Large Variation in Clinical Practice amongst Pediatricians in Treating Children with Recurrent Abdominal Pain / 대한소아소화기영양학회지

PURPOSE: To evaluate intra- and inter-observer variability and guideline adherence amongst pediatricians in treating children aged between 4 and 18 years referred with recurrent abdominal pain (RAP) without red flags. METHODS: The first part of the study is a retrospective single-center cohort study. The diagnostic work-ups of eight pediatricians were compared to the national guidelines. Intra- and inter-observer variability were examined by Cramer's V test. Intra-observer variability was defined as the amount of variation within a pediatrician and inter-observer variability as the amount of variation between pediatricians in the application of diagnostic work-up in children with RAP. Prospectively, the same pediatricians were requested to provide a report on their management strategy with a fictitious case to prove similarities in retrospective diagnostic work-up. RESULTS: A total of 10 patients per pediatrician were analyzed. Retrospectively, a (very) weak association between pediatricians' diagnostic work-ups was found (0.22), which implies high inter-observer variability. The association between intra-observer diagnostic was moderate (range, 0.35–0.46). The Cramer's V of 0.60 in diagnostic work-up between pediatricians in the fictitious case implied the presence of a moderately strong association and lower inter-observer variability than in the retrospective study. Adherence to the guideline was 66.8%. CONCLUSION: We found a high intra- and inter-observer variability and moderate guideline adherence in daily clinical practice amongst pediatricians in treating children with RAP in a teaching hospital.

Inter-observer variability in the histologic criteria of diagnosis of hydatidiform moles

@#Introduction: In the event of encountering hydropic villi in products of conception specimens, pathologists will have to distinguish complete and partial hydatidiform mole (CHM & PHM) from hydropic abortion (HA). The histological diagnostic criteria are subjective and demonstrate considerable inter-observer variability. Materials and Methods: This study evaluated the inter-observer variability in diagnosis of CHM, PHM and HA according to defined histologic criteria. Ninety abortus conception specimens were reviewed. Representative haematoxylin and eosin-stained slides were assigned independently to two pathologists who were asked to make a diagnosis of CHM, PHM or HA, and provide a report of the identified diagnostic histological criteria. Kappa value was calculated for the inter-observer agreement. Results: There was a total of 36.7% disagreement between two pathologists (K = 0.403, Strength of Agreement = moderate), of which 24.4% and 12.2%, were differentiating PHM from CHM and PHM from HA, respectively. Among defined diagnostic histological criteria, the highest rate of agreement was observed in the identification of cistern formation and hydropic changes (K = 0.746 and 0.686 respectively, Strength of Agreement = substantial). Conclusion: There was moderate to substantial agreement rate between two pathologists in identification of two essential histologic criteria for diagnosis of molar pregnancies i.e. “hydropic change” and “trophoblastic proliferation”.

Reliability of the michigan state university (msu) classification of lumbar disc herniation / Confiabilidade da universidade do estado de michigan (msu) classificação da herniação de disco lombar

ABSTRACT Objective: The Michigan State University (MSU) classification of lumbar disc herniation (LDH) is periodically used by various authors to classify disc herniation. We assessed the reliability of this classification system among orthopedic residents at our institute. Methods: Fifty T2 axial-cut magnetic resonance images (MRI) corresponding to the level of maximal disc herniation from patients diagnosed with a single LDH were selected and distributed to six orthopedic residents. All six residents gave a specific rating for each image based on the MSU classification; in addition, three residents gave ratings on two different occasions. The degree of agreement among residents was analyzed by calculating inter-observer and intra-observer reliability using the Kappa statistic. Results: The inter-observer reliability among the six residents calculated as the Fleiss' Kappa was 0.422, which indicates moderate reliability. The intra-observer reliability of three selected residents calculated by Cohen's Kappa was 0.750, 0.772, and 0.859, which indicates substantial to almost perfect reliability. Variations in ratings were frequent in images portraying a broad-based disc herniation with spinal canal stenosis. Conclusion: Our findings demonstrate moderate homogeneity of ratings given by residents; however, test-retest results proved the ratings to be consistent. Level of Evidence II, Diagnostic studies - investigating a diagnostic examination.

