Two-way Random Effects Model Research Articles

Impact of Country Level Corporate Governance on Profitability of Banks in India

In the recent years, there has been an uptick in the level of concern over corporate governance. This is mostly attributable to the widespread collapse of major corporations in both the local and international arenas. Both proactive and reactive actions have been adopted by governments in reaction to the growing number of instances of financial crisis in an effort to achieve stability in the sector. Nevertheless, the stability of banking operations continuesto be questionable despite the interventionist responsibilities played by the government. The primary objective of this research is to investigate the effect that corporate governance at the national level has on the profitability of Indian banks using a representative sample of 33financial institutions, including 21private and 12 public banks. Descriptive statistics, correlation analysis, and regression analysis of two-way variable intercept random effect model, and robustness checks including robust regression are utilized in the study. The purpose of study is to assess; via the use of empirical research methods, the impact that good corporate governance has on the profitability of the banking sector in India. Return on Equity (ROE), Return on Assets (ROA)and Net Interest Margin (NIM)were accepted as proxies for profitability in the banking industry.The empirical evidence presented in the paper demonstrates that good corporate governance has a considerable influence on the profit performance of the Indian banking sector. In the context of India's status as a developing economy, this study offers new research that establishes a relationship between country-level corporate governance and the profitability of banking institutions.

Quality of clinical practice guidelines relevant to rehabilitation of knee osteoarthritis: A systematic review

Objective This systematic review summarized the rehabilitation recommendations for treating and managing knee osteoarthritis (OA) in practice guidelines and evaluated their applicability and quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Data Sources PubMed, the Cochrane Library, EMBASE, CINAHL, PEDro, Guideline central, Guideline International Network and Agency for Healthcare Research and Quality (AHRQ) were used to search for relevant studies published between 1 January 2008 and 31 May 2022. Methods AGREE II was used to evaluate the included guidelines quality, SPSS 25.0 statistical software was used for data analysis, and the intra-group correlation coefficient value was calculated to verify the consistency between the raters. The two-way random effects model was used to calculate concordance scores, and each domain's total scores were calculated. Additionally, the median and interquartile range for domain and total scores were calculated. Results Twenty-four guidelines recommending knee OA rehabilitation were included. Inter-rater consistency evaluation ranged from 0.62 to 0.90. The domains where the guideline's overall and rehabilitation parts scored highest and lowest were scope and purpose (domain 1) and applicability (domain 5), respectively. The highly recommended rehabilitation opinions included aerobic exercise programs (21/24), weight control (16/24), self-education and management (16/24), gait/walking aids (7/24), and tai chi (6/24). However, the orthopedic insole and hot/cold therapy roles remain controversial. Conclusion The clinical practice guidelines' overall quality for knee OA rehabilitation is good; however, the applicability is slightly poor. Therefore, we should improve the promoting factors and hindering factors, guideline application recommendations, tools, and resources when developing relevant guidelines.

Validating Foot Center Axis and Ankle Rotation using Weight-Bearing CT

Category: Ankle; Ankle Arthritis Introduction/Purpose: Even as its popularity increases, there remain many unanswered questions regarding total ankle arthroplasty. One debate considers the proper rotation of the talar component to restore native, non-osteoarthritic anatomy. The foot center axis is a unique anatomic concept that considers the position of the native foot relative to the ankle. The present pilot study sought to evaluate the reproducibility of axial alignment measurements, including the foot center on weight-bearing CT in patients without ankle osteoarthritis. Methods: Following IRB approval, charts were reviewed to identify patients without ankle osteoarthritis, trauma or other deformity who received a weightbearing CT scan. A pilot group of n=8 patients were included for a total of n=10 limbs. Average age was 50.1 +/- 14 and there were 38% female patients. All measurements were made on MPR (multiplanar reformation) axial reconstructions. Cobb angle measurements between the anatomic foot center, the second, the fourth metatarsal and the gutter bisector or medial gutter line were recorded by n=4 observers. Intraclass correlation (ICC) was produced using a two-way random effects model with absolute agreement and other statistical testing was performed by IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY. Results: The average gutter bisector angle was 6.2 deg +/- 2.0 and the average angle between the medial base of the 1st metatarsal head, lateral base of the 5th metatarsal head and the posterior calcaneus was 33.0 deg +/- 2.6. Amongst the observers, the ICC for these landmarks were 0.95 and 0.96 respectively. The average cobb angle measurement between the gutter bisector angle and the second metatarsal was 8.3 deg +/- 7.3, with a corresponding ICC of 0.96. The average cobb angle measurement between the gutter bisector angle and the anatomic foot center was 5.6 deg +/- 4.3 and the average cobb angle measurement between the medial gutter line and the anatomic foot center was 6.23 deg +/- 6. Amongst the observers, the ICC for these measurements were 0.81 and 0.81 respectively. Conclusion: In a small pilot study of patients without osteoarthritis who underwent weight-bearing CT scans there was good (ICC>0.75-0.90) to excellent (ICC>0.90) agreement amongst observers for measurements of foot center axis and ankle rotation. These findings validate the reproducibility and agreement of these manually constructed measurements for assessing the relationship between the foot center axis and ankle rotation. Future studies will expand upon the use of these measurements to define non-arthritic anatomy. The anatomic foot center may be a useful guide for establishing intra-operative foot orientation when performing total ankle arthroplasty.

