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Background The statistical validities of the official Japanese classifications of activities of daily living (ADLs), including bedriddenness ranks (BR) and cognitive function scores (CFS), have yet to be assessed. To this aim, we evaluated the ability of BR and CFS to assess ADLs using inter-rater reliability and criterion-related validity. Methods New inpatients aged ≥75 years were enrolled in this hospital-based prospective observational study. BR and CFS were assessed once by an attending nurse, and then by a social worker/medical clerk. We evaluated inter-rater reliability between different professions by calculating the concordance rate, kappa coefficient, Cronbach’s α, and intraclass correlation coefficient. We also estimated the relationship of the Barthel Index and Katz Index with the BR and CFS using Spearman’s correlation coefficients. Results For the 271 patients enrolled, BR at the first assessment revealed 66 normal, 10 of J1, 15 of J2, 18 of A1, 31 of A2, 37 of B1, 35 of B2, 22 of C1, and 32 of C2. The concordance rate between the two BR assessments was 68.6%, with a kappa coefficient of 0.61, Cronbach’s α of 0.91, and an intraclass correlation coefficient of 0.83, thus showing good inter-rater reliability. BR was negatively correlated with the Barthel Index (r = − 0.848, p p Meanwhile, CFS at the first assessment revealed 92 normal, 47 of 1, 19 of 2a, 30 of 2b, 60 of 3a, 8 of 3b, 8 of 4, and 0 of M. The concordance rate between the two CFS assessments was 70.1%, with a kappa coefficient of 0.62, Cronbach’s α of 0.87, and an intraclass correlation coefficient 0.78, thus also showing good inter-rater reliability. CFS was negatively correlated with the Barthel Index (r = − 0.667, p p Conclusions BR and CFS could be reliable and easy-to-use grading scales of ADLs in acute clinical practice or large-scale screening, with high inter-rater reliabilities among different professions and significant correlations with well-established, though complicated to use, instruments to assess ADLs. Trial registration UMIN000041051 (2020/7/10).

[Purpose] This study aimed to clarify the required number of measurements to calculate trunk muscle thickness at each position. [Participants and Methods] The participants were 30 elderly males aged >65 years. The right lumbar multifidus (L2), lumbar multifidus (L5), erector spinae, transversus abdominis, internal oblique, and external oblique muscle thicknesses were measured on longitudinal images obtained using ultrasonography in the lying, sitting, and standing positions. Two measurement values for each muscle thickness was used to calculate the intraclass correlation coefficient (1.1–1.5). [Results] The intraclass correlation coefficients of the abdominal muscle thickness measurements with “great reliabilities” were as follows: 1.3–1.5 for the external oblique muscle and 1.2–1.5 for the internal oblique and transversus abdominis muscles in the lying position; 1.3–1.5 for the external oblique and transversus abdominis muscles and 1.2–1.5 for the internal oblique muscle in the sitting position; the intraclass correlation coefficient in the standing position was 1.5 for the external oblique muscle 1.1–1.5 for the internal oblique muscle and 1.3–1.5 for the transversus abdominis muscle. In all the positions, the intraclass correlation coefficient of the measurements of the back-muscle thicknesses ranged from 1.1 to 1.5 for the right lumbar multifidus (L2), lumbar multifidus (L5), and erector spinae. [Conclusion] Depending on the posture, the abdominal muscles require multiple measurements, whereas the back muscles only require a single measurement.

Long Zhen,1,2 Gang Wang,1 Gailing Xu,2 Le Xiao,1 Lei Feng,1 Xu Chen,1 Man Liu,1 Xuequan Zhu1 1The National Clinical Research Center for Mental Disorders and Beijing Key Laboratory of Mental Disorders and Beijing Anding Hospital, Capital Medical University, Beijing 100088, People’s Republic of China; 2Tianjin Mental Health Center, Tianjin Anding Hospital, Tianjin 300222, People’s Republic of ChinaCorrespondence: Gang WangThe National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Anding Hospital, Capital Medical University, Beijing 100088, People’s Republic of ChinaTel +86-13672146258Fax +86-02288188856Email andingyjs@163.comPurpose: Smartphone-based questionnaires have advantages compared with their paper versions, but there is a lack of consistent research on depressive disorder questionnaires. This study aimed to assess the equivalence between the paper and smartphone versions of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) and Patient Health Questionnaire-9 (PHQ-9) for patients with depressive disorders in psychiatric hospitals in China.Patients and Methods: This was a randomized crossover study of 110 depressed patients recruited from the outpatient department of Beijing Anding Hospital from March 2016 to September 2018. Group 1 completed both the QIDS-SR16 and PHQ-9 in paper format and then completed the smartphone version 1– 2 h later. Group 2 completed the scales in the reverse order. Reliability was evaluated using intraclass correlation coefficients (ICCs) with 95% confidence intervals (CI). The expected ICC was 0.9 (α=0.05).Results: The overall ICC score of the QIDS-SR16 paper and smartphone versions was 0.904 (95% CI: 0.861– 0.934), and the ICCs of each item ranged from 0.769 to 0.923. The overall ICC score of the PHQ-9 paper and smartphone versions was 0.951 (95% CI: 0.929– 0.967), and the ICCs of each item ranged from 0.779 to 0.914.Conclusion: This study demonstrated the equivalence of the paper and smartphone versions of the PHQ-9 and QIDS-SR16 in depressed patients in China.Keywords: depressive disorder, equivalence, intraclass correlation coefficient, questionnaires, smartphone

