The age‐related white matter changes scale correlates with cognitive impairment

Background and purpose: Age‐related white matter changes (ARWMC) are closely associated with cognitive impairment. Although the ARWMC scale has been widely used to grade white matter changes (WMC) severity, the correlation between this scale and cognitive impairment has not been studied. We aimed to validate the ARWMC scale against cognition in patients with stroke. Methods: We determined the severity of WMC for 172 patients with stroke on MRI by volumetric quantification and the ARWMC scale. Two scores (total score and global score) were derived from the ARWMC scale. We assessed executive function and global cognition using the Mattis dementia rating scale‐initiation/perseveration subset (MDRS I/P) and mini‐mental state examination (MMSE), respectively. We investigated the association between the three WMC measures (volume, total score, and global score) and clinical variables with cognitive impairment using multivariate regression analysis. Results: Even after adjusting for other clinical variables, total score and global score of ARWMC scale were independently associated with MDRS I/P (beta = ?0.248, P = 0.001 and beta = ?0.218, P = 0.005, respectively) and MMSE (adjusted odds ratio 1.181, 95%CI [1.038–1.343] and adjusted odds ratio 1.740, 95%CI [1.063–2.847], respectively). Conclusion: The ARWMC scale correlates well with cognitive impairment in patients with stroke.     

The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect

The Modified Ashworth Scale (MAS) is a clinical scale used to assess muscle spasticity. While the evidence indicates that the reliability of the MAS is better in the upper limb and in certain distal muscle groups, no investigation has compared the effect of limbs and muscle groups on the MAS reliability. This study aimed to evaluate the effect of limb and muscle group on the reliability of the MAS in patients with spastic hemiplegia. Thirty subjects with upper and lower limb muscle spasticity were recruited for this trial. Two female experienced physiotherapists participated in this examination of reliability, and rated each patient in a randomized order in a single session. For the intrarater reliability, the second rater repeated the test 1 week later. Shoulder adductor, elbow flexor, wrist flexor, hip adductor, knee extensor, and ankle plantar flexor were tested on the hemiplegic side. Results demonstrated moderate inter (kappa=0.514, SE=0.046, p < 0.001) and intrarater (kappa=0.590, SE=0.051, p<0.001) reliability. For the inter and intrarater reliability, the agreement obtained for the upper and lower limb was similar. In the upper limb, the agreement between raters on the distal wrist flexor was significantly higher than the agreement on the proximal shoulder adductor. In the lower limb, there was a similar agreement between raters on the distal ankle plantar flexor and proximal hip adductor. For within rater, the agreement on the proximal and distal muscles of both limbs was not statistically significant. The Modified Ashworth Scale had moderate reliability. The limbs had no effect on the reliability. The agreement on distal wrist flexor in the upper limb was significantly higher between rater than in the proximal shoulder adductor. The agreement obtained with the MAS was not good, which questions the validity of the measurements.     

Validation of CT‐MRI fusion for intraoperative assessment of stereotactic accuracy in DBS surgery

Deep brain stimulation is typically performed with intraoperative microelectrode recording and test stimulation for target confirmation. Recent studies have shown accurate, clinically efficacious results after lead placement without microelectrode recording or test stimulation, using interventional magnetic resonance imaging (MRI) or intraoperative computed tomography (CT; iCT) for verification of accuracy. The latter relies on CT–MRI fusion. To validate CT–MRI fusion in this setting, we compared stereotactic coordinates determined intraoperatively using CT–MRI fusion with those obtained on postoperative MRI. Deep brain stimulation electrodes were implanted with patients under general anesthesia. Direct targeting was performed on preoperative MRI, which was merged with preimplantation iCT images for stereotactic registration and postimplantation iCT images for accuracy confirmation. Magnetic resonance imaging was obtained 6 weeks postoperatively for comparison. Postoperative MRI was obtained for 48 patients, with 94 leads placed over a 1‐year period. Vector error of the targeted contact relative to the initial plan was 1.1 ± 0.7 mm on iCT and 1.6 ± 0.7 mm on postoperative MRI. Variance comparisons (F‐tests) showed that the discrepancy between iCT‐ and postoperative MRI‐determined errors was attributable to measurement error on postoperative MRI, as detected in inter‐rater reliability testing. In multivariate analysis, improved lead placement accuracy was associated with frame‐based stereotaxy with the head of the bed at 0° compared with frameless stereotaxy with the head of the bed at 30° (P = 0.037). Intraoperative CT can be used to determine lead placement accuracy in deep brain stimulation surgery. The discrepancy between coordinates determined intraoperatively by CT–MRI fusion and postoperatively by MRI can be accounted for by inherent measurement error. © 2014 International Parkinson and Movement Disorder Society     