Shear-Wave Elastography and Viscosity PLUS for the Assessment of Peripheric Muscles in Healthy Subjects: A Pre- and Post-Contraction Study.

Viscosity is a novel parameter, recently introduced in the use of elastographic techniques, correlating to shear-wave dispersion. The purpose of this study was to provide normal reference viscosity values for the peripheral muscles in healthy volunteers. This prospective study included 38 subjects who underwent US examinations between November 2021 and January 2022. Measurements were taken on the calf and the deltoid muscles in both pre- and post-contraction states. The age range was 21–29 years, with a median of 26 years. The SWE and ViPLUS values in the deltoid muscles were significantly higher than in the soleus muscles in both pre- and post-contraction sets (p = 0.002). There were statistically significant differences between the pre- and post-contraction values for both the SWE and ViPLUS values in the subgroup analysis. The ICC estimates and the 95% confidence intervals were based on a mean rating (k = 2), an absolute agreement, and a two-way random-effects model, demonstrating excellent agreement between the measurements taken by the two examiners.

Bootstrap inference of the skew-normal two-way classification random effects model with interaction

Bootstrap inference of the skew-normal two-way classification random effects model with interaction

A study to translate and validate the Thai version of the Victoria Respiratory Congestion Scale

PurposeFew clinical tools are available to objectively evaluate death rattles in palliative care. The Victoria Respiratory Congestion Scale (VRCS) was adapted from the Back's scale, which has been widely utilized in research and clinical practice. The VRCS will be translated into Thai and research will be conducted to determine its validity and reliability in assessing death rattles in palliative care.MethodsTwo qualified language specialists converted the original tool into Thai and then back to English. Between September 2021 and January 2022, a cross-sectional study was undertaken at a palliative care unit at Ramathibodi Hospital to determine the Thai VRCS's validity and reliability. Two evaluators independently assessed the volume of secretion noises using the Thai VRCS. The criterion-related validity of VRCS was determined by calculating the correlation between the sound level obtained with a standard sound meter and the VRSC scores using Spearman's correlation coefficient method. To assess inter-rater reliability and agreement measurement on ratings, we utilized a two-way random-effects model with Cohen's weighted kappa agreement.ResultsForty patients enrolled in this study with a mean age of 75.3 years. Fifty-five percent had a cancer diagnosis. Spearman's rho correlation coefficient was found to be 0.8822, p < 0.05, indicating a highly significant link. The interrater reliability analysis revealed that the interrater agreement was 95% and the Cohen's weighted kappa agreement was 0.92, indicating near-perfect agreement.ConclusionsThai VRCS demonstrated excellent criteria-related validity and interrater reliability. Using the Thai VRCS to assess adult palliative care patients' death rattles was recommended.