Air displacement plethysmography (ADP) is fast, accurate, and reliable. Nevertheless, in about 3% of the cases, standard ADP tests provide rogue results. To spot these outliers and improve precision, repeated trials protocols have been devised, but few works have addressed their reliability. This study was conducted to evaluate the test–retest reliabilities of two known protocols and a new one, proposed here. Ninety-two healthy adults (46 men and 46 women) completed six consecutive ADP tests. To evaluate the reliability of single measurements, we used the results of the first two tests, for multiple measures protocols, we computed the test result from trials 1–3 and the retest result from trials 4–6. Bland–Altman analysis revealed that the bias and the width of the 95% interval of agreement were smaller for multiple trials than for single ones. For percent body fat (%BF)/fat-free mass, the technical error of measurement was 1% BF/0.68 kg for single trials and 0.62% BF/0.46 kg for the new protocol of multiple trials, which proved to be the most reliable. The minimal detectable change (MDC) was 2.77% BF/1.87 kg for single trials and 1.72% BF/1.26 kg for the new protocol.

In shift work settings and on-call operations, workers may be at risk of sleep inertia when called to action immediately after awakening from sleep. However, individuals may differ substantially in their susceptibility to sleep inertia. We investigated this using data from a laboratory study in which 20 healthy young adults were each exposed to 36 h of total sleep deprivation, preceded by a baseline sleep period and followed by a recovery sleep period, on three separate occasions. In the week prior to each laboratory session and on the corresponding baseline night in the laboratory, participants either extended their sleep period to 12 h/day or restricted it to 6 h/day. During periods of wakefulness in the laboratory, starting right after scheduled awakening, participants completed neurobehavioral tests every 2 h. Testing included the Karolinska Sleepiness Scale to measure subjective sleepiness, for which the data were analyzed with nonlinear mixed-effects regression to quantify sleep inertia. This revealed considerable interindividual differences in the magnitude of sleep inertia, which were highly stable within individuals after both baseline and recovery sleep periods, regardless of study condition. Our results demonstrate that interindividual differences in subjective sleepiness due to sleep inertia are substantial and constitute a trait.

The regular monitoring of erythema, one of the most important skin lesions in atopic (allergic) dogs, is essential for successful anti-allergic therapy. The smartphone-based dermatoscopy enables a convenient way to acquire quality images of erythematous skin. However, the image sampling to evaluate erythema severity is still done manually, introducing result variability. In this study, we investigated the correlation between the most popular erythema indices (EIs) and dermatologists’ erythema perception, and we measured intra- and inter-rater variability of the currently-used manual image-sampling methods (ISMs). We showed that the EIBRG, based on all three RGB (red, green, and blue) channels, performed the best with an average Spearman coefficient of 0.75 and a typical absolute disagreement of less than 14% with the erythema assessed by clinicians. On the other hand, two image-sampling methods, based on either selecting specific pixels or small skin areas, performed similarly well. They achieved high intra- and inter-rater reliability with the intraclass correlation coefficient (ICC) and Krippendorff’s alpha well above 0.90. These results indicated that smartphone-based dermatoscopy could be a convenient and precise way to evaluate skin erythema severity. However, better outlined, or even automated ISMs, are likely to improve the intra- and inter-rater reliability in severe erythematous cases.

