Spine journals: is reviewer agreement on publication recommendations greater than would be expected by chance?

Background contextIt is commonly believed that the peer-review process is reliable and consistent. It appears, however, that depending on the journal and the editorial leadership, agreement by reviewers on whether to publish submitted articles varies widely; from substantial to slightly greater than one would expect with random assignments of acceptance or rejection.PurposeThe purpose was to assess peer-review agreement in major spine journals.Study design/SettingThis study is for the assessment of reviewer agreement.SamplesThe study consisted of consecutive reviews of 200 submitted articles.Outcome measuresAgreement via Kappa statistics.MethodsGroup A consisted of 200 consecutive article reviews for which the senior author was involved in the review or editorial process over the past 8 years for two major spine journals. Reviewers' recommendations were placed into one of two groups: accept/minimal revisions or major revision/reject. Standard Kappa statistics were used to assess reviewer agreement. Group B consisted of a similar set, but with wholly randomly generated recommendations. Again, Kappa statistics were used.ResultsKappa for Group A was 0.155 with a range of 0.017 to 0.294 at 95% confidence interval and agreement at 0.6; suggesting “slight” reviewer agreement. Kappa for Group B behaved as expected, with “poor” agreement.ConclusionsAgreement regarding peer-review recommendations for publication in spine journals appears to be better than would be expected in the random situation; but still only “slight.” This suggests that review methodology varies considerably among reviewers and that further study should be undertaken to determine “ideal” agreement levels and ways to increase review consistency/quality commensurate with the editorial missions of the journals.     

Sonographic bridging callus: An early predictor of fracture union

BackgroundThere is currently a lack of agreed criteria for sonographic assessment of callus and reliability between reviewers.The primary aim of this study was to determine criteria and reviewer agreement for sonographic bridging callus (SBC) on ultrasound. The secondary aim was to analyse the use of ultrasound to detect bridging callus in a prospective cohort of patients with a conservatively managed clavicle fracture.MethodsA prospective cohort of conservatively managed displaced midshaft clavicle fractures underwent ultrasound scanning at three-, six- and 12-weeks post-injury. The main outcome was nonunion confirmed at six months on CT scanning. Five patients with confirmed nonunion were compared against a control group of 15 patients with timely union at three months.The ultrasound scans were interpreted by two blinded reviewers to evaluate sonographic callus features with agreement determined by weighted kappa. A further validation study was undertaken by four blinded reviewers using the intraclass-correlation-coefficient (ICC) using the most clinically relevant findings of the pilot work.ResultsAt three weeks post-injury fibrocartilaginous material was present in 80% of patients (16/20). When detected this was associated with union (sensitivity 93%, specificity 60%, p = 0.03) with the inter-observer agreement rated ‘fair’ on kappa (0.44).At six weeks only 10% (2/20) of patients had bridging callus on radiograph but 60% (12/20) had sonographic bridging callus (SBC) and when present all united (sensitivity 80%, specificity 100%, p = 0.002). At 12 weeks, bridging callus was present on both radiographs and ultrasound in all patients that united (n = 15, sensitivity 100%, specificity 100%, p < 0.001). No patient that developed a nonunion at six months post-injury had SBC at any time point. At six-weeks the absence of SBC had a positive predictive value for nonunion of 63% of patients (5/8) and by 12 weeks it was 100% (5/5).The SBC detection rated ‘very strong’ for intra- (kappa 0.92) and inter-observer agreement (kappa 0.84). The ICC of SBC at six-weeks with four blinded reviewers was 0.82 (95% confidence interval 0.68–0.91).ConclusionsThis is the first study to establish time specific ultrasound fracture findings with a repeatable technique and assess the agreement between blinded reviewers.     

