An independent inter- and intra-observer agreement assessment of the Eno classification of sacroiliac joint degeneration

Background Recently, a scoring system to grade sacroiliac joint (SIJ) degeneration using computed tomography (CT) scans was described. No independent evaluation has determined the inter- and intra-observer agreement using this scheme. Purpose To perform an independent inter- and intra-observer agreement assessment using the Eno classification and determining gas in the SIJ. Material and Methods We studied 64 patients aged ≥60 years who were evaluated with abdominal and pelvic computed tomography scans. Six physicians (three orthopaedic spine surgeons and three musculoskeletal radiologists) assessed axial images to grade SIJ degeneration into grade 0 (normal), grade 1 (mild degeneration), grade 2 (significant degeneration), and grade 3 (ankylosis). We also evaluated the agreement assessing the presence of gas in the SIJ. After a four-week interval, all cases were presented in a random sequence for repeat assessment. We determined the agreement using the kappa (κ) or weighted kappa coefficient (wκ). Results The inter-observer agreement was moderate (wκ = 0.50 [0.44–0.56]), without differences among surgeons (wκ = 0.53 [0.45–0.61]) and radiologists (wκ = 0.49 [0.42–0.57]). The agreement evaluating the presence of gas was also moderate (κ = 0.45 [0.35–0.54]), but radiologists obtained better agreement (κ = 0.61 [0.48–0.72]) than surgeons (κ = 0.29 [0.18–0.39]). The intra-observer agreement using the classification was substantial (wκ = 0.79 [0.76–0.82]), without differences comparing surgeons (wκ = 0.75 [0.70–0.80]) and radiologists (wκ = 0.83 [0.79–0.87]). The intra-rater agreement evaluating gas was substantial (κ = 0.77 [0.72–0.82]), without differences between surgeons (κ = 0.71 [0.63–0.78]) and radiologists (κ = 0.84 [0.78–0.90]). Conclusion Given the only moderate agreement obtained using the Eno classification, it does not seem adequate to be used in clinical practice or in research.

Procedure for assessing patients referred to the UK’s military Heat Illness Clinic: a case series

IntroductionThe UK military operates a Heat Illness Clinic (HIC) to aid the return to exercise, training and occupational duty recommendations for individuals who have suffered exertional heat illness or heatstroke. This paper describes the process of assessment and reports representative data from n=22 patients referred to the HIC.MethodThe assessment included clinical consultation, and measurement of maximal oxygen consumption (V̇O2max) and a heat tolerance test (HTT) conducted on a treadmill in an environmental chamber with an air temperature of 34°C and 44% relative humidity. Patients began the HTT wearing military clothing, carrying a rucksack (mass 15 kg) and walking at 60% V̇O2max, at 30 min the rucksack and jacket were removed and the T-shirt at 45 min, individuals continued walking for 60–90 min. Patients were considered heat tolerant if rectal temperature achieved a plateau.ResultsN=14 patients were heat tolerant on the first assessment and of the n=8 patients required to return for repeat assessment, five were heat tolerant on the second assessment and the remaining three on the third assessment.ConclusionsIn conjunction with patient history and clinical evaluation, the HTT provides a physiological basis to assist with decisions concerning patient management and return to duty following an episode of heat illness.

Psychometric Properties of the Infant Toddler Activity Card Sort

The Infant Toddler Activity Card Sort (ITACS) is a new measure that engages caregivers in goal development by measuring participation in early childhood. Initial evaluation of the ITACS is required to assess its psychometric properties. To evaluate test–retest reliability, concurrent validity, and between-group differences of the ITACS. Caregivers ( N = 208) of children 0–3 years, who were typically developing (TD) or had a developmental delay (DD), completed the ITACS and Pediatric Evaluation of Disability Inventory–Computer Adaptive Test (PEDI-CAT) with repeat assessment after 2 weeks later ( n = 117). The ITACS demonstrated moderate concurrent validity with the PEDI-CAT. Children with DD had significantly more activity concerns on the ITACS than TD. Adequate test–retest reliability was not achieved. The ITACS is a useful tool for identifying caregiver concerns in activity engagement; interventions can be tailored to address concerns and increase participation in childhood routines.