Imaging biomarkers require technical, biological, and clinical validation to be translated into robust tools in research or clinical settings. This study contributes to the technical validation of radiomic features from magnetic resonance imaging (MRI) by evaluating the repeatability of features from four MR sequences: pre-contrast T1- and T2-weighted images, pre-contrast quantitative T1 maps (qT1), and contrast-enhanced T1-weighted images. Fifty-one patients with colorectal cancer liver metastases were scanned twice, up to 7 days apart. Repeatability was quantified using the intraclass correlation coefficient (ICC) and repeatability coefficient (RC), and the impact of non-Gaussian feature distributions and image normalisation was evaluated. Most radiomic features had non-Gaussian distributions, but Box&ndash, Cox transformations enabled ICCs and RCs to be calculated appropriately for an average of 97% of features across sequences. ICCs ranged from 0.30 to 0.99, with volume and other shape features tending to be most repeatable, volume ICC &gt, 0.98 for all sequences. 19% of features from non-normalised images exhibited significantly different ICCs in pair-wise sequence comparisons. Normalisation tended to increase ICCs for pre-contrast T1- and T2-weighted images, and decrease ICCs for qT1 maps. RCs tended to vary more between sequences than ICCs, showing that evaluations of feature performance depend on the chosen metric. This work suggests that feature-specific repeatability, from specific combinations of MR sequence and pre-processing steps, should be evaluated to select robust radiomic features as biomarkers in specific studies. In addition, as different repeatability metrics can provide different insights into a specific feature, consideration of the appropriate metric should be taken in a study-specific context.

Introduction: The etiologies of most chronic temporomandibular joint disorders are unknown. However, an association between habitual chewing on a particular side and chronic temporomandibular joint disorders has been reported. The aim of this study was to investigate the differences between sides (affected vs unaffected) of biodynamic factors (including lateral dental guidance determined by dental anatomy) or condylar path angles (determined by temporomandibular joint morphology) and chewing function (physiological alternate chewing vs single habitual chewing side). The study scope was to investigate possible etiological factors to improve the understanding of temporomandibular joint disorders. The null hypothesis was that no difference would be found between sides that are or are not affected by chronic temporomandibular joint disorders in chewing function or in levels of dental or temporomandibular joint remodeling. Methods: This cross-sectional, double-blind study involved 24 adults with substantial, chronic, unilateral symptoms diagnosed as temporomandibular joint disorders. Chewing function, temporomandibular joint remodeling (using axiography) and dental anatomy (lateral guidance angles using kinesiography) were assessed. Results: Habitual chewing on one particular side was observed in 17 of 24 participants; significantly more (n = 15) chewed on the affected side than on the unaffected side (P = 0.002 in a two-tailed Fisher’s exact test; risk estimate = 4.5; 95% CI 1.326–15.277). The condylar path (CP) angle was steeper on the affected side than on the unaffected side (mean (standard deviation) = 50.52° (9.98°) versus 45.50° (7.98°); P = 0.002 in a two-tailed t-test). The lateral guidance (LG) angles were flatter on the affected side in all 24 participants. Conclusion: Our results suggest that habitual chewing on one side may be associated with increasing condylar path, with flattening lateral guidance angles, and also with chronic temporomandibular joint disorder on the habitual chewing side This study was supported by the Carlos III Institute of Health (Ministry of Science and Innovation of the Government of Spain and the European Development Fund, ‘Una manera de hacer Europa’) (grant no. PI11/02507). The design, management, analysis, and reporting of the study are entirely independent of the Carlos III Institute of Health SI

International audience; Agreement between observers (i.e., inter-rater agreement) can be quantified with various criteria but their appropriate selections are critical. When the measure is qualitative (nominal or ordinal), the proportion of agreement or the kappa coefficient should be used to evaluate inter-rater consistency (i.e., inter-rater reliability). The kappa coefficient is more meaningful that the raw percentage of agreement, because the latter does not account for agreements due to chance alone. When the measures are quantitative, the intraclass correlation coefficient (ICC) should be used to assess agreement but this should be done with care because there are different ICCs so that it is important to describe the model and type of ICC being used. The Bland-Altman method can be used to assess consistency and conformity but its use should be restricted to comparison of two raters. (C) 2020 Societe francaise de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Background The design process of a removable partial denture (RPD) consists of rests, major connectors, minor connectors, denture base, and retainer. The abutment tooth contour determines the location of the retention portion of the clasp at the retention areas. The load capacity of the clasp depends on various factors such as type, the position of a clasp, tooth position, clasp length, and pullout location. As a general rule, the amount of retention required to dislodge the RPD from the supporting structure should always be the minimum necessary to resist reasonable dislodging forces. Excessive force from the clasps may cause many problems. Although there are many reports on the retentive force of cast clasps using large devices, it has not been possible to measure it using simple devices until now. Method The purpose of the present study is to develop a small-sized retentive force measurement device that can easily measure the retentive force of a clasp used for an RPD. It is to examine inter-rater and intra-rater reliability. A small-sized retentive force measurement device that can be easily measured in the laboratory has been developed. Using commercially available hard plaster cast, a skilled dental technician has made 10 types of cast clasps used in clinical practice using conventional techniques. Three assessors measured the retentive force of 10 types of cast clasps. To confirm the reliability, the intra-class correlation coefficients ICC (1,1) and ICC (1,3) of the 3 assessors were calculated, and the reliability within the assessor was examined. The inter-class correlation coefficients ICC (3,1) and ICC (3,3) were calculated, and the reliability of the assessors was examined. Result The intra-class correlation coefficients of 3 assessors are as follows: assessor 1 has ICC (1,1) = 0.971, ICC (1,3) = 0.990, assessor 2 has ICC (1,1) = 0.967, ICC (1,3) = 0.989, assessor 3 has ICC (1,1) = 0.962, ICC (1,3) = 0.987. The inter-class correlation coefficients of 3 assessors are as follows: ICC (3,1) = 0.993, ICC (3,3) = 0.998. From the evaluation standard of the intraclass correlation coefficients of reliability value by ICC, it was evaluated as almost perfect and high reproducibility was confirmed. Conclusion The developed small-sized retentive force measurement device has reproducibility within and between the assessors.