RESUMO Objetivo: A classificação da hérnia de disco lombar (LDH) da Michigan State University (MSU) é usada periodicamente por vários autores para classificar as hérnias discais. Pretendemos avaliar a confiabilidade deste sistema de classificação entre os residentes de ortopedia em nosso instituto. Métodos: Cinqüenta imagens de RM axial do corte T2 correspondendo ao nível de hérnia discal máxima de pacientes que foram diagnosticados com uma única LDH foram selecionadas e distribuídas para seis residentes ortopédicos. Todos os seis residentes deram uma classificação específica para cada imagem com base na classificação MSU; Além disso, três residentes deram notas em duas ocasiões diferentes. O grau de concordância entre os residentes foi analisado calculando-se a confiabilidade interobservador e intraobservador pela estatística Kappa. Resultados: Descobrimos que a confiabilidade interobservador entre seis residentes, calculando o Kappa de Fleiss, foi de 0,422; isso indica confiabilidade moderada. No entanto, a confiabilidade intra-observador de três residentes selecionados mostrou-se substancial (Kappa de Cohen = 0,750, 0,772 e 0,859 em três residentes, respectivamente). Variações na observação foram frequentes se houvesse hérnia discal ampla com estenose do canal vertebral. Conclusão: Nossos achados demonstram homogeneidade moderada das avaliações dadas pelos residentes; no entanto, teste-reteste provou que as classificações eram consistentes. Nível de Evidencia II, Estudos diagnósticos - investigação de um exame para diagnóstico.

Effect of 15 Minutes Brief Education for Medical Personnel in Diagnosing Barrett's Esophagus

BACKGROUND/AIMS: The higher prevalence of gastroesophageal reflux disease has preceded the increase of Barrett's esophagus and esophageal adenocarcinoma in Western countries. An increase of Barrett's esophagus and esophageal adenocarcinoma can also be predicted due to the increase of gastroesophageal reflux disease in Asia. Therefore, the ability of endoscopists to detect Barrett's esophagus can be important in the future. The aim of this study was to examine whether a short education program could improve the ability of gastrointestinal endoscopists and nurses to detect Barrett's esophagus. MATERIALS AND METHODS: Endoscopists and nurses of Gastrointestinal Endoscopic Center in Kosin Uinversity Gospel Hospital were enrolled in this study. Endoscopic images of biopsy proven Barrett's esophagus and normal gastroesophageal junction were obtained with conventional endoscopy. Thirty-seven still images of conventional endoscopy were used for slide test before and after 15 minutes education on Barrett's esophagus. RESULTS: Diagnostic ability of the doctor group after education did not changed (pre-education 79.6% vs. post-education 79.3%, P=0.906). Nurse group showed improved diagnostic ability for Barrett's esophagus after education (pre-education 68.7% vs. post-education 75.5%, P=0.008). After a short education program, inter-observer agreement of endoscopic diagnosis of Barrett's esophagus was improved in both doctor and nurse groups (doctor inter-observer correlation coefficient [ICC], 0.684→0.879; nurse ICC, 0.524→0.862). CONCLUSIONS: Even a short education program can improve the diagnostic ability, especially inter-observer agreement of endoscopic diagnosis for Barrett's esophagus. Further studies are needed to establish a role of education to improve diagnostic ability of Barrett's esophagus.

Impedance pH Monitoring: Intra-observer and Inter-observer Agreement and Usefulness of a Rapid Analysis of Symptom Reflux Association

BACKGROUND/AIMS: Symptom reflux association analysis is especially helpful for evaluation and management of proton pump inhibitor (PPI) refractory patients. An accurate calculation requires manual editing of 24-hour multichannel intraluminal impedance-pH (MII-pH) tracings after automatic analysis. Intra- and inter-observer agreement as well as reliability of rapid editing confined to the time around symptomatic episodes are unknown. Aim of this study was to explore these topics in a prospective multicenter study. METHODS: Forty consecutive patients who were off PPI therapy underwent MII-pH recordings. After automatic analysis, their tracings were anonymized and randomized. Three experienced observers, each one trained in a different European center, independently performed manual editing of 24-hour tracings on 2 separate occasions. Values of symptom index and symptom association probability for acid and non acid reflux were transformed into binary response (i.e., positive or negative). RESULTS: Intra-observer agreement on symptom reflux association was 92.5% to 100.0% for acid and 85.0% to 97.5% for non-acid reflux. Inter-observer agreement was 100.0% for acid and 82.5% to 95.0% for non-acid reflux. Values for symptom index and symptom association probability were similar. Concordance between 24-hour and rapid (2 minutes-window before each symptomatic episode) editings for symptom reflux association occured in 39 to 40 patients (acid) and in 37 to 40 (non-acid), depending on the observer. CONCLUSIONS: Intra- and inter-observer agreement in classifying patients with or without symptom reflux association at manual editing of 24-hour tracings was high, especially for acid reflux. Classifying patients according to a rapid editing showed excellent concordance with the 24-hour one and can be adopted in clinical practice.

