Direct mitral regurgitation quantification in hypertrophic cardiomyopathy using 4D flow CMR jet tracking: evaluation in comparison to conventional CMR

Background Quantitative evaluation of mitral regurgitation (MR) in hypertrophic cardiomyopathy (HCM) by cardiovascular magnetic resonance (CMR) relies on an indirect volumetric calculation. The aim of this study was to directly assess and quantify MR jets in patients with HCM using 4D flow CMR jet tracking in comparison to standard-of-care CMR indirect volumetric method. Methods This retrospective study included patients with HCM undergoing 4D flow CMR. By the indirect volumetric method from CMR, MR volume was quantified as left ventricular stroke volume minus forward aortic volume. By 4D flow CMR direct jet tracking, multiplanar reformatted planes were positioned in the peak velocity of the MR jet during systole to calculate through-plane regurgitant flow. MR severity was collected for agreement analysis from a clinical echocardiograms performed within 1 month of CMR. Inter-method and inter-observer agreement were assessed by intraclass correlation coefficient (ICC), Bland–Altman analysis, and Cohen’s kappa. Results Thirty-seven patients with HCM were included. Direct jet tracking demonstrated good inter-method agreement of MR volume compared to the indirect volumetric method (ICC = 0.80, p = 0.004) and fair agreement of MR severity (kappa = 0.27, p = 0.03). Direct jet tracking showed higher agreement with echocardiography (kappa = 0.35, p = 0.04) than indirect volumetric method (kappa = 0.16, p = 0.35). Inter-observer reproducibility of indirect volumetric method components revealed the lowest reproducibility in end-systolic volume (ICC = 0.69, p = 0.15). Indirect volumetric method showed good agreement of MR volume (ICC = 0.80, p = 0.003) and fair agreement of MR severity (kappa = 0.38, p < 0.001). Direct jet tracking demonstrated (1) excellent inter-observer reproducibility of MR volume (ICC = 0.97, p < 0.001) and MR severity (kappa = 0.84, p < 0.001) and (2) excellent intra-observer reproducibility of MR volume (ICC = 0.98, p < 0.001) and MR severity (kappa = 0.88, p < 0.001). Conclusions Quantifying MR and assessing MR severity by indirect volumetric method in HCM patients has limited inter-observer reproducibility. 4D flow CMR jet tracking is a potential alternative technique to directly quantify and assess MR severity with excellent inter- and intra-observer reproducibility and higher agreement with echocardiography in this population.

Comparison of CT Severity Index and Modified CT Severity Index in the Clinical Severity Assessment of Acute Pancreatitis

Objective: To compare the computed tomography severity index (CTSI) and the modified computed tomography severity index (MCTSI) in the clinical severity assessment of acute pancreatitis.Material and Methods: This retrospective cohort study comprised acute pancreatitis patients who underwent contrastenhanced abdominal computed tomography (CT) scans within 4 weeks after clinical onset. Two experienced abdominal radiologists, blinded to the clinical outcome, independently reviewed the CT images and retrospectively scored them using CTSI and MCTSI. Any discrepancies were resolved by a consensus review. The clinical severity assessment of each participant was categorized by the determinant-based classification of acute pancreatitis severity. The correlations of CTSI and MCTSI with the clinical severity assessment were analyzed.Results: This cohort study consisted of 40 participants—28 of them were men (70.0%)—with a mean age of 59.3 years. They were clinically divided into mild, moderate, severe, and critical groups comprising 11 (27.5%), 16 (40.0%), 7 (17.5%), and 6 (15.0%) participants, respectively. Due to the small number of patients in the severe and critical groups, we combined these into a single severe category (13 patients, 32.5%). The CTSI and MCTSI scores showed moderate and fair agreement with the clinical severity assessment. A trend linking poor clinical outcome with high CTSI/MCTSI scores (moderate and severe groups) more commonly than low scores (mild group) was observed. There was a very strong agreement between CTSI and MCTSI (rs =0.97).Conclusion: CTSI and MCTSI showed a moderate and fair agreement, respectively, with the clinical severity assessment. Compared to low scores, a poor clinical outcome was more often associated with high CTSI/MCTSI scores.

