Interrater reliability and physical examination of the pubovisceral portion of the levator ani muscle, validity comparisons using MR imaging

AIMS: Defects in the pubovisceral portion of the levator ani muscle are seen with MR imaging. This study aims to determine interrater reliability of physical examination in detecting these defects, and to validate findings from physical examination using comparisons with MR images. METHODS: Two examiners palpated the pubovisceral muscles of 29 women to assess for defects in this muscle. Each examiner was blinded to the others findings. MR scans were acquired on a further 24 women after structured clinical examination by one examiner. These images were read to determine pubovisceral muscle defects, blinded to patient identifiers. Agreement between raters and between MR imaging and clinical examination were calculated. RESULTS: The two examiners had positive agreement (presence of a defect) of 72.7% and negative agreement (absence of a defect) of 83.3%. The positive agreement between physical examination and MR imaging was 27.3% and the negative agreement 86.5%. CONCLUSION: The structured physical examination to detect defects in the pubovisceral portion of the levator ani muscle can be learned as shown by good interrater agreement. However, examination alone underestimates these defects compared with MR imaging.     

社区老年人跌倒危险评估工具的信效度检验

目的对社区老年人跌倒危险评估工具(FROP-Com)进行测量学检验,为社区老年人提供跌倒风险测评工具。方法使用FROP-Com对126名社区老年人进行跌倒危险评估,根据评估结果检验该工具的信度和效度,同时利用修订版跌倒功效量表进行效标效度检验。结果 FROP-Com评定者信度良好,护理研究生与社区医生对老年人跌倒危险评估评分比较,差异无统计学意义(P>0.05);内部一致性Cronbach′sα为0.859。有无跌倒社区老年人FROP-Com评分比较,差异有统计学意义(P<0.01);FROP-Com与修订版跌倒功效量表有较好的相关性(r=-0.64,P<0.01)。结论 FROP-Com是一种简单、方便、安全的评估工具,其信度和效度较好,适合医护人员用于社区老年人的跌倒危险评估,并能初步筛选出高危跌倒人群。     

The reliability of digital imaging in the remote assessment of wounds: defining a standard

CONTEXT: Telemedicine has been used for remote management of many medical problems. Given the ever-expanding demands to provide increasing service with increasingly limited resources, quality care and practice efficiency can be enhanced by telemedicine. OBJECTIVE: This study was undertaken to explore the reliability of wound assessment using computer-transmitted digital imagery compared with a traditional bedside evaluation and also to assess its potential role in healthcare delivery. DESIGN/SETTING/PATIENTS: In the hospital setting, rounding vascular surgeons and a surgical resident evaluated the wounds on the service. A digital photograph was obtained with a 3.3 megapixel camera, and a wound-assessment tool was completed. A plastic surgery attending then reviewed the images at a later date and completed the same data tool. MAIN OUTCOME MEASURES: Wounds were rated for eschar, exposed bone, cellulitis, purulence, swelling, granulation tissue, granulation color, and depth using a standardized data collection tool. kappa statistics were computed for all variables, between raters. RESULTS: There were 2 phases of the study. In both phases, there was 100% agreement by the rounding physicians that the digital image was representative of the wound. Phase 1 agreement between evaluators was moderate to almost perfect, as demonstrated by kappa values (range, 0.50-0.87). In phase 2, all variable kappa values were rated as almost perfect, except the ability to evaluate depth of the wound to the millimeter, which was rated as substantial. CONCLUSIONS: The ability to accurately evaluate a wound on the basis of a digital image is possible. However, it requires training of participants and is facilitated by use of an assessment tool. With these caveats, evaluation of wounds using digital images is equivalent to bedside examination. This technology can improve practice efficiency, provide needed expertise at remote sites, and is an acceptable alternative method of wound assessment.     