One-stop-shop CT arthrography of the wrist without subject repositioning by means of gantry-free cone-beam CT

Modern cone-beam CT systems are capable of ultra-high-resolution 3D imaging in addition to conventional radiography and fluoroscopy. The combination of various imaging functions in a multi-use setup is particularly appealing for musculoskeletal interventions, such as CBCT arthrography (CBCTA). With this study, we aimed to investigate the feasibility of CBCTA of the wrist in a “one-stop-shop” approach with a gantry-free twin robotic scanner that does not require repositioning of subjects. Additionally, the image quality of CBCTA was compared to subsequent arthrograms on a high-end multidetector CT (MDCTA). Fourteen cadaveric wrists received CBCTA with four acquisition protocols. Specimens were then transferred to the CT suite for additional MDCTA. Dose indices ranged between 14.3 mGy (120 kVp/100 effective mAs; full-dose) and 1.0 mGy (70 kVp/41 effective mAs; ultra-low-dose) for MDCTA and between 17.4 mGy (80 kVp/2.5 mAs per pulse; full-dose) and 1.2 mGy (60 kVp/0.5 mAs per pulse; ultra-low-dose) for CBCTA. Subjective image quality assessment for bone, cartilage and ligamentous tissue was performed by seven radiologists. The interrater reliability was assessed by calculation of the intraclass correlation coefficient (ICC) based on a two-way random effects model. Overall image quality of most CBCTA was deemed suitable for diagnostic use in contrast to a considerable amount of non-diagnostic MDCTA examinations (38.8%). The depiction of bone, cartilage and ligaments in MDCTA with any form of dose reduction was inferior to any CBCTA scan with at least 0.6 mAs per pulse (all p < 0.001). Full-dose MDCTA and low-dose CBCTA were of equal quality for bone tissue visualization (p = 0.326), whereas CBCTA allowed for better depiction of ligaments and cartilage (both p < 0.001), despite merely one third of radiation exposure (MDCTA–14.3 mGy vs. CBCTA–4.5 mGy). Moderate to good interrater reliability was ascertained for the assessment all tissues (ICC 0.689–0.756). Overall median examination time for CBCTA was 5.4 min (4.8–7.2 min). This work demonstrates that substantial dose reduction can be achieved in CT arthrography of the wrist while maintaining diagnostic image quality by employing the cone-beam CT mode of a twin robotic X-ray system. The ability of the multi-use X-ray system to switch between fluoroscopy mode and 3D imaging allows for “one-stop-shop” CBCTA in minimal examination time without the need for repositioning.

Effect of number of diffusion-encoding directions in diffusion metrics of 5-year-olds using tract-based spatial statistical analysis.

Methodological aspects and effects of different imaging parameters on DTI (diffusion tensor imaging) results and their reproducibility have been recently studied comprehensively in adult populations. Although MR imaging of children's brains has become common, less interest has been focussed on researching whether adult‐based optimised parameters and pre‐processing protocols can be reliably applied to paediatric populations. Furthermore, DTI scalar values of preschool aged children are rarely reported. We gathered a DTI dataset from 5‐year‐old children (N = 49) to study the effect of the number of diffusion‐encoding directions on the reliability of resultant scalar values with TBSS (tract‐based spatial statistics) method. Additionally, the potential effect of within‐scan head motion on DTI scalars was evaluated. Reducing the number of diffusion‐encoding directions deteriorated both the accuracy and the precision of all DTI scalar values. To obtain reliable scalar values, a minimum of 18 directions for TBSS was required. For TBSS fractional anisotropy values, the intraclass correlation coefficient with two‐way random‐effects model (ICC[2,1]) for the subsets of 6 to 66 directions ranged between 0.136 [95%CI 0.0767;0.227] and 0.639 [0.542;0.740], whereas the corresponding values for subsets of 18 to 66 directions were 0.868 [0.815;0.913] and 0.995 [0.993;0.997]. Following the exclusion of motion‐corrupted volumes, minor residual motion did not associate with the scalar values. A minimum of 18 diffusion directions is recommended to result in reliable DTI scalar results with TBSS. We suggest gathering extra directions in paediatric DTI to enable exclusion of volumes with motion artefacts and simultaneously preserve the overall data quality.

Myeloma Spine and Bone Damage Score (MSBDS) on Whole-Body Computed Tomography (WBCT): Multiple Reader Agreement in a Multicenter Reliability Study.