The Unified Dyskinesia Rating Scale: Presentation and clinimetric profile

We developed and tested a rating scale aimed to capture the essential features of dyskinesia in Parkinson's disease (PD). Although several scales assess selected attributes of PD‐dyskinesias, no comprehensive rating tool exists. Available rating scales were evaluated by the investigators and patient focus groups. Modifications were finalized into the Unified Dyskinesia Rating Scale (UDysRS). The UDysRS has four parts: I: Historical Disability (patient perceptions) of On‐Dyskinesia impact (maximum 44 points); II: Historical Disability (patient perceptions) of Off‐Dystonia impact (maximum 16 points); III: Objective Impairment (dyskinesia severity, anatomical distribution over seven body regions, and type (choreic or dystonic) based on four activities observed or video‐recorded (28 points); IV: Objective Disability based on Part III activities (maximum 16 points). For clinimetric testing, 70 PD patients with all severities of dyskinesia were interviewed and videotaped. Twenty movement disorder experts rated the videotapes with the UDysRS. Internal consistency was examined with Cronbach's alpha. Inter‐ and intra‐rater reliability was evaluated with generalized weighted and nonweighted Kappa coefficients, and intraclass correlation coefficients. Both subjective (Sections I and II) and objective (Sections III and IV) demonstrated high internal consistency (alpha: 0.915, 0.971). Interrater reliability for the objective sections was acceptable for all items and likewise for intrarater reliability except for right leg. Reliable factor structures were found for both subjective (six factors) and objective sections (five factors). The UDysRS is a clinimetrically sound rating scale for dyskinesia in PD, demonstrating acceptable levels of internal consistency and inter‐ and intra‐rater reliability. Testing scale responsivity to treatment interventions is planned. © 2008 Movement Disorder Society     

Semi‐automatic volumetric assessment of perihemorrhagic edema with computed tomography

Background and purpose: Magnetic resonance imaging (MRI) shows perihemorrhagic edema (PHE) after intracerebral hemorrhage (ICH) with high contrast, but the procedure is often difficult or not available for clinical use. The aim of the present study was to establish and validate an observer independent method for quantification of PHE on computed tomography (CT) by comparing with simultaneously performed MRI. Methods: Patients with spontaneous supratentorial ICH were included. Twenty‐two patients received coregistered MRI and CT on day 1, and 27 patients on day 5 after admission. Volumes for PHE and ICH were measured (i) manually on CT, (ii) manually on MRI (fluid‐attenuated inversion recovery sequence), and (iii) threshold based on CT. To identify optimal threshold values (Hounsfield units) for best correlation of CT with MRI, upper and lower thresholds were adjusted gradually until the PHE volume on CT best fitted the PHE volume on MRI. The established threshold range was prospectively validated in another 15 patients. Results: A threshold range 5–33 Hounsfield units (HU) resulted in best correlation both on days 1 and 5. Using these thresholds in the validation group, PHE volumes on CT and MRI were highly comparable (31 ± 26 ml vs. 30 ± 27 ml) with good correlation (R² = 0.96, P < 0.01) and high inter‐ (0.96) and intraobserver (0.96) reliability. Manually traced PHE on CT was significantly larger (37.3 ± 37 ml vs. 30 ± 27 ml, P < 0.01) with worse inter‐ (0.89) and intraobserver (0.90) reliability. Conclusions: Threshold‐based CT volumetry of PHE with a threshold range 5–33 HU is a reliable and observer independent method for quantification of PHE after spontaneous ICH.     

A preliminary evaluation of the reliability and validity of a self‐reported communicative functioning item pool

Background: Item banking, an approach to test development based in item response theory (IRT), is beginning to be applied to the measurement of communicative functioning in aphasia. This approach involves calibrating a set of test items responding to a particular latent trait to a common measurement scale. One method for validating such scales is to examine the degree to which obtained item calibration estimates agree with a priori item rankings based on theory or expert opinion.

Aims: The purpose of this study was to evaluate the utility of magnitude estimation (ME) procedures for validating item banks containing self‐reported functional performance items, and to make a preliminary analysis of the validity of a proposed item pool for measuring self‐reported communicative functioning in aphasia.

Methods & Procedures: A total of 14 raters made ME ratings of physical and communicative functioning items. These ratings were evaluated for their intra and inter‐observer reliability and, for subsets of the items, their correspondence with previously published IRT calibration estimates was also evaluated.

