Inter-Rater Agreement between Trachoma Graders: Comparison of Grades Given in Field Conditions versus Grades from Photographic Review

ABSTRACT

Purpose: Trachoma surveillance is most commonly performed by direct observation, usually by non-ophthalmologists using the World Health Organization (WHO) simplified grading system. However, conjunctival photographs may offer several benefits over direct clinical observation, including the potential for greater inter-rater agreement. This study assesses whether inter-rater agreement of trachoma grading differs when trained graders review conjunctival photographs compared to when they perform conjunctival examinations in the field.

Methods: Three trained trachoma graders each performed an independent examination of the everted right tarsal conjunctiva of 269 children aged 0–9 years, and then reviewed photographs of these same conjunctivae in a random order. For each eye, the grader documented the presence or absence of follicular trachoma (TF) and intense trachomatous inflammation (TI) according to the WHO simplified grading system.

Results: Inter-rater agreement for the grade of TF was significantly higher in the field (kappa coefficient, κ, 0.73, 95% confidence interval, CI 0.67–0.80) than by photographic review (κ?=?0.55, 95% CI 0.49–0.63; difference in κ between field grading and photo grading 0.18, 95% CI 0.09–0.26). When field and photographic grades were each assessed as the consensus grade from the three graders, agreement between in-field and photographic graders was high for TF (κ?=?0.75, 95% CI 0.68–0.84).

Conclusions: In an area with hyperendemic trachoma, inter-rater agreement was lower for photographic assessment of trachoma than for in-field assessment. However, the trachoma grade reached by a consensus of photographic graders agreed well with the grade given by a consensus of in-field graders.     

Trachoma in Jimma Zone, South Western Ethiopia.

A population-based survey on trachoma was carried out in Jimma zone. The survey showed that trachoma is hyperendemic: of 7,423 people examined, 33.02% had signs of trachoma, 28.9% of males and 37.01% of females; 26.13% of the urban and 34.09% of the rural population had clinical signs of trachoma. Active trachoma (TF/TI) was seen in 24.5% of the study population (an estimated half million people). The prevalence of signs of active trachoma among children 0–10 years of age was 35.7%. Blinding trachoma (CO/TT) was seen in 3.81% of the population: 6.86% of the female population aged 15 years had trichiasis and/or entropion.
Both active and critical trachoma were significantly associated with the female gender ( P < 0.0000001 for each), living in rural areas ( P < 0.0001 for each type), parental illiteracy ( P < 0.0000001 for each) and absence of a latrine ( P < 0.01 for each). Shorter distance of the household water supply was associated with a higher prevalence of both active and cicatricial trachoma. This was significant only for cases of active trachoma living in households within 16 to 30 minutes walking distance from the water source ( P < 0.03).
An estimated 17000 people in the zone are blind; 3500 of these from trachoma. About 52,000 people are in danger of blindness from trichiasis. Primary eye care activities such as promoting health education (face washing) among community members, especially women and children, mass chemotherapy for trachoma, training of health workers and establishment of community-based surgical services are recommended. These are to be executed by the Zonal Health Department in close collaboration with the community, governmental and non-governmental organisations.     

The prospect of dental fluorosis prevention in Wonji Ethiopia

This study identified factors that are associated with dental fluorosis among school adolescents in an endemic area using a control design. Data were collected using a directed self-administered questionnaire. Dental fluorosis was confirmed by a dentist. Out of the 472 students who participated in the study, 398 had dental fluorosis and the remaining 74 were free of dental fluorosis. A logistic regression analysis revealed children born in Wonji compared to those born elsewhere [Adjusted OR (95% CI): 5.12 (2.68, 9.75)]; males compared to female [Adjusted OR (95% CI): 2.76 (1.52, 5.00)]; and those who obtained their regular drinking water from pipe distribution compared to those who obtained water from other sources [Adjusted OR (95% CI): 3.5 (1.24, 10.02] were more likely to have dental fluorosis. Students in the age group 13-14 year compared to those in 11-12 year were less likely to have dental fluorosis [Adjusted OR (95% CI): 0.43 (0.25, 0.76)]. The findings indicate that the risk of dental fluorosis is still much higher for the population in Wonji and recommend strengthening appropriate intervention systems at household and community levels.     

Paricalcitol reduces albuminuria and inflammation in chronic kidney disease: a randomized double-blind pilot trial

Vitamin D receptor activation is associated with improved survival in patients with chronic kidney disease, but the mechanism of this benefit is unclear. To better understand the effects of vitamin D on endothelial function, blood pressure, albuminuria, and inflammation in patients with chronic kidney disease (2 patients stage 2, remaining stage 3), we conducted a pilot trial in 24 patients who were randomly allocated equally to 3 groups to receive 0, 1, or 2 microg of paricalcitol, a vitamin D analog, orally for 1 month. Placebo-corrected change in flow mediated dilatation with a 1-microg dose was 0.5% and 0.4% with a 2-microg dose (P>0.2). At 1 month, the treatment:baseline ratio of high sensitivity C-reactive protein was 1.5 (95% CI: 1.1 to 2.1; P=0.02) with placebo, 0.8 (95% CI: 0.3 to 1.9; P=0.62) with a 1-microg dose, and 0.5 (95% CI: 0.3 to 0.9; P=0. 03) with a 2-microg dose of paricalcitol. At 1 month, the treatment:baseline ratio of 24-hour albumin excretion rate was 1.35 (95% CI: 1.08 to 1.69; P=0.01) with placebo, 0.52 (95% CI: 0.40 to 0.69; P<0.001) with a 1-microg dose, and 0.54 (95% CI: 0.35 to 0.83; P=0. 01) with a 2-microg dose (P<0.001 for between group changes). No differences were observed in iothalamate clearance, 24-hour ambulatory blood pressure, or parathyroid hormone with treatment or on washout. Thus, paricalcitol-induced reduction in albuminuria and inflammation may be mediated independent of its effects on hemodynamics or parathyroid hormone suppression. Long-term randomized, controlled trials are required to confirm these benefits of vitamin D analogs.