Observer variability in sonographic measurement of kidney sizes among children in Benin City, Nigeria / Variabilidad del observador en las mediciones sonográficas del tamaño del riñón entre los niños en Benin City, Nigeria

AIM: To assess the level of inconsistency in replicating sonographic kidney size measurements in a population of healthy Nigerian children. SUBJECTS AND METHODS: In this prospective cross-sectional study, convenience sampling technique was used to select a sample of Nigerian children. Both consent from participants and ethical approval from the local authority were obtained before the study commenced. Three radiologists carried out the replicate sonographic measurements using a DP-1100 mechanical sector scanner with a 3.5 MHz convex probe. All examinations were done with subjects in the supine oblique position. Longitudinal and transverse scans were performed. Renal lengths and widths were measured from the longitudinal scans while thickness was measured from the transverse scans. Renal volumes were calculated with the ellipsoid formula. Analysis of variance, Student's t-test, Pearson's correlation coefficient and z-test were used to test the statistical significance of results. SPSS version 17.0 was used in the analysis of results while statistical significance of all results was tested at p < 0.05. RESULTS: Mean intra-observer measurement errors in replicate sonographic measurements of kidney sizes ranged from 0.36-0.43 cm, 0.22-0.63 cm, 0.37-0.52 cm and 5.93-9.62 ml for kidney length, width, thickness and volume, respectively. Mean inter-observer measurement errors were in the range of 0.29 0.48 cm, 0.18-0.23 cm, 0.34-1.82 cm and 5.92-7.28 ml for length, width, thickness and volume, respectively. Mean intra-observer errors were not statistically significant (p > 0.05) but mean interobserver errors were (p < 0.05). Differences in all measurement errors of right and left kidney length, width, thickness and volume were not statistically significant (p > 0.05). Measurement errors correlated weakly with kidney sizes. Observer errors in renal length were not significantly different from what was reported among Caucasians (p > 0.05) whereas that of volume was (p < 0.05). CONCLUSION: Errors in replicate sonographic kidney size measurements obtained by a single observer were less than errors in the same measurements by different observers; therefore, replicate sonographic measurements by a single observer were more consistent in this population.

OBJETIVO: Evaluar el nivel de inconsistencia cuando se repiten las mediciones sonográficas del tamaño del riñón en una población de niños nigerianos saludables. SUJETOS Y MÉTODOS: En este estudio prospectivo transversal, se utilizó la técnica de muestreo por conveniencia para seleccionar una muestra de niños nigerianos. Antes de comenzar el estudio, se obtuvo tanto el consentimiento de los participantes como la aprobación ética de la autoridad local. Tres radiólogos llevaron a cabo la repetición de las mediciones sonográficas mediante un escáner de sector mecánico DP-1100 con una sonda convexa de 3.5 MHz. Todos los exámenes se realizaron con sujetos en posición supina oblicua. Se realizaron escaneos longitudinales y transversales. La longitud y el ancho renales fueron medidos a partir de los escaneos longitudinales, mientras que el espesor se midió a partir de los escaneos transversales. Los volúmenes renales se calcularon con fórmula elipsoide. El análisis de varianza, la prueba t de Student, el coeficiente de correlación de Pearson, y la prueba Z, fueron utilizados para probar la significación estadística de los resultados. El programa SPSS versión 17.0 fue utilizado en el análisis de los resultados mientras que la significación estadística de los resultados fue probada en p < 0.05. RESULTADOS: Los errores intraobservadores promedio en la repetición de las mediciones sonográficas de los tamaños de riñón variaron de 0.36-0.43 cm, 0.22-0.63 cm, 0.37-0.52 cm, 5.93-9.62 mL en cuanto a longitud, ancho, espesor y volumen, respectivamente. Los errores interobservadores promedio de medición estuvieron en un rango de 0.29-0.48 cm, 0.18-0.23 cm, 0.34-1.82 cm y 5.92-7.28 mL de longitud, ancho, espesor y volumen, respectivamente. Los errores intraobservadores promedio no fueron estadísticamente significativos (p > 0.05) pero los errores interobservadores fueron (p < 0.05). Las diferencias en todos los errores de medición del riñón derecho e izquierdo en relación con la longitud, ancho, espesor y volumen, no fueron estadísticamente significativos (p > 0.05). Los errores de medición guardaron una débil correlación con los tamaños del riñón. Los errores de observador en relación con la longitud renal no fueron significativamente diferentes de lo que se informó entre los caucásicos (p > 0.05), mientras que el resultado para el volumen fue (p < 0.05). CONCLUSIÓN: Los errores en la repetición de las mediciones sonográficas del tamaño del riñón obtenidas por un solo observador, son menos que los errores en las mismas mediciones por diferentes observadores. Por lo tanto, las mediciones sonográficas repetidas por un único observador eran más consistentes entre esta población.