Objective: To assess the reliability of the myeloma spine and bone damage score (MSBDS) across multiple readers with different levels of expertise and from different institutions. Methods: A reliability exercise, including 104 data sets of static images and complete CT examinations of patients affected by multiple myeloma (MM), was performed. A complementary imaging atlas provided detailed examples of the MSBDS scores, including low-risk and high-risk lesions. A total of 15 readers testing the MSBDS were evaluated. ICC estimates and their 95% confidence intervals were calculated based on mean rating (k = 15), absolute agreement, a two-way random-effects model and Cronbach’s alpha. Results: Overall, the ICC correlation coefficient was 0.87 (95% confidence interval: 0.79–0.92), and the Cronbach’s alpha was 0.93 (95% confidence interval: 0.94–0.97). Global inter- and intra-observer agreement among the 15 readers with scores below or equal to 6 points and scores above 6 points were 0.81 (95% C.I.: 0.72–0.86) and 0.94 (95% C.I.:0.91–0.98), respectively. Conclusion: We present a consensus-based semiquantitative scoring systems for CT in MM with a complementary CT imaging atlas including detailed examples of relevant scoring techniques. We found substantial agreement among readers with different levels of experience, thereby supporting the role of the MSBDS for possible large-scale applications. Significance and Innovations • Based on previous work and definitions of the MSBDS, we present real-life reliability data for quantitative bone damage assessment in multiple myeloma (MM) patients on CT. • In this study, reliability for the MSBDS, which was tested on 15 readers with different levels of expertise and from different institutions, was shown to be moderate to excellent. • The complementary CT imaging atlas is expected to enhance unified interpretations of the MSBDS between different professionals dealing with MM patients in their routine clinical practice.

Smartphone-based behavioral monitoring and patient-reported outcomes in adults with rheumatic and musculoskeletal disease

BackgroundRheumatic and musculoskeletal diseases (RMD) are associated with depression, fatigue, and disturbed sleep – symptoms that often impact behavior and activity. Patient reported outcomes (PROs) are a way of collecting information on the patient symptom experience directly from the individual. The purpose of this study was to measure and compare user smartphone sensor and activity data in adults with RMDs and assess associations with PROs.MethodsWe invited adults with RMDs enrolled in the FORWARD Databank to participate by installing a custom app on their smartphone and answering PROs (pain, global, HAQ-II) questions daily and weekly over 3 years. Passive data collected included mobility distance, unique calls and text messages, call durations, and number of missed calls. Confounders included sociodemographic, clinical, passive phone behavior, and seasonal factors. Kappa statistics between PRO and flares were computed to measure agreement. The agreement between daily and weekly VAS pain was estimated using the intraclass (ICC) correlation of a two-way random effect model. The relationship between the weekly PRO outcomes and the passive phone data was analyzed with a linear mixed-effect model (LMM), including a random intercept for participant and slope for time in the study with an unstructured covariate structure.ResultsOf the 446 participants, the mean (SD) age was 54 (12) years, most (65.5%) had rheumatoid arthritis (RA), the vast majority (91%) were female, and the US Northeast has the least representation (12%). Longer reaction times, interaction diversity, and higher mobility were associated with worse PROs while longer text messages were associated with better PROs. Participants in this study showed good levels of adherence which holds promise for future interventions using passive behavior measures in self-management and clinical follow-up.ConclusionThis is the first study to examine passive smartphone behavior with PROs in RMDs and we found significant associations between these behaviors and important health outcomes of pain and function. As smartphone usage continues to change, future studies should validate and expand on our findings with a goal of finding changes in patient symptoms passively through mobile device monitoring.

Assessing the diagnostic accuracy and interobserver agreement of MRI perfusion in differentiating disease progression and pseudoprogression following treatment for glioblastoma in a tertiary UK centre

To assess the local diagnostic accuracy and interobserver agreement of dynamic susceptibility contrast-enhanced magnetic resonance perfusion (DSC MRP) reporting in differentiating between disease progression and pseudoprogression (PP) at a tertiary UK centre. This retrospective study included adults with histology-proven glioblastoma who underwent an index DSC MRP examination following treatment. Each index examination was evaluated by three reporters independently, including qualitative assessment and measurement of mean regional cerebral blood volume (rCBVmean) ratios. Consensus opinion was used as the reference standard and considered clinical, radiological and histological follow-up information. Examination reports were compared to each other and to the consensus opinion. Thirty-two cases were included (19 progression, 13 pseudoprogression). Interobserver agreement was fair for qualitative opinion (κ=0.58, 95% confidence interval [CI] 0.40-0.76) and good for rCBVmean ratio measurement (intraclass correlation coefficient [ICC, two-way random effects model] 0.63, 95% CI=0.43-0.78). Qualitative opinion showed diagnostic accuracies of 77.1% (95% CI=67.4-85.1) for progression and 75% (95% CI=65.1-83.3) for pseudoprogression. rCBVmean ratios were higher for progression (6.85±3.98) than pseudoprogression (3.71±3.40); a 3.0 threshold value maximised the sum of sensitivity (91.1%) and specificity (69.7%) on receiver operating characteristic analysis. DSC MRP and rCBVmean ratio measurement aid differentiation between progression and pseudoprogression following treatment for glioblastoma. Measurement of the rCBVmean ratio shows good interobserver agreement and can change opinion and improve confidence in DSC MRP reporting. Individual centres should validate their own threshold rCBVmean ratio values to optimise diagnostic accuracy.