Outcomes & Results: Intra‐rater reliability was moderate to high, and inter‐rater reliability was high. Correspondence with IRT calibrations was high for physical items, and moderate for communication items. The distribution of ME ratings for the communication items was negatively skewed.

Conclusions: ME procedures have utility for investigating the validity of functional performance items. The results suggest that communicative functioning may have a more complex latent structure than physical functioning, and that the proposed item pool might benefit from the inclusion of additional items at the lower end of the scale.     

Chronic inflammatory demyelinating polyneuropathy disease activity status: recommendations for clinical research standards and use in clinical practice

Defining long‐term outcomes in chronic inflammatory demyelinating polyneuropathy (CIDP) has been complicated by varying definitions of treatment response and differing scales measuring impairment or disability. An expert panel was convened to devise a CIDP Disease Activity Status (CDAS) and to classify long‐term outcome by applying it to 106 patients with a consensus diagnosis of CIDP. Sixty of these cases were graded blindly by three independent reviewers to assess inter‐rater reliability. The mean duration of follow‐up was 6.4 years (range, 3 months–23 years). Eleven percent of patients were classified as cured (stable examination and off treatment for ≥5 years), 20% were in remission (stable and off treatment for <5 years), 44% had stable active disease but required ongoing therapy for at least 1 year, 7% were improving after recent initiation of therapy, and 18% had unstable active disease (treatment naïve or treatment refractory). Excellent inter‐rater reliability was observed (kappa scores: 0.93–0.97; p < 0.0001). The CDAS is considered a simple and reproducible tool to classify patients with CIDP according to disease activity and treatment status that can be applied easily in practice and potentially to select patients for clinical trials.     

Increased total homocysteine level is associated with clinical status and severity of white matter changes in symptomatic patients with subcortical small vessel disease

Objective

Elevated plasma total homocysteine (tHcy) is an independent risk factor for ischemic stroke and has been linked to cerebral small vessel disease (SVD), in particular. Controversy persists as to whether increased tHcy is associated with functional status and cognitive decline in these patients.

Methods

Plasma tHcy, MTHFR polymorphism, vascular risk factors, functional and cognitive status and severity of lesions on MRI, assessed with the Age-Related White Matter Changes (ARWMC) visual grading scale, were analyzed in 95 patients with SVD and 41 healthy control subjects.

Results

Plasma tHcy levels were higher in patients with SVD (14.4 ± 5.0 μmol/L) compared to healthy SVD-free controls (8.9 ± 3.9 μmol/L). In SVD patients, tHcy levels strongly correlated with cognitive status (age-adjusted risk 5.8, 95% CI 1.3–25.3, p = 0.015), functional status (age-adjusted risk 3.2, 95% CI 1.2–8.8, p = 0.022) and severity of MRI lesions (age-adjusted risk 1.2, 95% CI 1.1–1.4; p = 0.004). Only total ARWMC score was independently associated with increased tHcy levels (OR 1.2, 95%CI 1.1–1.4, p = 0.004). Independent predictors of WMC occurrence were tHcy levels (OR 1.2, 95%CI 1.1–1.3, p = 0.003) and mRS score (OR 2.2, 95%CI 1.2–4.1, p = 0.017).

Conclusions

In patients with cerebral SVD there is a positive association of increased plasma tHcy levels with clinical status and severity of WMC.     

Evaluation of three nurse‐administered depression rating scales on acute admission and continuing care geriatric psychiatry wards

Several instruments measuring depression in institutional settings have been described but individual instruments have only occasionally been compared with each other. Some psychometric properties, including internal consistency, test‐retest and inter‐rater reliability, and concurrent validity of three nurse‐administered depression rating scales were evaluated on acute admission and continuing care geriatric psychiatry wards. The Depressive Signs Scale (DSS) was significantly correlated with the Depression in Dementia Mood Scale (DDMS) (rho = +0.59) and the Cornell Scale (rho = +0.71). The DDMS was correlated with the Cornell Scale (rho = +0.32). The internal consistency, as measured by Cronbach's alpha, for the DSS, the DDMS and the Cornell Scale was 0.47, 0.64 and 0.74 respectively. The test‐retest reliability of the DSS, the DDMS and the Cornell Scale was 0.73, 0.62 and 0.83 respectively. The DSS and the Cornell scale had poor inter‐rater reliability, but the DDMS had satisfactory inter‐rater reliability of 0.59. These scales, with a novel form of administration, are not suitable for detecting significant clinical depression in acutely admitted and continuing‐care geriatric psychiatry inpatients. However, the DDMS has satisfactory properties for use in measuring presence and quantity of depressive symptoms. Copyright © 2001 Whurr Publishers Ltd.     