Variabilidad en la medición del índice acetabular / Variability in measurement of acetabular index

Introducción: La Displasia del desarrollo de la cadera (DDC) es un espectro de enfermedades que abarca desde la luxación franca de la cadera hasta la displasia acetabular leve. El screening de detección de DDC se realiza de rutina en nuestro país, mediante una radiografía de pelvis a los 3 meses. El índice acetabular medido en estas radiografías se utiliza para evaluar la cadera displásica, tanto en la presentación inicial como durante el seguimiento posterior. Objetivo: Evaluar la variabilidad tanto intra como inter observador en la medición del índice acetabular, entre profesionales médicos. Material y Métodos: Cuatro evaluadores (un cirujano-ortopédico infantil, un médico general, un pediatra y un radiólogo) realizaron la medición del índice acetabular en 100 radiografías de screening (200 caderas), en tres ocasiones, separadas por un mes cada una (600 mediciones totales). Un observador independiente evaluó la reproductibilidad en la medición. Se utilizó el coeficiente de correlación intraclase para determinar diferencias significativas. Resultados: La variabilidad intra observador fue menor que la interobservador. La variabilidad intra observador fue similar para los diferentes evaluadores, +/- 1,5°. La variabilidad inter observador fue de +/- 3,4°. Conclusiones: Demostramos una alta concordancia entre las mediciones, determinando una alta reproductibilidad del índice acetabular. El índice acetabular es un método seguro para el diagnóstico y seguimiento de displasia acetabular.

Developmental dysplasia of the hip (DDH) is a spectrum of diseases ranging from frank dislocation of the hip to mild acetabular dysplasia. DDH screening for detection is performed routinely in our country using pelvic x-ray at 3 months of age. The radiographic measured acetabular index is used to evaluate the dysplastic hip, at initial presentation and during follow-up. Objective: Evaluation of the intra- and inter-observer variability, among medical professionals, when measuring acetabular index. Methods: Four reviewers (a children orthopedic surgeon, a general practitioner, a pediatrician and a radiologist) performed acetabular index measurement in 100 radiographs (200 hips), on three occasions, separated each by one month (600 total measurements). An independent observer evaluated the measurement reproducibility. The intra-class correlation coefficient to determine significant differences was used. Results: The intra-observer variability was less than the inter-observer variability. The intra-observer variability was similar among the different assessors, +/- 1.5 degrees. The inter-observer variability was +/- 3.4 degrees. Conclusions: A high concordance among measurements was reported, evidencing a high reproducibility of the acetabular index; this index is a reliable method for the diagnosis and follow-up of acetabular dysplasia.

Estandarización en la observación y clasificación de lesiones epiteliales premalignas y malignas / Standardization in the observation and classification of premalignant and malignant epithelial lesions

Los criterios histológicos para determinar el grado de displasia, la clasificación de Broders y el frente de invasión tumoral (FIT) son parámetros subjetivos no cuantificables que pueden indicar el grado de evolución de displasias y carcinomas. Un factor importante a considerar durante la valoración histológica, es la variabilidad del diagnóstico entre patólogos. El objetivo es estandarizar los criterios y determinar la variabilidad intra e inter observador en el diagnóstico de displasias y COCE. Se seleccionaron y estandarizaron los criterios morfológicos para el diagnóstico y se revisaron los casos seleccionados aleatoriamente por tres patólogos bucales (30 displasias y 30 carcinomas) del Laboratorio de Patología Clínica y Experimental de la DEPeI de la FO, UNAM. Cada patólogo analizó y registró los parámetros establecidos para displasia, COCE y FIT en 2 ocasiones. Se aplicó el test Kappa para valorar la concordancia intra e inter observador. El Observador 1 v/s el 2 obtuvo una concordancia para COCE de 0,75 y en displasias de 0,60 e intraobservador de 0,90. El observador 2 v/s el 3 presentó una concordancia para COCE de 0,75 y en displasias de 0,59 e intraobservador de 0,91. El Observador 3 Vs el 1 tuvo una concordancia para COCE de 0,77, y en displasias de 0,59 e intraobservador de 0,92. La concordancia intraobservador e interobservador en COCE fue de buena a excelente, pero en displasias fue aceptable confirmando que su evaluación presenta mayor grado de dificultad. Con una adecuada estandarización se puede obtener una buena concordancia entre patólogos.