Laboratory tests are frequently ordered by general practitioners (GPs), but little is known about time trends and between-GP variation of their use. In this retrospective longitudinal study, we analyzed over six million consultations by Swiss GPs during the decade 2009&ndash, 2018. For 15 commonly used test types, we defined specific laboratory testing rates (sLTR) as the percentage of consultations involving corresponding laboratory testing requests. Patient age- and sex-adjusted time trends of sLTR were modeled with mixed-effect logistic regression accounting for clustering of patients within GPs. We quantified between-GP variation by means of intraclass correlation coefficients (ICC). Nine out of the 15 laboratory test types considered showed significant temporal increases, most eminently vitamin D (ten-year odds ratio (OR) 1.88, 95% confidence interval (CI) 1.71&ndash, 2.06) and glycated hemoglobin (ten-year OR 1.87, 95% CI 1.82&ndash, 1.92). Test types both subject to substantial increase and high between-GP variation of sLTR were vitamin D (ICC 0.075), glycated hemoglobin (ICC 0.101), C-reactive protein (ICC 0.202), and vitamin B12 (ICC 0.166). Increasing testing frequencies and large between-GP variation of specific test type use pointed at inconsistencies of medical practice and potential overuse.

Introduction A new generation of large‐scale studies is using neuroimaging to investigate adolescent brain development across health and disease. However, imaging artifacts such as head motion remain a challenge and may be exacerbated in pediatric clinical samples. In this study, we assessed the scan–rescan reliability of multimodal MRI in a sample of youth enriched for risk of mental illness. Methods We obtained repeated MRI scans, an average of 2.7 ± 1.4 weeks apart, from 50 youth (mean age 14.7 years, SD = 4.4). Half of the sample (52%) had a diagnosis of an anxiety disorder; 22% had attention‐deficit/hyperactivity disorder (ADHD). We quantified reliability with the test–retest intraclass correlation coefficient (ICC). Results Gray matter measurements were highly reliable with mean ICCs as follows: cortical volume (ICC = 0.90), cortical surface area (ICC = 0.89), cortical thickness (ICC = 0.82), and local gyrification index (ICC = 0.85). White matter volume reliability was excellent (ICC = 0.98). Diffusion tensor imaging (DTI) components were also highly reliable. Fractional anisotropy was most consistently measured (ICC = 0.88), followed by radial diffusivity (ICC = 0.84), mean diffusivity (ICC = 0.81), and axial diffusivity (ICC = 0.78). We also observed regional variability in reconstruction, with some brain structures less reliably reconstructed than others. Conclusions Overall, we showed that developmental MRI measures are highly reliable, even in youth at risk for mental illness and those already affected by anxiety and neurodevelopmental disorders. Yet, caution is warranted if patterns of results cluster within regions of lower reliability., Developmental MRI measures are highly reliable, even in youth at risk for mental illness and those already affected by anxiety and neurodevelopmental disorders. Yet, caution is warranted if patterns of results cluster within regions of lower reliability.