Initial Experience on Hyperpolarized [1-13C]Pyruvate MRI Multicenter Reproducibility-Are Multicenter Trials Feasible?

Background: Magnetic resonance imaging (MRI) with hyperpolarized [1-13C]pyruvate allows real-time and pathway specific clinical detection of otherwise unimageable in vivo metabolism. However, the comparability between sites and protocols is unknown. Here, we provide initial experiences on the agreement of hyperpolarized MRI between sites and protocols by repeated imaging of same healthy volunteers in Europe and the US. Methods: Three healthy volunteers traveled for repeated multicenter brain MRI exams with hyperpolarized [1-13C]pyruvate within one year. First, multisite agreement was assessed with the same echo-planar imaging protocol at both sites. Then, this was compared to a variable resolution echo-planar imaging protocol. In total, 12 examinations were performed. Common metrics of 13C-pyruvate to 13C-lactate conversion were calculated, including the kPL, a model-based kinetic rate constant, and its model-free equivalents. Repeatability was evaluated with intraclass correlation coefficients (ICC) for absolute agreement computed using two-way random effects models. Results: The mean kPL across all examinations in the multisite comparison was 0.024 ± 0.0016 s−1. The ICC of the kPL was 0.83 (p = 0.14) between sites and 0.7 (p = 0.09) between examinations of the same volunteer at any of the two sites. For the model-free metrics, the lactate Z-score had similar site-to-site ICC, while it was considerably lower for the lactate-to-pyruvate ratio. Conclusions: Estimation of metabolic conversion from hyperpolarized [1-13C]pyruvate to lactate using model-based metrics such as kPL suggests close agreement between sites and examinations in volunteers. Our initial results support harmonization of protocols, support multicenter studies, and inform their design.

Interobserver reliability of scapula fracture classifications in intra- and extra-articular injury patterns

BackgroundMorphology and glenoid involvement determine the necessity of surgical management in scapula fractures. While being present in only a small share of patients with shoulder trauma, numerous classification systems have been in use over the years for categorization of scapula fractures. The purpose of this study was to evaluate the established AO/OTA classification in comparison to the classification system of Euler and Rüedi (ER) with regard to interobserver reliability and confidence in clinical practice.MethodsBased on CT imaging, 149 patients with scapula fractures were retrospectively categorized by two trauma surgeons and two radiologists using the classification systems of ER and AO/OTA. To measure the interrater reliability, Fleiss kappa (κ) was calculated independently for both fracture classifications. Rater confidence was stated subjectively on a five-point scale and compared with Wilcoxon signed rank tests. Additionally, we computed the intraclass correlation coefficient (ICC) based on absolute agreement in a two-way random effects model to assess the diagnostic confidence agreement between observers.ResultsIn scapula fractures involving the glenoid fossa, interrater reliability was substantial (κ = 0.722; 95% confidence interval [CI] 0.676–0.769) for the AO/OTA classification in contrast to moderate agreement (κ = 0.579; 95% CI 0.525–0.634) for the ER classification system. Diagnostic confidence for intra-articular fracture patterns was superior using the AO/OTA classification compared to ER (p < 0.001) with higher confidence agreement (ICC: 0.882 versus 0.831). For extra-articular fractures, ER (κ = 0.817; 95% CI 0.771–0.863) provided better interrater reliability compared to AO/OTA (κ = 0.734; 95% CI 0.692–0.776) with higher diagnostic confidence (p < 0.001) and superior agreement between confidence ratings (ICC: 0.881 versus 0.912).ConclusionsThe AO/OTA classification is most suitable to categorize intra-articular scapula fractures with glenoid involvement, whereas the classification system of Euler and Rüedi appears to be superior in extra-articular injury patterns with fractures involving only the scapula body, spine, acromion and coracoid process.

