intraclass correlation coefficient (ICC) was computed for intrarater (ICC1,1) and inter-rater (ICC2,1) analysis using a two-way random effects model. Paired t-test assessed the statistical difference between measurement methods. Results: Forty-two lesions were analyzed with surface areas ranging from 0.2 to 23 cm2 (average 4.33 ± 5.44 cm2). A high level of reliability was observed for repeat wound area measurements by the same examiner (ICC1,1 = 0.997) and between examiners with iPhone 13 mini (ICC2,1 = 0.998). There was no significant difference between iPhone 12 and iPad mini/Structure Sensor (p = 0.78) or between iPhone 13 mini and iPhone 12 (p = 0.22). Minimal difference existed between iPhone 13 mini and iPad mini/Structure Sensor (p = 0.049, Cohen's d = 0.01). Innovation: Increased pervasiveness of smartphones in clinical care, coupled with advances in smartphone imaging and machine learning, allows for a potential solution to the problem of fast and accurate wound measurements. The application investigated produces wound measurement results quickly and with demonstrated accuracy. It does not require a calibration sticker or reference marker and allows for automatic wound boundary delineation. Conclusion: The results of this study suggest that a digital planimetry mobile application may offer high levels of reliability across devices and users.