Tumor-infiltrating lymphocytes (TILs) represent cancer microenvironment. We previously reported TILs was prognosticators in pancreatic ductal adenocarcinoma (PDAC) patients by immunohistochemically measuring them in surgically-resected tissues. The aim of this study was to assess how best to evaluate TILs in PDAC tissue biopsies. First, we showed expression of CD3, CD4, or CD8 genes in PDAC tissue measured by quantitative RT-PCR (RT-qPCR) was prognostic using 241 surgically-resected specimens. We assessed whether the TILs in biopsied tissues can be effectively evaluated by comparing between immunohistochemistry and RT-qPCR. As a study model, we sampled twenty biopsies from surgically-resected PDAC specimen (n = 17). We investigated the variation levels of TILs in the different biopsies from the same specimen and evaluated using the intraclass correlation coefficient (ICC). The ICC value was 0.58 for CD3, 0.61 for CD4, and 0.46 for CD8, respectively; these ICC values meant correlations of "moderate" to "substantial" levels. To reach "near perfect", 3, 3, and 5 times biopsies were necessary for CD3, CD4, and CD8, respectively. When ICC values of immunolabeled TILs were of "low", ≥6 times biopsies were necessary to reach "moderate" levels. We found that TILs measured by RT-qPCR and repeated sampling increased reliability in TILs detected from biopsied PDAC tissues.

IF 6.448 (2017); International audience; The Pemphigus Disease Area Index (PDAI) and Autoimmune Bullous Skin Disorder Intensity-Score (ABSIS) scores have been proposed to provide an objective measure of pemphigus activity. These scores have been evaluated only on already treated patients mainly with mild to moderate activity. The objective was to assess the interrater reliability of ABSIS and PDAI scores and their correlation with other severity markers in a large international study. Consecutive patients with newly diagnosed pemphigus were enrolled in 31 centers. Severity scores were recorded during a 24-month period by the same two blinded investigators. Serum was collected at each visit for ELISA measurement of anti-desmoglein antibodies. The intraclass correlation coefficient (ICC) and Spearman rank correlation coefficient were calculated. A total of 116 patients with pemphigus vulgaris (n = 84) or pemphigus foliaceus (n = 32) were included. At baseline, the ABSIS and PDAI ICCs were 0.90 (95% confidence interval [CI] = 0.85-0.93), and 0.91(95% CI = 0.87-0.94), respectively. The ICCs for PDAI were higher in moderate and extensive pemphigus (ICC = 0.82, 95% CI = 0.63-0.92 and ICC = 0.80, 95% CI = 0.62-0.90, respectively) than in patients with intermediate (significant) extent (ICC = 0.50, 95% CI = 0.27-0.68). Conversely, the ICCs for ABSIS were lower in patients with moderate extent (ICC = 0.44, 95% CI = 0.004-0.74) than in those with intermediate or extensive forms, (ICC = 0.69, 95% CI = 0.51-0.81 and ICC = 0.75, 95% CI = 0.51-0.88, respectively). During patients' follow-up, the ICCs of both ABSIS and PDAI scores remained higher than 0.70. ABSIS and PDAI skin (r = 0.71 and r = 0.75) but not mucosal (r = 0.32 and r = 0.37) subscores were correlated with the evolution of anti-DSG1 and anti-DSG3 ELISA values, respectively. ABSIS and PDAI scores are robust tools to accurately assess pemphigus activity.

BackgroundRepeatability and reproducibility are essential for clinicians for several purposes. Although discouraged, use of the Coefficient of Variation (CV) for assessing repeatability and reproducibility, rather than the Intraclass Correlation Coefficient (ICC), is still widespread. The aim of the present study was to highlight how using inappropriate indices may lead to misleading results, and this is done by simulation study and using real data on Anterior Active Rhinomanometry (AAR) in both healthy children and ones with rhinitis.MethodsA simulation study was carried out to highlight how using inappropriate indices could be misleading. Then a comparison was made between CV and ICC to assess repeatability and reproducibility of AAR, for which previous studies have given underestimated results. AAR is recommended as the gold standard tool for measuring nasal resistance in clinical practice.ResultsA simulation study showed that the ICCs estimated from data generated assuming a true CV yielded results in agreement with estimated CVs; by contrast, if data were generated assuming a true ICC, CVs yielded conflicting results. For AAR, ICCs showed good repeatability, whereas CVs showed unacceptable repeatability. AUC and 95% CI for AAR showed good performance in predicting current symptoms of rhinitis in the overall study population.ConclusionsThe present study focused on the importance of the choice of appropriate indices of repeatability and reproducibility, demonstrating the repeatability of AAR in both healthy children and ones with rhinitis.Trial registrationClinicalTrials.gov(ID:NCT03286049; Registration Date: September 15, 2017; Actual Study Start Date: January 10, 2018).