Repeat individualized assessment using isomorphic questions: a novel approach to increase peer discussion and learning

It is demonstrated that the fully automatic generation of isomorphic questions allows for both repeat assessment, and for this assessment to be individualized. While this does require a substantial up-front effort, once prepared assessments can be reproduced with relative ease and with a near-zero probability of students receiving the same question a second time. We show the effectiveness of this approach using survey and performance data obtained from large year 2 and year 3 computer science classes. A greater than 10-fold increase in online peer discussion was observed, compared to the previous year. Contents analysis of the surveys showed that repeat testing was generally regarded favourably. Quantitative analyses found that prior homework did little to improve initial test performance, but was of vital importance in studying for the follow-up isomorphic test. Moreover, the performance gain on the isomorphic questions was the same for all students regardless of their overall ability, and was retained in the final exam.

Progression of pediatric celiac disease from potential celiac disease to celiac disease: a retrospective cohort study

Background A subset of patients with serology suggesting celiac disease have an initially negative biopsy but subsequently develop histopathologic celiac disease. Here we characterize patients with potential celiac disease who progress to celiac disease. Methods We performed a retrospective analysis of children (0–18 years of age) with biopsy-confirmed celiac disease seen at St. Louis Children’s Hospital between 2013 and 2018. Results Three hundred sixteen of 327 (96%) children with biopsy-confirmed celiac disease were diagnosed on initial biopsy. The 11 children with potential celiac disease who progressed to celiac disease had lower anti-tissue transglutaminase (anti-TTG IgA) concentrations (2.4 (1.6–5) X upper limit of normal (ULN) vs. 6.41 (3.4–10.5) X ULN) at time of first biopsy. Their median anti-TTG IgA concentrations rose from 2.4 (1.6–5) X ULN to 3.6 (3.1–9.2) X ULN between biopsies. Conclusions Four percent of biopsy confirmed celiac patients initially had a negative biopsy, but later developed histopathologic celiac disease. This is likely an underestimate as no surveillance algorithm was in place. We recommend repeat assessment in children whose serology suggests celiac disease despite normal small bowel biopsy.

The reproducibility of measuring maximum abdominal aortic aneurysm diameter from ultrasound images

Background Accurate repeat assessment of the diameter of an abdominal aortic aneurysm (AAA) is important. This study investigated the reproducibility of different methods of measuring AAA diameter from ultrasound images. Methods Fifty AAA patients were assessed by ultrasound. Maximum AAA diameter was measured independently by three trained observers on two separate occasions using a standardised protocol. Five diameters were measured from each scan, three in the anterior–posterior (AP) and two in the transverse (TV) plane, including inner-to-inner (ITI), outer-to-outer (OTO) and leading edge-to-leading edge (LETLE). Intra- and inter-observer reproducibility were reported as reproducibility coefficients. Statistical comparison of methods was performed using linear mixed effects models. Results Intra-observer reproducibility coefficients (AP LETLE 2.2 mm; AP ITI 2.4 mm; AP OTO 2.6 mm) were smaller than inter-observer reproducibility coefficients (AP LETLE 4.6 mm: AP ITI 4.5; and AP OTO 4.8 mm). There was no statistically significant difference in intra-observer reproducibility of three types of measurements performed in the AP plane. Measurements obtained in the TV plane had statistically significant worse intra-observer reproducibility than those performed in the AP plane. Conclusions This study suggests that the comparison of maximum AAA diameter between repeat images is most reproducibly performed by a single trained observer measuring diameters in the AP plane.

Training using a simulation-based workshop reduces inaccuracies in estimations of testicular volume