A reliability and validity study for different coronal angles using ultrasound imaging in adolescent idiopathic scoliosis

Background Context

Radiation exposure remains a big concern in adolescent idiopathic scoliosis (AIS). Ultrasound imaging of the spine could significantly reduce or possibly even eliminate this radiation hazard. The spinous processes (SPs) and transverse processes (TPs) were used to measure the coronal deformity. Both landmarks provided reliable information on the severity of the curve as related to the traditional Cobb angle. However, it remained unclear which coronal ultrasound angle is the most appropriate method to measure the curve severity.

Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures

Objective data comparing sensitivity and accuracy between traditional and computed imaging techniques used for diagnosing mandibular fractures is sparse. To address the paucity of information the authors studied prospectively 33 mandibular fractures in 21 consecutive patients with standard mandibular series, panoramic tomography, axial computed tomography (CT), and coronal CT. Differences in diagnostic accuracy and sensitivity as compiled by four blinded reviewers were calculated. Although overall sensitivities of mandibular fracture detection were not statistically significant between the imaging studies, a distinction between the four methods did exist. Coronal CT was the most accurate imaging method, followed by mandibular series, panoramic topography, and axial CT. Excluding technically inadequate studies, panoramic tomography was 100% accurate and sensitive. Diagnostic accuracy and sensitivity did not correlate measurably with reviewers' impressions of the quality of a particular exam. Axial CT detected significantly fewer angle fractures than standard radiographs (60% vs. 98%, p = 0.006) and coronal CT (60% vs. 100%, p = 0.008). False-positives were unusual except for plain mandibular radiographs. The clear definition of both coronal and axial CT scans made their analysis simpler than the plain radiographs. Lack of fracture displacement was the single most important factor in missed fractures with all modalities. Despite reviewer concerns about the quality of the plain mandibular series, the high accuracy and sensitivity of this imaging technique and applicability in all patients, coupled with its low cost, make it an excellent screening exam for all patients with suspected mandibular fractures. In clinically stable and cooperative patients with mandibular trauma, panoramic radiography and coronal CT are recommended to confirm clinical suspicions when the mandibular series is equivocal. To supplement the mandibular series in the uncooperative or multisystem trauma patient, axial CT scans have not been beneficial. These diagnostic modalities do not obviate the need for a careful physical exam.     

Interobserver reliability in the interpretation of diagnostic lumbar MRI and nuclear imaging.

BACKGROUND CONTEXT: Assessment of patients with complaints of low back or leg pain varies with the subspecialty of the treating physician. The evaluation of the spine patient may include magnetic resonance imaging (MRI), bone scan, or single-photon emission computed tomography (SPECT) imaging. The interpretation of these tests and the examiner's biases will impact the outcome of patient treatment and the cost to the health-care system. PURPOSE: To evaluate interobserver reliability of MRI and nuclear imaging studies and determine the predictability of nuclear medicine results based upon MRI findings. STUDY DESIGN/SETTING: Retrospective radiographic review for patients with low back pain. MRI, planar bone scan imaging, and SPECT imaging techniques were evaluated. PATIENT SAMPLE: Seventeen patients (80 lumbar levels) who presented to an orthopedic spine specialist with a complaint of mechanical low back or leg pain were randomly selected. Inclusion criteria were age greater than 21 years and a workup that included MRI, bone scan, and SPECT scan images. OUTCOME MEASURES: Interobserver reliability was determined using kappa values (0.6 to <0.8=substantial; 0.8-1=perfect). Interobserver reliability was evaluated for all studies and compared with a "group consensus." METHODS: A team of orthopedists and radiologists of varying experience levels were assembled to interpret the imaging studies. All readings were performed independently followed by group interpretation and discussion. The reviewers were asked to assess each lumbar level (L1-L2 through L5-S1). Phase one: Is the level degenerative? Is there a spondylolisthesis present? Does the level have Modic changes on MRI? Phase two: Based on the MRI, will the planar bone scan be positive? After this prediction, was the planar scan positive? Identify the lesion location (anterior column vs. posterior column). Phase three: Based on their assessment and predicted results on planar bone scan, was the SPECT scan able to improve this assessment? RESULTS: High kappa values were demonstrated in the identification of a degenerative disc, spondylolisthesis, and Modic change (0.773, 0.728, and 0.669, respectively). Bone scan and SPECT scan yielded poorer kappa results (0.539 and 0.460, respectively). Reviewer-predicted bone scan results demonstrated a positive predictive value of 68% and a negative predictive value of 84%. Predicated SPECT results were similar (positive predictive value 66% and negative predictive value 84%). SPECT identified 24% more lesions in the lumbar spine when compared with bone scan. CONCLUSIONS: MRI interpretation of the lumbar spine is comparable between specialties. Nuclear imaging studies (bone scan/SPECT) demonstrated a poorer correlation between examiners. The presence of MRI changes enables an accurate prediction of bone scan or SPECT scan findings. SPECT scan demonstrates an increased sensitivity in the detection of spinal abnormalities and the ability to localize a lesion when compared with planar bone scan.     