Three-dimensional verification of the radiographic visibility of the root pulp used for forensic age estimation in mandibular third molar

Objectives The aim of this study was to assess the reliability of panoramic radiography (OPG) using age estimation method using cone-beam computed tomography (CBCT) verification in the evaluation of radiographic visibility of root pulp (RPV) of mandibular third molars for age estimation. Methods CBCT and OPG images of 429 mandibular third molars from 290 patients were evaluated. RPV of fully mineralized mandibular third molars was evaluated as stages 0, 1, 2, and three for both imaging methods. Descriptive statistics were performed separately for stages by age for both genders. The consistency of these scores with chronological age was evaluated for both imaging methods. The reliability of OPG evaluation was also analyzed with CBCT scores. Results: Spearman’s rho correlation demonstrated a positive correlation between RPV and chronological age for both genders and for OPG and CBCT evaluation. Considering the minimum ages of both imaging methods, all stages were above the age of 18 except for the female group of Stage two and all Stage 0. For the comparison of OPG and CBCT RPV Staging scores, the κ score was found to be 0.312 (p < 0.001), indicating a fair agreement. Conclusion In conclusion, the absence of Stage 3 at age of 18 and under might have a forensic value for RPV age estimation method. Considering the fair agreement in the verification of OPG scores, it is not possible to determine the exact age with the RPV detected in OPG images, the use of CBCT for the RPV evaluation is recommended to available cases

Normative Performance Measurement in Simulated Air Combat

BACKGROUND: Normative performance (NP) describes the pilots adherence to tactics, techniques, and procedures (TTPs). Until now, there has not been a global NP measurement technique for beyond visual range (BVR) air combat, and the methodology and technology related to the evaluation of NP have fallen behind the pace of the overall technical progress of distributed mission operations (DMO) training.METHODS: Platform-independent core air combat tasks were identified. The execution of these tasks is directed with TTPs. BVR air combat missions were flown in a DMO simulator system and the design NP was varied between missions. Observers viewed debriefs of these missions and attempted to identify TTP-regulated air combat tasks. Once identified, they scored the pilots NP in those tasks. The scoring was based on the level of TTP adherence and the impact a nonadherence had on the mission accomplishment.RESULTS: All observers were able to identify most of the TTP-regulated air combat tasks. There was a strong positive correlation between the observed and design NP scores. The overall Kappa indicated a fair agreement between the observers. The percentage of observers NP assessments which agreed with the design NP varied from 49.60 to 85.28% in different air combat missions. On average, 73.9%6 of the observers NP scores agreed with the design NP scores.CONCLUSIONS: Observers were able to accurately identify TTP-regulated tasks and score NP of these tasks during an air combat debrief. There was a moderate agreement between the observers NP scores.Mansikka H, Virtanen K, Mkinen L, Harris D. Normative performance measurement in simulated air combat. Aerosp Med Hum Perform. 2021; 92(11):908-912.

Inter-observer agreement using the LI-RADS version 2018 CT treatment response algorithm in patients with hepatocellular carcinoma treated with conventional transarterial chemoembolization

Aim To determine inter-reader agreement in categorization of imaging features using the Liver Imaging Reporting and Data System (LI-RADS) treatment response (LR-TR) algorithm in patients with hepatocellular carcinoma (HCC) treated with conventional transarterial chemoembolization (cTACE). Methods Two radiologists used the LR-TR algorithm to assess 112 computed tomography (CT) examinations of 102 patients treated with cTACE. The inter-observer agreement in categorization of LR-TR features was assessed using kappa (κ) statistics. Results There was substantial inter-observer agreement between the two reviewers using the LR-TR algorithm (κ = 0.70; 95% CI 0.58–0.81). The two reviewers categorized tumors as non-viable in 37 (33.0%) and 39 (34.8%) of 112 examinations, viable in 58 (51.8%) and 62 (55.4%) examinations, and equivocal in 18 (16.1%) and 11 (9.8%) examinations, respectively. There was almost perfect inter-observer agreement for the LR-TR non-viable category (κ = 0.80; 95% CI 0.68–0.92), substantial agreement for the viable category (κ = 0.78 95% CI 0.67–0.90), and fair agreement for the equivocal category (κ = 0.25; 95% CI 0.02–0.49). Conclusion The LR-TR algorithm conveys high degrees of inter-observer agreement for the assessment of CT imaging features in the viable and non-viable categories. Further refinement of indeterminate features may be necessary to improve the correct categorization of equivocal lesions. Graphic abstract