Interrater reliability of quantitative ultrasound measures of muscle in critically ill patients.

Quantitative neuromuscular ultrasound is increasingly used to study muscle pathology and changes in muscle mass during critical illness. Advantages of ultrasound are high axial resolution, low procedural risks, no ionizing radiation, and ease of use early in the course of disease. However, ultrasound is known to be an operator dependent imaging modality and the intensive care unit setting poses additional challenges to obtaining reliable measurements. There is limited evidence validating the feasibility and reliability of its application in this setting. To conduct a standardized protocol for measuring muscle linear depth and cross-sectional area in critically ill populations with a high degree of interrater agreement and feasibility. Prospective observational cohort study of interrater reliability. Medical intensive care unit at an academic medical center and a level one trauma and burn center. Fifteen critically ill patients were evaluated using a standardized ultrasound protocol measuring total elbow flexor, knee extensor, and tibialis anterior depth, as well as rectus femoris cross-sectional area. Each site was independently scanned by two investigators. Reliability of measurements between observers was determined by calculating intraclass correlation coefficients (ICCs) using a two-way random effects model and absolute agreement. An ICC > 0.75 was considered good and >0.90 was considered excellent. In critically ill patients, interrater reliability of linear depth measured at elbow flexor, knee extensor, tibialis anterior, and cross-sectional area of rectus femoris sites was good to excellent with ICC between 0.87 (0.54-0.97) and 0.99 (0.97-1.00). Interrater reliability was improved by creating a summary index of measures resulting in an ICC of 0.99 (0.98-1.00). Feasibility, as definite by the percentage of each measure that was obtainable, ranged from 75%-100%. Using a standardized protocol, ultrasound measures obtained in critically ill patients demonstrated high levels of interrater agreement with good to excellent feasibility.

Translation of Karnofsky Performance Status (KPS) for use in inpatient cancer rehabilitation.

Better tools are needed to predict functional decline and oncologic prognosis in inpatient cancer rehabilitation. The Karnofky Performance Status (KPS) is a widely used scale of functional performance in oncology, although the scale differs from current rehabilitation terminology. Use of the KPS in inpatient rehabilitation may support a shared method of communication between cancer rehabilitation providers and the primary oncology teams. To establish interrater reliability for translation of the KPS for use in inpatient cancer rehabilitation. Retrospective interrater reliability review. A large inpatient rehabilitation hospital system. Fifty randomized charts were chosen for review from a larger database of all patients admitted to an inpatient cancer rehabilitation program in 2020. Not applicable. The KPS scale was translated into common inpatient rehabilitation grading consistent with the Continuity and Assessment Record and Evaluation (CARE) Item Set to support its use in this specialty area. Additionally, a list of best practice guidelines and scoring instructions were created to assist raters in determining appropriate levels within the scale. Members of the inpatient cancer rehabilitation team scored all patients within the larger database (n=424) throughout 2020. A blinded rater completed retrospective chart reviews to score the 50-chart sample. A two-way random effects model was used to calculate an intraclass correlation coefficient (ICC) for the KPS scores at each of three time points (premorbid, admission, and discharge). The KPS interpretation for rehabilitation proved to be statistically reliable for the 50-chart sample. The premorbid KPS interrater reliability was acceptable (ICC=0.67; 95% confidence interval [CI]: 0.40-0.82), admission KPS reliability was good (ICC=0.88, 95% CI: 0.78-0.93), and discharge reliability was excellent (ICC=0.96; 95% CI: 0.91-0.98). The KPS translation at three time points (premorbid, admission, and discharge) during the inpatient rehabilitation continuum has acceptable interrater reliability.

Test-Retest Reliability and Agreement of Single Pulse Transcranial Magnetic Stimulation (TMS) for Measuring Activity in Motor Cortex in Patients With Acute Ischemic Stroke.