The Achilles Tendon Length Measure and the Achilles Tendon Resting Angle show acceptable construct validity using the Copenhagen Achilles Length Measure as gold standard

BackgroundElongation of the Achilles tendon after rupture is a frequent complication. The Achilles Tendon Length Measure (ATLM) and the Achilles Tendon Resting Angle (ATRA) are indirect length measures using the resting angle of the ankle. Copenhagen Achilles Length Measure (CALM) is a direct ultrasound measure. The purpose of this study was to examine the construct validity of ATLM and ATRA using CALM as gold standard.MethodsAs the three measurements measure slightly different constructs and have different scales a direct comparison was not possible. Instead a mixed linear regression model was performed investigating the three models: CALM-ATRA, CALMATLM and ATRA-ATLM.Results130 patients were available for analysis. All three regression models demonstrated a statistically significant (p < 0.01) linear relationship and acceptable certainty of the estimates.ConclusionATRA and ATLM were found to have acceptable construct validity when using CALM as gold standard for assessing tendon elongation after an Achilles tendon rupture.     

Accuracy of ultrasonic detection of renal scarring in different centres using DMSA as the gold standard.

BACKGROUND: There is an ongoing debate over the radiological investigations of children with urinary tract infections (UTIs) with some authorities suggesting that ultrasound scan (USS) alone is an accurate tool to diagnose renal parenchymal scarring post-pyelonephritis. All studies on this subject have been performed at paediatric teaching centres whereas most children with UTIs are managed by General Paediatricians in District General Hospitals (DGHs) in the United Kingdom. We wished to identify whether results of scans in DGHs differed from those in teaching centres. METHODS: We looked at all children with a clinical history of UTIs having a DMSA and USS over a one year period in two DGHs and one teaching centre. A total of 476 children's results were reviewed, 297 from the DGHs and 179 from the teaching centre. RESULTS: The cohort had a total of 949 renal units. There were 79 scarred renal units (kidneys) on DMSA (8%) in 72 patients (15%). Just 18 renal units were detected as being scarred on USS (22.8%). Nine of 32 scarred renal units in the teaching centre were detected compared with nine of 47 in the DGHs (P = 0.40). Thirty-nine (49%) of the scarred renal units were in patients >5-years old. Of these 12 (30.7%) were detected on USS, nine of 17 within the teaching centre compared with just three of 22 at the DGHs (P = 0.01). CONCLUSION: Overall only a small percentage of scars are detected on USS. In the over 5-year old group, where USS alone might be preferred, DGHs were significantly worse at detecting scarred kidneys. We conclude that if the detection of renal scars is a prime reason for imaging in children with UTIs, ultrasonography alone is inappropriate at any age and DMSA ought to be the primary investigation.     

Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard

Dimercaptosuccinic acid (DMSA) renal scan is presently the technique of choice for assessing renal scars. Recent advances suggest that ultrasonography could replace DMSA scan for this purpose. This paper describes the experience of a tertiary pediatric referral hospital performing ultrasonography and DMSA scans in the assessment of renal scarring. Investigations were conducted 3–6 months after patients presented with urinary tract infection (UTI). Results were extracted from the radiology information system and recorded for analysis. All children with a UTI who had undergone DMSA and ultrasound examination on the same day between January 1995 and December 1999 were included; 930 kidneys were compared. DMSA scan was utilized as the reference method. When used to detect focal renal scarring, ultrasonography had a sensitivity of 5.2%, specificity of 98.3%, a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 75.8%. When used to detect diffuse renal scarring, ultrasonography had a sensitivity of 47.2%, specificity of 91.8%, PPV of 60.8% and NPV of 86.6%. Our results demonstrate that although ultrasonography has a good specificity for the detection of renal scarring compared with DMSA, it has low sensitivity, PPV and NPV. Ultrasonography cannot be substituted for DMSA scan in the evaluation of focal renal scarring.     

Assessment of osteoporosis using standard radiographs of the wrist.

BACKGROUND: This study evaluated the ability of the orthopaedic surgeon to radiographically assess bone density in the wrist with sufficient accuracy to determine which patients require treatment for osteoporosis. METHODS: Thirty-eight patients with unilateral distal radius fractures, 30 of whom were female, were included in this study. The mean age was 55 years (range 45 to 82). Standard radiographs of the fractured and normal wrists were taken. Dual energy x-ray absorptiometry was performed on the normal distal radius of all patients within 1 week of their injury. The radiographs were viewed in blinded randomized fashion on two separate occasions by three orthopaedic surgeons and once by a fourth. The participants were required to determine the presence of osteoporosis. Visual analog scales (VAS) were used to evaluate (1) porosity, (2) cortical thickness, (3) trabecular thickness, and (4) the number of trabeculae in the ultradistal radius. RESULTS: Intraobserver agreement assessing osteoporosis averaged 81% (kappa of 0.5393). VAS assessment was unreliable for all four parameters. Radiographic determination of osteoporosis had a specificity of 61% and a sensitivity of 61% using x-rays of the uninjured wrist. CONCLUSION: We conclude that orthopaedic surgeons cannot predict with sufficient accuracy using plain x-rays whether a patient is significantly osteoporotic.     

The effectiveness of skeletal imaging for quality assessment in posterior cruciate ligament reconstruction: reliability and validity of radiographs and computed tomography

Purpose

For intra- and postoperative evaluation of precise and anatomic graft tunnel position, radiographs (XR) and computed tomography (CT) scans have been suggested. The purpose of this study was to evaluate the reliability and validity of XR and CT for quality assessment following PCL reconstruction.

Methods

Postoperative radiographs and CT scans were obtained in 45 consecutive patients following a standard single-bundle PCL reconstruction. Femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. To assess the reliability and validity of XR and CT scans three independent observers evaluated radiographic and CT images for the position of femoral and tibial tunnel apertures.

Results

Almost perfect inter- and intra observer agreement (0.79–0.99) was found for all CT measurements except for the distance of the tunnel position to the previous physis line. Almost perfect and strong inter- and intraobserver agreement (0.70–0.98) was found for all tibial measurements on XR which tended to increase with repeated interpretation and to decrease with low levels of observer qualification. Femoral measurements yielded only poor-to-moderate reliability (0.02–0.5) between raters on XR but strong intraagreement within experienced observers (0.45–0.86). Specificity for XR was calculated with 75.7 % for P2 and P3 and with 71 % for femoral tunnel depth and height.

Conclusion

XR and CT represent complementary imaging modalities and both offer considerable accuracy and precision for the determination of femoral and tibial tunnel apertures following PCL reconstruction and can be recommended for intra- and postoperative quality assessment.     