The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging

ObjectiveTo evaluate the feasibility of point-of-care ankle ultrasound compared with magnetic resonance imaging (MRI) for diagnosing major ligaments and Achilles tendon injuries in patients with recurrent ankle sprain and chronic instability, and to evaluate inter-observer reliability between an emergency physician and a musculoskeletal radiology fellow.Material and methodsA prospective cross-sectional study was conducted in an emergency department. Patients with recurrent ankle sprain and chronic instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Findings were classified normal, partial tear, and complete tear. MRI was used as the reference standard. We calculated diagnostic values for point-of-care ankle ultrasound for both reviewers and compared them using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and between the two reviewers.ResultsEighty-five patients were enrolled. Point-of-care ankle ultrasound showed acceptable sensitivity (96.4–100%), specificity (95.0–100%), and accuracy (96.5–100%); these performance markers did not differ significantly between reviewers. Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC = 0.846–1.000; musculoskeletal radiology fellow, ICC = 0.930–1.000), as was inter-observer agreement (ICC = 0.873–1.000).ConclusionPoint-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. Moreover, it may reduce the interval from emergency department admission to admission for surgical intervention, and may save costs.     

Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical,system and human factors peer-review tool

BackgroundThere is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents.MethodsMedical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus.ResultsA total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2–12) years, the median ISS was 25 (IQR 16–30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%).ConclusionThe peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.     

Comparison of radiographs and computed tomography (CT) imaging for preoperative evaluation and planning for shoulder arthroplasty

BackgroundThe purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty.MethodsPreoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns.ResultsThe 3 reviewers agreed that quality of AXRs was significantly inadequate (P < .001) for assessing glenoid wear in advanced glenoid wear patterns compared to simple wear patterns. Following evaluation on AXRs alone, the need for CT imaging was significantly higher in advanced glenoid wear patterns compare to simple ones (81% vs. 31%; P < .001). The addition of CT images did not result in a significant change to the preoperative plan in simple glenoid wear patterns but in advanced glenoid wear, addition of CT can change the preoperative plan with respect to arthroplasty type and/or strategy for addressing glenoid wear.ConclusionAxillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids).Level of evidenceLevel IV     

Radiographic,Functional, and Oncologic Outcomes of Cemented Modular Proximal Femur Replacement Using the “French Paradox” Technique

BackgroundEndoprostheses are frequently used in the management of tumors involving the proximal femur. Aseptic loosening is a common complication that has been linked to the cementing technique. The “French paradox” is well-known cementing technique in the arthroplasty literature. No previous reports have assessed loosening in proximal femur replacements using this technique. We examined rates of femoral stem aseptic loosening in proximal femur replacements, functional outcomes, complications, and oncologic outcomes.MethodsWe conducted a retrospective review of 47 patients who underwent proximal femur replacement between 2000 and 2019. Two reviewers evaluated preoperative and postoperative radiographs using the International Society of Limb Salvage scoring system and Barrack criteria for stem loosening. The acetabulum was evaluated according to the criteria of Baker et al. Functional outcomes were assessed using Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score. The mean follow-up was 44 months.ResultsThe mean International Society of Limb Salvage scores for the 2 reviewers were 86% ± 6% and 84% ± 6%. The first reviewer graded femoral stem loosening as “possibly loose” in 2 patients, one of whom was graded as possibly loose by the second reviewer. The 2 reviewers found no acetabular erosion in 16 (70%) and 15 (65.4%) patients, respectively. The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score at last follow-up were 61% and 72%, respectively. Twenty complications occurred in 13 patients, and 5 patients experienced local recurrence.ConclusionDespite complications, we showed favorable femoral component survival rates. Cementing the proximal femur prosthesis with tight canal fit and thin cement mantle is a viable option for the short and medium term.Level of EvidenceIII.     

Work-from-home-related musculoskeletal pain during the COVID-19 pandemic: A rapid review protocol