Prospective evaluation of optical coherence tomography for disease detection in the Casey mobile eye clinic

This study was designed to evaluate iVue Spectral-domain optical coherence tomography (SD-OCT) effectiveness in screening for eye disease compared to clinical examination. Subjects were recruited from the Casey Eye Community Outreach Program Mobile Clinic during its routinely scheduled outreach clinics to indigent, underserved populations throughout Oregon. Macular optical coherence tomography interpretation and automated optical coherence tomography analysis were compared to the clinical examination, with specific attention to findings indicative of retinal abnormalities, risks for glaucoma, and narrow angles. As a result, a total of 114 subjects were included in this study. In diabetics, optical coherence tomography and clinical exam were in fair agreement (kappa = 0.39), with 22% of eyes having abnormal findings on macular optical coherence tomography and 26% of eyes having diabetic retinopathy or diabetic macular edema on fundus exam. In non-diabetics, optical coherence tomography and clinical exam were in fair agreement (kappa = 0.28), with 11% of eyes having abnormal findings on macular optical coherence tomography and 9% on fundus exam. Using optical coherence tomography ganglion cell complex and retinal nerve fiber layer analysis, 18% of eyes were found to be glaucoma suspects, whereas clinical exam of cup-to-disc ratio detected 8% and intraocular pressure 5%. Agreements between optical coherence tomography and other methods were poor (kappa < 0.11) for glaucoma suspect. Anterior segment optical coherence tomography of the angle found 8% of eyes to have occludable angles, whereas slit lamp and gonioscopy found 5% of eyes to have narrow angles, with moderate agreement (kappa = 0.57). In summary, optical coherence tomography detected additional retinal abnormalities, glaucoma suspects, and narrow angles compared to clinical exam alone and may serve as a useful adjunct to the clinical exam in screening for eye disease in a low-risk, medically underserved, ethnically diverse population.

An assessment of the psychometric properties of the Stoplight Pain Scale in a Canadian paediatric emergency department

Objective This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS). Methods A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure. Results A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen’s κ, agreement for SPS and FPS-R was ‘fair’ for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and ‘poor’ for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had ‘fair’ agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed ‘poor’ agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R. Conclusion The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

OPTIMAL ASSESSMENT OF FATIGUE IN RHEUMATOID ARTHRITIS: VISUAL ANALOG SCALE VERSUS FUNCTIONAL ASSESSMENT OF CHRONIC ILLNESS THERAPY – FATIGUE