Construct validity and reliability of the Concussion Knowledge Assessment Tool (CKAT)

ObjectiveTo evaluate the test-retest reliability and construct validity of the concussion knowledge assessment tool (CKAT) as a measure of knowledge of concussion and its management among chiropractic subgroups and to compare these properties for two scoring strategies for the CKAT.MethodsThree chiropractic subgroups (first year students, interns and sports chiropractors) completed the CKAT via SurveyMonkey with as second administration two to six weeks later for a subset of respondents. Scatter plots and Intraclass Correlation Coefficients (ICC) were used for test-retest reliability. A priori hypotheses regarding the relationship of CKAT scores across known subgroups, and with concussion knowledge self-rankings were established prior to data collection. Distributions of CKAT scores were compared across the subgroups using boxplots and ANOVA for known groups validity, and correlation of CKAT scores with concussion knowledge self-ranking was examined.ResultsTest-retest ICC for the revised scoring was 0.68 (95%CI 0.51–0.80). First year students had a mean revised CKAT (out of 49) of 36.9 (SD= 4.7), interns 39.9 (SD=3.0) and sports chiropractors 41.8 (SD=3.2) which are significantly different (F_2,125=17.54; p<0.0001).ConclusionsThe CKAT distinguished between chiropractic subgroups expected to have different levels of knowledge, supporting construct validity, however, it did not achieve adequate test-retest reliability.     

Visual assessment of the mandibular cortex on panoramic radiographs to identify postmenopausal women with low bone mineral densities.

OBJECTIVE: The purpose of this study was to determine whether simple visual estimation of the mandibular inferior cortex width on panoramic radiographs is useful for identifying postmenopausal women with low skeletal bone mineral density (BMD). STUDY DESIGN: Panoramic radiographs were made on 100 women aged 50-84 years who also had BMD assessment of the lumbar spine and femoral neck by dual-energy x-ray absorptiometry. The panoramic images were examined twice by 4 observers to evaluate the thickness of the mandibular inferior cortex. RESULTS: Intraobserver agreement varied from moderate to almost perfect. Interobserver agreements varied from fair to almost perfect. Overall mean sensitivity, specificity and positive predictive value in identifying women with low BMD were 54.7%, 82.0%, and 72.5% in the lumbar spine and 51.8%, 82.2%, and 75.7% in the femoral neck, respectively. CONCLUSIONS: Our results suggest that simple visual estimation of the mandibular inferior cortex on panoramic radiographs may be useful for identifying postmenopausal women with low BMD.     

Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To examine clinical and magnetic resonance imaging (MRI) features of hamstring muscle injury to determine if any are predictive for recurrent injury. BACKGROUND: Hamstring muscle strain injury and subsequent recurrent injury are common. Little information exists on factors that may increase the risk for recurrent injury. METHODS AND MEASURES: The subjects were athletes from 3 professional Australian Rules football teams (n = 162). Anthropometric measurements, clinical signs, convalescent interval, and MRI assessment and measurement were undertaken and recorded in athletes with hamstring muscle strain injury. Athletes were followed for the presence, or absence, of recurrent injury to the same-side posterior thigh over the same and subsequent playing seasons. RESULTS: Thirty athletes met criteria for hamstring injury. Twelve (40%) of 30 athletes had recurrent injury within the same season, with an additional 7 athletes having recurrent injury in the subsequent season. None of the features examined were associated with increased recurrent injury risk within the same playing season. Statistical analysis demonstrated that when combining the same with the subsequent playing season a larger size of initial hamstring injury, as measured by MRI, was associated with an increased risk for recurrent injury (P<.01). A measured transverse size of injury greater than 55% of the muscle, or calculated volume of injury greater than 21.8 cm3, resulted in an increased risk for hamstring recurrence of 2.2 (95% CI, 0.88-5.32) and 2.3 (95% CI, 0.94-5.81) times, respectively, when compared to athletes with hamstring injuries below these measurements. CONCLUSIONS: A larger size of hamstring injury was indicative of higher risk for recurrent injury but only after the subsequent playing season was considered along with the same playing season. None of the other parameters tested, including a shorter convalescent interval and clinical features, were associated with an increased risk for recurrent injury. However, due to low sample size the certainty of these conclusions may be limited.     