The Prudhoe Cognitive Function Test, a scale to assess cognitive function in adults with Down's syndrome: inter-rater and test–retest reliability

Background The Prudhoe Cognitive Function Test (PCFT) was designed to measure cognitive function in subjects with all degrees of intellectual disability (ID) and to be administered by non‐specialist raters. The aim of the present study was to measure the test–retest and inter‐rater reliability of the PCFT. Methods Three raters, one a specialist and two non‐specialists, administered the PCFT to 14 subjects with Down's syndrome on two occasions separated by 4 weeks. Results The intra‐class correlation coefficients (ICCs) between the rater pairs (n = 3) were 0.99, 0.99 and 0.98 (P < 0.01). Floor effects were recorded for two items. The ICC for test–retest reliability was 0.99 (P < 0.01). Conclusions The PCFT is a highly reliable instrument when used by either specialist or non‐specialist raters. It has excellent temporal stability.     

The utility of the Generalized Anxiety Disorder Severity Scale (GADSS) with older adults in primary care

Background: The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults. Methods: This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n=223) referred for treatment of worry and/or anxiety. Results: The GADSS demonstrated adequate internal consistency, strong inter‐rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity. Conclusions: Results provide mixed preliminary support for use of the GADSS with older adults. Depression and Anxiety, 2009. Published 2008 Wiley‐Lis, Inc.     

Being reliable: issues in determining the reliability and making sense of observations of adults with congenital deafblindness?

Background Most research into interactions with people who are congenitally deafblind involves observational data. In order for practitioners and researchers to have confidence in the findings of observational studies, researchers need to demonstrate that the processes employed are replicable and trustworthy. This paper draws on data from an observational study of adults with congenital deafblindness to illustrate issues in determining inter‐rater reliability, and interpreting observational data. Method Data from 34 10‐min observations of adults with congenital deafblindness and their interactions with support staff were assessed for inter‐rater reliability using percentage agreement calculated in three different ways and Cohen's κ. Results Large variation resulted from the different ways in which inter‐rater reliability was calculated, largely due to high levels of non‐occurrence of many behaviours in the coding tool used. Conclusion This study highlights the need to exercise caution when ascertaining the reliability of observational studies and demonstrates the value in using multiple methods for calculating inter‐rater reliability. The paper concludes with an examination of the potential merits of using consensus coding in observational studies of interactions with people with congenital deafblindness or profound intellectual and multiple disabilities.     

Ota,M. (2003). The development of prosodic structure in early words: Continuity,divergence and change. Amsterdam: Benjamins. Pp. 224, hbk,ISBN 90‐272‐5293‐9, €95.00, ISBN 1‐58811‐4694, $114.00.

One of the ways to improve the reliability in perceptual voice quality rating is to provide listeners with external anchors. A paired comparison matching paradigm using synthesized Cantonese voice stimuli that covered a range of rough and breathy qualities were used to investigate the rating reliability. Twenty‐five speech pathology students rated the severity of roughness and breathiness of natural pathological voice samples using two paradigms: an eight‐point anchored matching (paired comparison) paradigm and an eight‐point non‐anchored equal‐appearing‐interval (EAI) scale paradigm. The listeners also rated their confidence in judging each testing stimulus on a seven‐point EAI scale. The results showed that the paired comparison method specifically improved the inter‐rater reliability in rating male rough stimuli and mildly dysphonic female stimuli. The intra‐rater agreement and confidence ratings remained similar across the two rating paradigms. These results suggest that the paired comparison paradigm may be used as an alternative perceptual voice quality evaluation tool.     

Wireless pH‐motility capsule for colonic transit: prospective comparison with radiopaque markers in chronic constipation

Background Colon transit (CT) measurements are used in the management of significant constipation. The radiopaque marker (ROM) method provides limited information. Methods We proposed to validate wireless motility capsule (WMC), that measures pH, pressure and temperature, to ROM measurement of CT in patients with symptomatic constipation evaluated at multiple centers. Of 208 patients recruited, 158 eligible patients underwent simultaneous measurement of colonic transit time (CTT) using ROM (Metcalf method, cut off for delay >67 h), and WMC (cutoff for delay >59 h). The study was designed to demonstrate substantial equivalence, defined as diagnostic agreement >65% for patients who had normal or delayed ROM transit. Key Results Fifty‐nine of 157 patients had delayed ROM CT. Transit results by the two methods differed: ROM median 55.0 h [IQR 31.0–85.0] and WMC (43.5 h [21.7–70.3], P < 0.001. The positive percent agreement between WMC and ROM for delayed transit was ～80%; positive agreement in 47 by WMC/59 by ROM or 0.796 (95% CI = 0.67–0.98); agreement vs null hypothesis (65%) P = 0.01. The negative percent agreement (normal transit) was ～91%: 89 by WMC/98 by ROM or 0.908 (95% CI = 0.83–0.96); agreement vs null hypothesis (65%), P = 0.00001. Overall device agreement was 87%. There were significant correlations (P < 0.001) between ROM and WMC transit (CTT [r = 0.707] and between ROM and combined small and large bowel transit [r = 0.704]). There were no significant adverse events. Conclusions & Inferences The 87% overall agreement (positive and negative) validates WMC relative to ROM in differentiating slow vs normal CT in a multicenter clinical study of constipation.     