Purpose To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode. Methods Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland–Altman method for concordance and intraclass correlation coefficient were used. Results Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7–6.3] for MVF and 0.073 (95% CI, 0.063–0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters ( p =0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5–7.5) for MVF and 0.065 (95% CI, 0.059–0.071) for PI. No influence was found for the middle cerebral artery side, volunteer's sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8–85.6) and 72.9% (95% CI 67.4–77.6) for MFV and PI, respectively. Conclusions There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.

Purpose To investigate autophagy in the outflow pathway and ganglion cell layer in the aging and ocular hypertensive mouse. Methods Both 4-month-old and 18-month-old C57BL/6J and GFP-LC3 mice were subjected to unilateral injection of hypertonic saline into a limbal vein, causing sclerosis of the outflow pathway and subsequent elevation of intraocular pressure (IOP). IOP was measured on a weekly basis using a rebound tonometer. Protein expression levels of LC3B, Lamp1, and p62 were evaluated by western blot and/or immunofluorescence. Retinal ganglion cell (RGC) count was performed in whole retinal flat mounts using an anti-Brn3a antibody. Optic nerves were fixed with 4% paraformaldehyde and resin-embedded for axon counts and electron microscopy. Results In contrast to 18-month-old mice, which developed sustained elevated IOP with a single injection, 4-month-old mice were refractory to high elevations of IOP. Interestingly, both the percentage of animals that developed elevated IOP and the mean ∆IOP were significantly higher in the transgenic mice compared to C57BL/6J. Immunofluorescence and western blot analysis showed dysregulated autophagy in the iridocorneal and retina tissues from 18-month-old mice compared to 4-month-old ones. Moreover, the LC3-II/LC3-I ratio correlated with IOP. As expected, injected hypertensive eyes displayed axonal degeneration and RGC death. RGC and axon loss were significantly exacerbated with aging, especially when combined with GFP-LC3 expression. Autophagic structures were observed in the degenerating axons. Conclusions Our results indicate dysregulation of autophagy in the trabecular meshwork and retinal tissues with aging and suggest that such dysregulation of autophagy contributes to neurodegeneration in glaucoma.

This study was designed to identify the neural substrates activated during a phoria adaptation task using functional magnetic resonance imaging (MRI) in young adults with normal binocular vision and to test the repeatability of the fMRI measurements for this protocol. The phoria adaptation task consisted of a block protocol of 90 seconds of near visual crossed fixation followed by 90 seconds of far visual uncrossed fixation, repeated three times; the data were collected during two different experimental sessions. Results showed that the oculomotor vermis, cuneus, and primary visual cortex had the greatest functional activity within the regions of interest studied when stimulated by the phoria adaptation task. The oculomotor vermis functional activity had an intraclass correlation coefficient (ICC) of 0.3, whereas the bilateral cuneus and primary visual cortex had good ICC results of greater than 0.6. These results suggest that the sustained visual fixation task described within this study reliably activates the neural substrates of phoria adaptation. This protocol establishes a methodology that can be used in future longitudinal studies investigating therapeutic interventions that may modify phoria adaptation.

Objectives Minimal clinically important differences (MCIDs) are used as fixed numbers in the interpretation of clinical trials. Little is known about its dynamics. This study aims to explore the impact of baseline score, study setting, and patient characteristics on health status MCIDs in chronic obstructive pulmonary disease (COPD). Study Design and Setting Baseline and follow-up data on the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and St. George's Respiratory Questionnaire (SGRQ) were retrospectively analyzed from pulmonary rehabilitation (PR) and routine clinical practice (RCP). Anchor- and distribution-based MCID estimates were calculated and tested between settings, gender, age, Global initiative for Obstructive Lung Disease (GOLD) classification, comorbidities, and baseline health status. Results In total, 658 patients were included with 2,299 change score measurements. MCID estimates for improvement and deterioration ranged for all subgroups 0.50–6.30 (CAT), 0.10–0.84 (CCQ), and 0.33–12.86 (SGRQ). Larger MCID estimates for improvement and smaller ones for deterioration were noted in patients with worse baseline health status, females, elderly, GOLD I/II patients, and patients with less comorbidities. Estimates from PR were larger. Conclusion Baseline health status and setting affected MCID estimates of COPD health status questionnaires. Patterns were observed for gender, age, spirometry classification, and comorbidity levels. These outcomes would advocate the need for tailored MCIDs.

Background Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors’ HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients. Methods A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types. Results We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%. Conclusions The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting. Electronic supplementary material The online version of this article (10.1186/s12913-018-3634-4) contains supplementary material, which is available to authorized users.