Transcranial magnetic stimulation (TMS) is often used to examine neurophysiology. We aimed to investigate the inter-rater reliability and agreement of single pulse TMS in hospitalised acute ischemic stroke patients. Thirty-one patients with first-time acute ischemic stroke (median age 72 (IQR 64-75), 35% females) underwent TMS motor threshold (MT) assessment in 4 muscles bilaterally, conducted by 1 of 2 physiotherapists. Test-retest reliability was evaluated using a two-way random effects model (2,1) absolute agreement-type Interclass Correlation Coefficient (ICC). Standard Error of Measurement (SEM) and Smallest Detectable Change (SDC) were used to evaluate agreement. Reliability, SEM, and SDC of TMS was found to be moderate in right opponens pollicis (0.78 [CI 95% 0.55-0.89], SEM: 4.51, SDC: 12.51), good in right vastus medialis and tibial anterior (0.88 [CI 95% 0.72-0.96], SEM: 2.89, SDC: 8.01 and 0.88 [CI 95% 0.76-0.94], SEM: 2.88, SDC: 7.98 respectively), and excellent in right and left biceps brachii (0.98 [CI 95% 0.96-0.99], SEM: 1.79 SDC: 4.96, and 0.94 [CI 95% 0.89-0.97], SEM: 2.17 SDC: 6.01), opponens pollicis (0.92 [CI 95% 0.83-0.96], SEM: 2.68 SDC: 8.26, vastus medialis (0.92 [CI 95% 0.84-0.96], SEM: 2.87 SDC: 7.95), and tibial anterior (0.93 [CI 95% 0.86-0.96], SEM: 2.51 SDC: 6.95). The TMS demonstrated moderate to excellent inter-rater reliability confirming the ability of these measures to reliably discriminate between individuals in the current study sample. Improvements of less than 4.96 to 12.51 could be a result of measurement error and may therefore not be considered a true change.

Within- and between-session test-retest reliability of pain-free grip strength in individuals with lateral elbow tendinopathy

Introduction: Pain-free grip strength is an important clinical outcome measure in lateral elbow tendinopathy (LET). This study examined the test-retest reliability and minimal detectable change (MDC) for pain-free grip strength between- and within-session in individuals with LET. Methods: Data from 27 individuals (16 males) with LET, recruited for a randomised crossover trial examining the effects of biomechanical tape, were used for this study. Participants underwent three testing sessions, biomechanical tape, control tape, and no tape. During each session pain-free grip strength was measured at three timepoints: baseline, immediately after application, and post-exercise. Baseline measures from the first two data collection sessions, completed between 2 and 28 days apart, were used to examine between-session reliability. The baseline and immediately post-application measures (completed 20 to 30 minutes apart) from the no-tape condition, were used to examine within-session reliability. Pain-free grip strength was assessed in two positions: shoulder neutral, elbow at 90°, forearm pronated (flexed position), and shoulder at 90°, elbow extended, forearm pronated (extended position). Participants were asked to cease gripping as soon as they felt pain and the force (N) was recorded. At each timepoint and position, three trials of pain-free grip strength separated by 30 seconds’ rest were measured using a grip force transducer (ADInstruments, NZ). The mean of the three trials was calculated. To determine test-retest reliability, intraclass correlation coefficients (ICCs) with 95%CI were performed using an absolute agreement, two-way random-effects model (ICC2,3). The MDC at the 95% confidence level was calculated by multiplying the standard error of measurement by 1.96 and then by √2. Results: Between-session ICCs (95%CI) were ICC2,3=0.86 (0.69 - 0.94) and ICC2,3=0.93 (0.84 - 0.97) for the flexed and extended positions, respectively. Within-session ICCs (95%CI) were ICC2,3=0.96 (0.92 - 0.98) and ICC2,3=0.97 (0.93 - 0.98) for the flexed and extended positions, respectively. Between-session MDCs were 97.8 N (flexed) and 94.0 N (extended) and within-session MDCs were 49.3 N (flexed) and 63.8 N (extended). Discussion: The reliability of pain-free grip strength was excellent in both testing positions. Researchers and clinicians should expect to see a change of 94 to 98 N between-session and 49 to 64 N within-session, depending on upper limb position, to be confident a true change has occurred. Conflict of interest statement: The authors have no conflict of interest of relevance to this submission.

Examining Impacts of COVID-19-Related Stay-At-Home Orders through a Two-Way Random Effects Model.