BackgroundThe recent COVID-19 pandemic has forced various workforce industries to work from home. The work-from-home set-up has exposed some workers to some office-related work, typically not included in their jobs, consequently exposing them to an increased risk for developing musculoskeletal pain.MethodsWe will search PubMed, MEDLINE, and CINAHL for observational studies published between May 2020–June 2021. This review will include published peer-reviewed studies in the English language. We will include studies that recruited adults aged 20–65 from any work industry reporting on outcomes related to musculoskeletal functions (i.e., pain, disorder, condition, etc.). Two independent reviewers will screen the search results. Two independent reviewers will accomplish risk of bias assessment using the JBI-MAStARI critical appraisal tools. Likewise, data extraction will be performed by one reviewer and verified by a second reviewer. Pooled prevalence estimates will be generated using Revman V.5.2.1, where Forest plots will be generated to determine overall estimates of random-effects and confidence intervals. To quantify heterogeneity, we will index the I² and X² p-value. A narrative synthesis summarised into tables and themes will likewise be used to summarize the extracted data.DiscussionA rapid review methodology was chosen to rapidly synthesize the available literature on the prevalence of musculoskeletal pain associated with work-from-home conditions during the COVID-19 pandemic, which is essential in informing health programs and policies that address both the public and private industry sectors.Systematic review registrationThis is registered in the PROSPERO Registry (CRD42021266097).     

Italian recommendations on enzymatic debridement in burn surgery

IntroductionNexobrid®, a bromelain-based type of enzymatic debridement, has become more prevalent in recent years. We present the recommendations on enzymatic debridement (Nexobrid®)’s role based on the practice knowledge of expert Italian users.MethodsThe Italian recommendations, endorsed by SIUST (Italian Society of Burn Surgery), on using enzymatic debridement to remove eschars for burn treatment were defined. The definition followed a process to evaluate the level of agreement (a measure of consensus) among selected experts, representing Italian burn centers, concerning defined clinical aspects of enzymatic debridement. The consensus involved a multi-phase process based on the Delphi method.ResultsThe consensus panel included experts from Italy with a combined experience of 1068 burn patients treated with enzymatic debridement. At the end of round 3 of the Delphi method, the panel reached 100% consensus on 26 out of 27 statements. The panel achieved full, strong consensus (all respondents strongly agreed on the statement) on 24 out of 27 statements.DiscussionThe statements provided by the Italian consensus panel represent a “ready to use” set of recommendations for enzymatic debridement in burn surgery that both draw from and complete the existing scientific literature on the topic. These recommendations are specific to the Italian experience and are neither static nor definitive. As such, they will be updated periodically as further quality evidence becomes available.     

开放科学环境下医学期刊同行评议模式现状——基于国内麻醉学者的调查

目的 了解开放科学环境下国内麻醉学者对医学期刊同行评议模式的认知情况。
方法 采用自制的调查问卷,于2019年5月通过问卷星平台发放和收集,包括审稿模式、是否开放其他审稿人的意见、是否关注稿件的结局、对开放科学的了解程度等。
结果 受访者来自全国28个省、自治区、直辖市,71.6%的受访者选择双盲评审,超过50%的受访者没有接受过审稿方面的培训,超过90%的受访者希望看到其他审稿人意见,同时,超过90%的受访者对发表后评议了解不多甚至是完全不了解。
结论 开放科学环境下国内麻醉学者对同行评议模式的了解程度有限,需对审稿专家进行相关培训,以提高国内学者对同行评议模式的认知度。     

Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI

ObjectiveThe purpose of this study was to determine the intra- and interobserver reliability of a modified Modic classification for bone marrow changes seen on lumbar spine magnetic resonance imaging (MRI), taking into consideration mixed signals.MethodsLumbar MRI scans from 94 patients with low back pain were assessed independently by 2 spine specialists (senior [senior1], junior) and a radiologist (senior2). One reviewer (senior1) assessed the MR images twice at a three-week interval for evaluation of intraobserver reliability. Senior2 and junior reviewers assessed the MR images once. Pure edema endplate signal changes were classified as Modic type I, and pure fatty endplate changes as Modic type II. A mixture of types I and II but predominantly edema signal changes was classified as Modic I-2 and a mixture of types I and II but predominantly fatty changes was classified as Modic II-1.ResultsThe intraobserver agreement was excellent (weighted kappa 0.85). The interobserver agreement was moderate to substantial (weighted kappa range 0.56–0.74). Interobserver reliability depended on the experience of the observer, thus highlighting the importance of a learning curve.ConclusionThis study shows that the modified Modic classification is reliable and easy to apply for observers with different clinical experience. The inclusion of mixed marrow changes in the modified classification may have clinical and therapeutic implications.     