Translation, cultural adaptation assessment, and both validity and reliability testing of the Kidney Disease Quality of Life--Short Form version 1.3 for use with Iranian patients

Aim: The aims of the study were to translate the Kidney Disease Quality of Life – Short Form version 1.3 (KDQOL‐SF ver. 1.3) questionnaire into Iranian (Farsi), and to then assess it in terms of validity and reliability on Iranian patients. Methods: The questionnaire was first translated into Farsi by two independent translators, and then subsequently translated back into English. After translation disparities had been reconciled, the final Iranian questionnaire was tested. An initial test–retest reliability evaluation was performed over a 10 day period on a sample of 20 patients recruited from a larger group (212 patients with end‐stage renal disease on haemodialysis). Afterwards, reliability was estimated by internal consistency, and validity was assessed using known group comparisons and constructs for the patient group as a whole. Finally, the factor structure of the questionnaire was extracted by performing exploratory factor analysis. Results: All of the scales in the questionnaire showed good test–retest reliability (i.e. intraclass correlations between test and retest scores were >0.7). All of the scales met the minimal criteria (0.7) for internal consistency and Cronbach's‐α ranged 0.71–0.93. Furthermore, results from a discriminate validity evaluation showed that the questionnaire could be used to discriminate between subgroups of the patients. Finally, a principal component analysis of the disease‐specific scales indicated that this part of the questionnaire could be summarized into an 11 factor structure that jointly accounted for 79.81% of the variance. Conclusion: The Iranian version of the KDQOL‐SF questionnaire is both highly reliable and valid for use with Iranian patients on haemodialysis.     

Intrarater and interrater reliability of assessment of lumbar multifidus muscle thickness using rehabilitative ultrasound imaging

STUDY DESIGN: Within-session intrarater and interrater reliability study. OBJECTIVE: To establish the intrarater and interrater reliability of thickness measurements of the multifidus muscle in a parasagittal plane, conducted by an experienced ultrasound operator and a novice assessor. BACKGROUND: There is considerable evidence for the important role of the multifidus muscle in segmental stabilization of the lumbar spine. The cross-sectional area of the multifidus muscle has been assessed in healthy subjects and patients with low back pain using real-time ultrasound imaging. However, few studies have measured the thickness of the multifidus muscle using a parasagittal view. METHODS AND MEASURES: The thickness of the multifidus muscle was measured at rest, using real-time ultrasound imaging, in 10 subjects without a history of low back pain, at the levels of the L2-3 and L4-5 zygapophyseal joints. The measure was carried out 3 times at each level by 2 assessors (1 experienced, 1 novice). Intrarater (model 3) and interrater (model 2) reliability was assessed by calculation of an F statistic (analysis of variance), the intraclass correlation coefficient (ICC), and the standard error of measurement (SEM). RESULTS: On the basis of an average of 3 trials, the 2 operators showed very high interrater agreement on the measurement of thicknesses at the L2-3 level (ICC2,3 = 0.96; 95% CI: 0.84 to 0.99) and the L4-5 vertebral level (ICC2,3 = 0.97; 95% CI: 0.87 to 0.99), with no systematic differences in muscle size across operators (P > .05). Interrater reliability was relatively lower for the L2-3 level (ICC2,1 = 0.85; 95% CI: 0.51 to 0.96) than the L4-5 level (ICC2,1 = 0.87; 95% CI: 0.52 to 0.97) when a single trial per rater was used, but these values still indicated a high level of agreement. In addition, the novice and experienced operator produced reliable intrarater measurements at L2-3 (ICC3,1 = 0.89; 95% CI: 0.72 to 0.97 and 0.94; 95% CI: 0.86 to 0.99) and at L4-5 (ICC3,1 = 0.88; 95% CI: 0.68 to 0.97 and 0.95; 95% CI: 0.86 to 0.99), with no systematic differences in muscle size across trials (P > .05). The consistently low SEM values also indicate low measurement error. CONCLUSION: A novice and an experienced assessor were both able to reliably perform this measure at rest for 2 vertebral levels using real-time ultrasound imaging. An average of 3 trials produced higher interrater reliability scores, though using a single trial per rater was also reliable.