The COVID-19 pandemic has had far-reaching impacts on public health and safety, economics, and the transportation system. To reduce the spread of this disease, federal and local governments around the world have introduced stay-at-home orders and other restrictions on travel to "non-essential" businesses to implement social distancing. Preliminary evidence suggests substantial variability in the impacts of these orders in the United States, both across states and over time. This study examines this issue using daily county-level vehicle miles traveled (VMT) data for the 48 continental U.S. states and the District of Columbia. A two-way random effects model is estimated to assess changes in VMT from March 1 to June 30, 2020 as compared with baseline January travel levels. The implementation of stay-at-home orders was associated with a 56.4 percent reduction in VMT on average. However, this effect was shown to dissipate over time, which may be attributable to "quarantine fatigue." In the absence of full shelter-in-place orders, travel was also reduced where restrictions on select businesses were introduced. For example, restrictions on entertainment, indoor dining, and indoor recreational activities corresponded to reductions in VMT of 3 to 4 percent while restrictions on retail and personal care facilities showed 13 percent lower traffic levels. VMT was also shown to vary based on the number of COVID case reports, as well as with respect to other characteristics, including median household income, political leanings, and how rural the county was in nature.

Cross-cultural adaptation of the Richards-Campbell Sleep Questionnaire for intensive care unit inpatients in Brazil: internal consistency, test-retest reliability, and measurement error

Study objectivesTo perform the cross-cultural adaptation of the Richards-Campbell sleep questionnaire (RCSQ) to Portuguese-Brazil and to eval its internal consistency, test-retest reliability, and measurement error in intensive care unit (ICU) inpatients. MethodsThe study enrolled 113 inpatients at medical/surgical ICU in Curitiba, Brazil. The RCSQ was first translated to Portuguese-Brazil according to the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes and then applied in 30 inpatients. The final version (RCSQ-PT-Br) was applied to measure content validity (83 inpatients, 47 men [56.6%], 60.4 ± 14.2 years), and test-retest reliability and measurement error (a subset of 53 inpatients). Internal consistency of the RCSQ-PT-Br was estimated using Cronbach's a; test-retest reliability (2 independent rates) was assessed using the single measurement, absolute agreement, two-way random effects model (ICC2,1). ResultsGroup-average RCSQ-PT-Br total score was 46.9 ± 26.7 (range 3.4–98.8). The RCSQ-PT-Br total score showed good content internal consistency (Cronbach's α = 0.850 95%CI = [0.789–0.897]) and excellent test-retest reliability (ICC2,1 = 0.840 95% CI = [0.739–0.904]). Measurement error was low (standard error of mean = 11 mm, mean difference = 30 mm). ConclusionsThe RCSQ-PT-Br is a valid and reliable instrument to evaluate the sleep of patients hospitalized in the ICU in Brazil.

Adaptation and validation of the Nigerian Igbo Multidimensional Scale of Perceived Social Support in patients with chronic low back pain

IntroductionSocial support may be important in the perpetuation of symptoms in chronic low back pain (CLBP). The multidimensional scale of perceived social support (MSPSS) is one of the best measures of social support with applicability in Africa.AimsThe aims of this study were to translate, culturally adapt, test–retest, and assess cross-sectional psychometric properties of the Igbo-MSPSS.MethodsForward and backward translation of the MSPSS was done by clinicians and non-clinician translators and evaluated by a specialist review committee. The adapted measure was piloted amongst twelve adults with CLBP in rural Nigeria. Cronbach’s alpha and McDonald’s omega coefficient were used for investigating internal consistency. Intra-class correlation coefficient (ICC: two-way random effects model, average of raters’ measurements, absolute definition of agreement) reflecting both the degree of correlation and agreement between measurements was used for the statistical investigation of test–retest reliability. Criterion validity of the adapted measure was investigated with the eleven-point box scale, back performance scale, Roland Morris Disability Questionnaire, and World Health Organisation Disability Assessment Schedule amongst 200 people with CLBP in rural Nigeria using Spearman’s correlation analyses. Exploratory factor analyses conducted using Kaiser criterion and parallel analysis as methods for determining dimensionality were used to determine the structural validity of the adapted measure amongst the same sample of 200 rural dwellers.ResultsIgbo-MSPSS had excellent internal consistency (0.88) and ICC of 0.82. There were moderate correlations with measures associated with the social support construct. The same item–factor pattern in the three-dimensional structure (with Kaiser criterion) as in the original measure and a two-dimensional structure (with parallel analysis) were produced.ConclusionsIgbo-MSPSS is a measure of social support with some evidence of validity and reliability and can be used clinically or for research. Future studies are required to confirm its validity and reliability.