Neurological soft signs in never-treated schizophrenia

Objective: Studies of Neurological Soft Signs (NSS) in schizophrenia are confounded by handedness, inconsistent methodology, and prior treatment with neuroleptics. The study objective is to examine NSS in never‐treated schizophrenia. Method: We examined the NSS in treatment‐naïve schizophrenia patients (n = 21) and age, sex, education, and handedness matched normal controls (n = 21) using the modified Neurological Evaluation Scale with good inter‐rater reliability. Results: Schizophrenia patients had significantly more NSS than normals. No significant correlation was found between illness duration and NSS. Conclusion: Higher neurological signs in never‐treated patients and their lack of association with illness duration suggest neurodevelopmental etiopathogenesis of schizophrenia.     

Validity and reliability of the Spanish versions of the Bech-Rafaelsen's mania and melancholia scales for bipolar disorders

Objective: To assess classical psychometric properties of the Spanish versions of the Bech‐Rafaelsen’s mania (MAS) and melancholia (MES) scales. Method: Observational, prospective, and multicentric study in bipolar out‐patients. Convergent validity was assessed against the Young Mania Rating Scale and the Montgomery‐Åsberg Depression Rating Scale. Discriminant validity, reliability, and sensitivity to change, were also assessed. Results: One hundred and thirteen bipolar patients with a manic episode and 102 bipolar patients with a depressive episode were included. Both the MAS and the MES showed appropriate convergent validity (r > 0.90), discriminant validity (P < 0.0001), internal consistency (Cronbach’s alpha >0.80), test–retest reliability [intraclass correlation coefficient (ICC) = 0.69 for the MAS and 0.94 for the MES], inter‐rater reliability (ICC > 0.80), and sensitivity to change at 4 weeks since inception (P < 0.0001; within‐group effect size ≥1.8). Conclusion: The Spanish versions of both scales present appropriate psychometric estimates in bipolar patients treated in ambulatory care.     

Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit

BACKGROUND AND PURPOSE

In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU).

METHODS

In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on‐call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter‐rater agreement between the pre‐ and in‐hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter‐rater agreement was analyzed with Cohen's kappa.

RESULTS

Fifty‐one cerebral CT scans from the MSU were included. Inter‐rater agreement between prehospital anesthesiologists and the in‐hospital on‐call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital.

CONCLUSION

This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.     

CT and MRI rating of white matter changes

The impact of white matter changes (WMC) detectable on CT or MRI on various diseases like ischemic stroke and intracerebral hemorrhage and their association with cognitive impairment was and still is under debate. To assess WMC in a qualitative and/or semiquantitative fashion rating scales have been developed. For MRI most widely used scales are the scales of Manolio, Fazekas, Schmidt, and Scheltens. Most recently a new scale extending earlier suggestions has been introduced by Wahlund et al. applicable for both CT and MRI. This article will review strengths and weaknesses of these rating scales and will discuss further requirements and future perspectives.     

Validity and reliability of nerve and muscle ultrasound

Introduction: Nerve and muscle ultrasound has been studied in several conditions, but validity and reliability have not been assessed systematically. Methods: Nerve cross‐sectional area and muscle thickness were measured ultrasonographically at several sites in 4 cadavers, which were then dissected, and actual measurements were obtained. To assess intrarater and interrater reliability, between 3 and 5 ultrasonographers, with varying experience levels, made repeated measurements on healthy volunteers. Results: Correlation coefficients for nerve and muscle validity were >0.968 (P < 0.001), and for intrarater reliability were >0.901 (P < 0.001) for still and real‐time images. Correlation coefficients for interrater reliability were more varied, but for still images they were all significant at the P < 0.001 (0.542–0.998) level, and for real‐time images they were significant at the P < 0.05 level for half the sites (0.243–0.981). Conclusion: Overall, nerve and muscle ultrasound is a valid and reliable diagnostic imaging technique. Muscle Nerve, 2013