Background:Fatigue is an important outcome for patients with rheumatoid arthritis (RA). As recommended by the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) task force in 2008, fatigue should be measured in all RA clinical trials whenever possible. Despite these recommendations, it is largely ignored and rarely assessed in clinical practice.Objectives:The aim of this study was to compare the scales being used to measure fatigue in RA.Methods:We conducted a cross-sectional study including patients with RA (ACR/EULAR 2010). Patients with other acute or chronic diseases that may induce fatigue (such as cancer, infection or depression) were excluded. Demographic and disease-related data were collected. Fatigue was assessed using two scores. The fatigue Visual Analog Scale (VAS) ranging between 0 and 100 cm. Fatigue was considered mild if the fatigue VAS was <20 cm, moderate if 20≤VAS<50 and severe if VAS>50 cm. The Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) which is a short 13-item questionnaire validated in RA. The score FACIT-F ranges between 0 and 52. Fatigue was considered mild if the FACIT-F score was ≥40, moderate if 20≤FACIT-F<40 and severe if 0≤FACIT-F<20. We used Cohen’s kappa (κ) to determine the agreement between fatigue VAS and FACIT-F. The κ result was interpreted as follows: values ≤ 0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement. A p value inferior to 0.05 was considered significant.Results:We included 100 RA patients (84 women and 16 men) with a mean age of 49.5±10 years old [18-65]. The mean disease duration was 87.3 months [1-360]. RF and ACPA were positive in 75% and 72.6% of cases respectively. The mean pain VAS was 49 cm [0-100]. The mean numbers of tender and swollen joints were 5.3 [0-36] and 1 [0-9] respectively. The mean levels of ESR and CRP were 38.1 mm [10-120] and 10.8 mg/l [2-61] respectively. The mean DAS28 ESR was 3.68 [1.90-8.33].The mean fatigue VAS was 49.1 cm [5-100]. Fatigue was mild in 9% of patients, moderate in 31% of patients, and severe in 60% of patients.The mean FACIT-F score was 27.1 [0-51]. Fatigue was mild in 26% of patients, moderate in 57% of patients and severe in 17% of patients.A fair agreement was noted between the two scores (κ=0.303, p<0.001).The fatigue VAS and FACIT-F were both correlated with the following variables: pain VAS (r=0.685, p<0.001 and r=-0.605, p<0.001), ESR (r=0.384, p<0.001 and r=-0.405, p<0.001), and DAS28 ESR (r=0.684, p<0.001 and r=-0.744, p<0.001).Conclusion:The fatigue VAS and FACIT-F are easy, brief and valid measures for monitoring this symptom and its effects on patients with RA. A fair agreement was noted between the two scores.Disclosure of Interests:None declared

Performance of Self-Collected Saliva Testing Compared with Nasopharyngeal Swab Testing for the Detection of SARS-CoV-2

The aim of this study was to determine whether self-collected pure saliva (SCPS) is comparable to nasopharyngeal (NP) swabs in the quantitative detection of SARS-CoV-2 by RT-PCR in asymptomatic, mild patients with confirmed COVID-19. Thirty-one patients aged from 18 to 85 years were included between 9 June and 11 December 2020. A SCPS sample and a NP sample were taken for each patient. Quantitative PCR was performed to detect SARS-CoV-2 viral load. Results of SCPS vs NP samples testing were compared. Statistical analyses were performed. Viral load was significantly correlated (r = 0.72). The concordance probability was estimated at 73.3%. In symptomatic adults, SCPS performance was similar to that of NP swabs (Percent Agreement = 74.1%; p = 0.11). Thus, the salivary test based on pure oral saliva samples easily obtained by noninvasive techniques has a fair agreement with the nasopharyngeal one in asymptomatic, mild patients with a confirmed diagnosis of COVID-19.

INTER-OBSERVER AGREEMENT IN INTERPRETING UROFLOWMETRY MEASUREMENTS IN INDONESIA

Objective: We evaluated the comparability and repeatability of analyses based on uroflowmetry reports among urologists in Indonesia. Material & Methods: We assessed the inter-observer agreement when interpreting urodynamic examinations. Four urologists analyzed 20 sets of uroflowmetry data and gave their interpretations of the normality of the curve, reason of abnormality, grade classification, and pattern of the uroflowmetry curves. The consensus among observers was analyzed using the kappa statistic. Results: The kappa values for the analyses of the normality of the curves indicated fair to the moderate agreement. Agreement on the reason of abnormality showed poor to fair consensus. The shape of the flow curve had kappa values ranging from 0.047 to 0.225, indicating poor to fair consensus. Based on grade also showed kappa value from 0.047 to 0.169, indicating a poor agreement. Conclusion: Interpretations of uroflowmetry tracings showed only the poor to a fair agreement despite the normality of the uroflow curve. Variability in interpretation can strongly impact patient treatment. Therefore, further work is needed to standardize the reporting and interpretation of uroflowmetry studies to optimize patient care.