ObjectiveTo estimate the magnitude of the correlation between neonatal outcomes of twins and demonstrate how this information can be used in the design of randomised controlled trials (RCTs) in women with twin pregnancies.DesignSecondary analysis of data from 12 RCTs.SettingObstetric care in multiple countries, 2004-2012.Population or sample4504 twin pairs born to women who participated in RCTs to assess treatments given during pregnancy.MethodsIntraclass correlation coefficients (ICCs) were estimated using log-binomial and linear models.Main outcome measuresPerinatal death, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, sepsis, neonatal intensive care unit admission, birthweight, low birthweight and two composite measures of adverse neonatal outcome.ResultsICCs for the composite measures of adverse neonatal outcome were all above 0.5, indicating moderate to strong correlation between adverse outcomes of twins. For individual neonatal outcomes, median ICCs across trials ranged from 0.13 to 0.79 depending on the outcome. An example illustrates how ICCs can be used in sample size calculations for RCTs in women with twin pregnancies.ConclusionsThe correlation between neonatal outcomes of twins varies considerably between outcomes and may be lower than expected. Our ICC estimates can be used for designing and analysing RCTs that recruit women with twin pregnancies and for performing meta-analyses that include such RCTs. Researchers are encouraged to report ICCs for neonatal outcomes in twins in their own RCTs.Tweetable abstractCorrelation between neonatal outcomes of twins depends on the outcome and may be lower than expected.Tweetable abstract Correlation between neonatal outcomes of twins depends on the outcome and may be lower than expected.

Background Health economic evaluations rely on the accurate measurement of health service resource use in order to calculate costs. These are usually measured with patient completed questionnaires using instruments such as the Client Service Receipt Inventory (CSRI). These rely on participants’ recall and can be burdensome to complete. Health service activity data are routinely captured by electronic databases. The aim was to test methods for obtaining these data and compare with those data collected using the CSRI, within a feasibility study of an enhanced rehabilitation intervention following hip fracture (Fracture in the Elderly Multidisciplinary Rehabilitation: FEMuR). Methods Primary care activity including prescribing data was obtained from the Secure Anonymised Information Linkage (SAIL) Databank and secondary care activity (Emergency Department attendances, out-patient visits and in-patient days) directly from Betsi Cadwaladr University Health Board (BCUHB), North Wales, UK. These data were compared with patient responses from the CSRI using descriptive statistics and the intraclass correlation coefficient (ICC). Results It was possible to compare health service resource use data for 49 out of 61 participants in the FEMuR study. For emergency department (ED) attendances, records matched in 23 (47%) cases, 21 (43%) over-reported on electronic records compared with CSRI and five participants (10%) under-reported, with an overall ICC of 0.42. For out-patient episodes, records matched in only six cases, 28 participants over-reported on electronic records compared with CSRI and 15 (12%) under-reported, with an overall ICC of only 0.27. For in-patient days, records matched exactly in only five cases (10%), but if an error margin of 7 days was allowed, then agreement rose to 39 (66%) cases, and the overall ICC for all data was 0.88. It was only possible to compare prescribing data for 12 participants. For prescribing data, the SAIL data reported 117 out of 118 items (99%) and the CSRI only 89 (79%) items. Conclusions The use of routinely collected data has the potential to improve the efficiency of trials and other studies. Although the methodology to make the data available has been demonstrated, the data obtained was incomplete and the validity of using this method remains to be demonstrated. Trial registration Trial registration: ISRCTN22464643 Registered 21 July 2014. Electronic supplementary material The online version of this article (10.1186/s40814-018-0269-5) contains supplementary material, which is available to authorized users.

Correlation and linear regression are the most commonly used techniques for quantifying the association between two numeric variables. Correlation quantifies the strength of the linear relationship between paired variables, expressing this as a correlation coefficient. If both variables x and y are normally distributed, we calculate Pearson′s correlation coefficient (r). If normality assumption is not met for one or both variables in a correlation analysis, a rank correlation coefficient, such as Spearman′s rho (ρ) may be calculated. A hypothesis test of correlation tests whether the linear relationship between the two variables holds in the underlying population, in which case it returns a P < 0.05. A 95% confidence interval of the correlation coefficient can also be calculated for an idea of the correlation in the population. The value r2 denotes the proportion of the variability of the dependent variable y that can be attributed to its linear relation with the independent variable x and is called the coefficient of determination. Linear regression is a technique that attempts to link two correlated variables x and y in the form of a mathematical equation (y = a + bx), such that given the value of one variable the other may be predicted. In general, the method of least squares is applied to obtain the equation of the regression line. Correlation and linear regression analysis are based on certain assumptions pertaining to the data sets. If these assumptions are not met, misleading conclusions may be drawn. The first assumption is that of linear relationship between the two variables. A scatter plot is essential before embarking on any correlation-regression analysis to show that this is indeed the case. Outliers or clustering within data sets can distort the correlation coefficient value. Finally, it is vital to remember that though strong correlation can be a pointer toward causation, the two are not synonymous.