Consensus Recommendations of the German Consortium for Hereditary Breast and Ovarian Cancer

BackgroundThe German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC) has established a multigene panel (TruRisk®) for the analysis of risk genes for familial breast and ovarian cancer.SummaryAn interdisciplinary team of experts from the GC-HBOC has evaluated the available data on risk modification in the presence of pathogenic mutations in these genes based on a structured literature search and through a formal consensus process.Key MessagesThe goal of this work is to better assess individual disease risk and, on this basis, to derive clinical recommendations for patient counseling and care at the centers of the GC-HBOC from the initial consultation prior to genetic testing to the use of individual risk-adapted preventive/therapeutic measures.     

What Are the Demographic and Radiographic Characteristics of Patients With Symptomatic Extraarticular Femoroacetabular Impingement?

BackgroundExtraarticular femoroacetabular impingement (FAI) can result in symptomatic hip pain, but preoperative demographic, radiographic, and physical examination findings have not been well characterized.Questions/purposesThe purposes of this study were to (1) define the demographic characteristics of patients with symptomatic extraarticular FAI; and (2) identify relevant radiographic and physical examination findings that are associated with intraoperative locations of extraarticular FAI.MethodsFor purposes of this study, we defined extraarticular FAI as abnormal contact between the extraarticular regions of the proximal femur (greater trochanter, lesser trochanter, extracapsular femoral neck) and the ilium or ischium. The diagnosis was suspected preoperatively, but it was confirmed at the time of surgery by direct visualization of extraarticular impingement after surgical hip dislocation. A prospective single-center hip preservation registry was used to retrospectively characterize patients presenting between October 2010 and November 2013 with symptomatic hip pain and intraoperative findings of extraarticular FAI (N = 75 patients, 86 hips). Detailed demographic data were recorded. Radiographs, CT, and MRI scans were reviewed for all patients by two of the authors (BFR, ELS). Outcome instruments including modified Harris hip score (mHHS), Hip Outcome Score (HOS), and International Hip Outcome Tool (iHOT-33) were assessed preoperatively. A comparison group of all patients (N = 1690 patients, 1989 hips) undergoing surgery for intraarticular FAI over the study period were included for demographic comparisons. Cases with extraarticular FAI accounted for 4% (75 of 1765 patients) of our cohort over the study time period.ResultsPatients with extraarticular FAI were more likely to be younger (mean ± SD, 24 ± 7 years versus 30 ± 11 years; difference [95% confidence interval {CI}], −7 [−9 to −4]; p < 0.001), female (85% versus 49%; odds ratio [95% CI], 6 [3 to 12]; p < 0.001), to have undergone prior hip surgery (44% versus 10%; odds ratio [95% CI], 9 (6 to 15); p < 0.001), and have lower preoperative outcome scores after adjustment for age, sex, and revision status (mHHS 55 ± 15 versus 63 ± 15; adjusted difference [95% CI], −4 (−8 to −1); p = 0.017; HOS ADL 64 ± 19 versus 73 ± 18; adjusted difference [95% CI], −7 (−11 to −3); p = 0.002) than patients undergoing surgery for intraarticular FAI. Within the extraarticular FAI group, preoperative femoral version on CT was different among patients with anterior versus posterior extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 21° [20, 30], respectively; p = 0.005) and anterior versus complex extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 20° [10, 30], respectively; p = 0.007]. Preoperative external rotation in extension was increased in patients with anterior versus complex extraarticular FAI (median [first quartile, third quartile], 70° [55, 75] versus 40° [20, 60]; p < 0.001).ConclusionsExtraarticular FAI is an uncommon source of impingement symptoms. We suspect the diagnosis often is missed, because many of these patients had prior hip surgery before the procedure that diagnosed the extraarticular impingement source. This diagnosis seems more common in younger, female patients. Radiographic and physical examination findings correspond to locations of intraoperative extraarticular impingement. Future studies will need to determine whether surgical treatment of extraarticular impingement pathology improves pain and function in this subset of patients.

Level of Evidence

Level III, therapeutic study.