ObjectivesMeasuring testicular volume (TV) by orchidometer is routine in the clinic when staging male puberty. We have developed a simulation model for TV estimation and investigated whether training medical students, using a workshop with simulation models, could improve the accuracy and reliability of TV estimation.MethodsAll participating medical students watched a video representing standard undergraduate training in male pubertal assessment. Volunteers were then randomised directly to assessment or to attend a workshop consisting of a further video and four stations contextualising and practising the skills required for TV estimation, prior to assessment. Three child mannequins displaying testes of 3 mL, 4 mL (twice), 5, 10 and 20 mL were used for assessment. Participants were asked to return a fortnight later for repeat assessment to assess intra-observer reliability, the effect of repeated examinations on accuracy and time on skill retention.ResultsNinety students participated (55F), 46 attended the workshop and were considered “trained”. There was no difference between the groups in numbers of correct estimations (29% trained, 27% untrained, p=0.593). However, the trained group’s estimations were closer to the true volume, with more from the trained group one bead away (p=0.002) and fewer more than three beads away from the true volume (p<0.001), compared to the untrained group. Trained participants were more accurate at the second assessment (n=80) (p<0.001) and had greater intra-observer reliability (p=0.004).ConclusionsOverall TV estimation accuracy was poor. Workshop-style training improved accuracy, reliability and retention of skill acquisition and could be considered as a useful learning tool.

A Simple Pre-Operative Nuclear Classification Score (SPONCS) for Grading Cataract Hardness in Clinical Studies

Background: The aim of this study was to evaluate whether a simplified pre-operative nuclear classification score (SPONCS) was valid, both for clinical trials and real-world settings. Methods: Cataract classification was based on posterior nuclear color: 0 (clear), 1 (subcapsular/posterior cataract with clear nucleus), 2 (mild “green nucleus” with plus sign for yellow reflection of the posterior cortex), 3 (medium “yellow nucleus” with plus sign for brown/red posterior cortex reflection), 4 (advanced with 4 being “red/brown nucleus” and 4+ white nucleus), and 5 (hypermature/Morgagnian nucleus). Inter- and intra-observer validity was assessed by 30 Ophthalmologists for 15 cataract cases. The reliability of the cataract grading score in a surgical setting was evaluated. Correlation of nuclear scores was compared with phacoemulsification cumulative dissipated energy (CDE) in 596 patients. Results: Analysis of mean intra-observer Cohen kappa agreement was 0.55 with an inter-observer score of 0.54 for the first assessment and 0.49 for the repeat assessment one week later. When evaluating results by nuclear color alone, there was a substantial agreement for both the intra-observer (0.70) and inter-observer parameters: 0.70 for the first test, and 0.66 on repetition with randomization of the cases after a week. CDE levels were found to be significantly different between all SPONCS score groups (p < 0.001), with a lower CDE related to a lower SPONCS score. A strong correlation was found between the SPONCS score and CDE (Spearman′s rho = 0.8, p < 0.001). Conclusion: This method of grading cataract hardness is both simple and repeatable. This system can be easily incorporated in randomized controlled trials to lower bias and confounding effects regarding nuclear density along with application in the clinical setting.

752. Management of 20 Patients Diagnosed with Posaconazole-Induced Pseudohyperaldosteronism

Background Posaconazole-induced pseudohyperaldosteronism (PIPH) has been associated with elevated posaconazole serum concentrations. Clinicians are faced with the difficult task of managing patients with PIPH while not compromising the efficacy of antifungal prophylaxis or treatment. Commonly, modifications to posaconazole therapy are utilized in managing PIPH including dosage reduction of posaconazole or therapeutic switch to an alternative antifungal. Methods We retrospectively reviewed 20 consecutive adult patients diagnosed with PIPH in this case series. Patient data including blood pressure, electrolytes, endocrine laboratory values, and posaconazole serum concentrations collected before and after therapeutic intervention. Results Out of 20 patients included, 17 patients (85%) underwent therapeutic modification with posaconazole dose reduction (N=11) as the most common change. Other modifications included posaconazole discontinuation (N=3), switch to an alternative antifungal (N=2), and addition of spironolactone (N=1). Clinical improvement (a decrease in systolic blood pressure and increase in serum potassium) was observed in 9 of 17 patients (52.9%). Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p1 Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p2 Table 1. Management of Posaconazole-Induced Pseudohyperaldosteronism - p3 Conclusion We report our experience with PIPH management, for which there is currently no universally effective strategy. We suggest a stepwise approach for PIPH management, starting with posaconazole dose reduction and repeat assessment of clinical and laboratory parameters. If resolution of PIPH is not achieved, an alternative triazole antifungal or the addition of an aldosterone antagonist are additional potential interventions. Even with this approach, it is possible for PIPH to persist after therapeutic modification. Thus, early diagnosis and continuous, close monitoring of patients is warranted. Disclosures All Authors: No reported disclosures