In the histological criteria for determining the degree of dysplasia, the Broders classification and the front of tumor invasion (FTI) are unquantifiable subjective parameters that may indicate the degree of development of carcinomas. An important factor to consider during the histological evaluation is the variability in the diagnosis of pathologists. The objective to standardize criteria and determine the intra and inter-observer variability in the diagnosis of dysplasias and OSCC. We selected and standardized morphological criteria for the diagnosis, and the cases were reviewed randomly by three oral pathologists (30 dysplasias and 30 carcinomas) from the Laboratory of Clinical and Experimental Pathology of the FO DEPeI, UNAM. Each pathologist analyzed and recorded the parameters for dysplasia and OSCC FIT on two occasions. Kappa test was applied to assess intra and inter-observer agreement. Observer 1 v/s 2 match for OSCC was 0.75, 0.60 for dysplasias and intra observer 0.90. Observer 2 v/s 3 presented a concordance of 0.75 for OSCC, 0.59 for dysplasias and intra-observer 0.91. Observer 3 v/s observer 1 for OSCC was 0.77, 0.59 for dysplasias and intra-observer 0.92. Intra observer and inter-observer concordance in OSCC were good or excellent, but in dysplasia was acceptable, confirming that its assessment showed the greatest difficulty with proper standardization we can obtain a better consensus between pathologists.

Thyroid Ultrasound: Change of Inter-observer Variability and Diagnostic Performance after Training

PURPOSE: To investigate and compare inter-observer variability and diagnostic performance of thyroid ultrasound (US) between a faculty member and observing residents. MATERIALS AND METHODS: From October 2007 to June 2009, 18 residents underwent training in thyroid US section. Group 1 included 8 residents that were trained for the first time and group 2 included 10 residents that were trained for the second time. US features of nodules were recoded according to the composition, echogenicity, margin, calcifications, shape, and final assessment by a faculty member and residents, respectively. Following a discussion, a faculty member performed fine needle aspiration. Then, the inter-observer variability and diagnostic performance between a faculty member and residents were investigated and compared for US. RESULTS: In group 1, agreement for composition in resident 1, calcification for residents 5 and 6, and shape for resident 4 were slight, moderate, moderate, and moderate, respectively. In group 2, agreement for composition in residents 1 and 10 were moderate. Substantial or greater agreement was observed more frequently in group 2 than 1. The diagnostic performances for both the faculty and residents were high and not statistically different. CONCLUSION: Agreement for US features between a faculty and residents as well as diagnostic performance were high. Moreover, diagnostic performance of residents that underwent training a second time of training was higher than residents that underwent training only once.

Outcomes of US BI-RADS 4A, 4B, and 4C Lesions

PURPOSE: The aim of our study was to evaluate the outcomes of sonographic (US) BIRADS category 4 lesions according to subcategories 4A, 4B, and 4C and palpability. MATERIALS AND METHODS: We retrospectively reviewed the pathology results of 512 US BI-RADS category 4 lesions in 460 patients after ultrasound-guided percutaneous biopsy (n = 435) and surgical biopsy (n = 77). We analyzed the results according to subcategories 4A, 4B, 4C, and palpability, and compared outcomes of five breast radiologists. RESULTS: In BI-RADS 4A lesions (n = 302), biopsy results indicated 48 malignancies (15.9%). In BI-RADS 4B lesions (n = 113), biopsy revealed 69 malignancies (61.1%). Among BI-RADS 4C lesions (n = 97), 87 lesions were malignancies (89.7 %). Palpability had no correlation with the rate of malignancy in BI-RADS category 4 lesions, and the rate of malignancy for category 4A ranged widely from 8.1% - 26.4%. CONCLUSIONS: The outcomes of US BI-RADS category 4 lesions according to subcategories varied widely between radiologists, especially for 4A lesions. The US finding itself warrants a BI-RADS 4 subcategory. In category 4 lesions, the malignant rate was the same between palpable and nonpalpable lesions.