Background: The aim of this study was to evaluate reliability of four different assays for measuring infliximab trough levels and antibodies to infliximab (ATI). Methods: In this non-interventional, cross-sectional study including IBD patients, infliximab levels and ATI were measured using four different assays: Lisa-Tracker, Promonitor, Q-Inflixi and Sanquin. Reliability and agreement for infliximab levels was assessed using the intraclass correlation coefficient (ICC) and Bland–Altman plots. Qualitative agreement for infliximab (based on a pre-established target window of trough levels between 3 µg/ml and 7 µg/ml) and for ATI were estimated by Cohen’s kappa. Results: Serum samples of 84 IBD patients were evaluated for infliximab using the four assays. Reliability was ‘substantial’ between Lisa-Tracker versus Promonitor and ‘almost perfect’ between the remaining assay pairs, with ICCs [95% confidence interval (CI)] ranging from 0.93 (0.70–0.97) for Lisa-Tracker versus Promonitor to 0.97 (0.95–0.98) for Q-Inflixi versus Sanquin. Bland–Altman plots showed significant bias between assays except Promonitor versus Q-Inflixi, which had excellent agreement. The greatest differences in mean infliximab were found between Promonitor versus Lisa-Tracker (–0.91 µg/ml) and Lisa-Tracker versus Q-Inflixi (0.69 µg/ml). Qualitative agreement for infliximab was ‘almost perfect’ for Promonitor versus Q-Inflixi (kappa 0.84) and Q-Inflixi versus Sanquin (kappa 0.81), and ‘substantial’ for the remaining pairs. More than 10% of patients who had infliximab levels within the target interval by Lisa-Tracker had suboptimal concentrations (7 µg/ml) by Lisa-Tracker. In the remaining paired comparisons, fewer than 5% of patients were placed in different subgroups. Qualitative agreement for ATI fluctuated between ‘moderate’ and ‘almost perfect’. Conclusions: All four assays seem suitable for therapeutic drug monitoring of infliximab. Promonitor and Q-Inflixi had the best agreement, making those assays fully interchangeable. Systematic biases between Lisa-Tracker with Promonitor and Q-Inflixi suggest that these assays should not be interchanged during the follow up of an individual patient.

Background: Brain tumor is one of the most common tumors. A successful treatment might be achieved with an early identification. Pathological investigation as the gold standard method for tumor identification has some limitations. Noninvasive assessment of tumor specifications may be possible using perfusion-weighted magnetic resonance imaging (MRI). Cerebral blood volume (CBV) and cerebral blood flow (CBF) could be calculated based on dynamic contrast-enhanced MRI (DCE-MRI) in addition to dynamic susceptibility contrast MRI (DSC-MRI) modality. Each category of the cerebral hemodynamic and permeability indices revealed the specific tumor characteristics and their collection could help for better identification of the tumor. Some mathematical methods were developed to determine both cerebral hemodynamic and permeability indices based on a single-dose DCE perfusion MRI. There are only a few studies available on the comparison of DSC- and DCE-derived cerebral hemodynamic indices such as CBF and CBV. Aim: The objective of the study was to validate first-pass perfusion parameters derived from T1-based DCE method in comparison to the routine T2*-based DSC protocol. Materials and Methods: Twenty-nine patients with brain tumor underwent DCE- and DSC-MRIs to evaluate the agreement between DSC- and DCE-derived cerebral hemodynamic parameters. Agreement between DSC- and DCE-derived cerebral hemodynamic indices was determined using the statistical method described by Bland and Altman. The reliability between DSC- and DCE-derived cerebral hemodynamic indices was measured using the intraclass correlation analysis. Results: The achieved magnitudes for DCE-derived CBV (gray matter [GM]: 5.01 ± 1.40 mL/100 g vs. white matter [WM]: 1.84 ± 0.74 mL/100 g) and DCE-derived CBF (GM: 60.53 ± 12.70 mL/100 g/min vs. WM: 32.00 ± 6.00 mL/100 g/min) were in good agreement with other studies. The intraclass correlation coefficients showed that the cerebral hemodynamic indices could accurately be estimated based on the DCE-MRI using a single-compartment model (>0.87), and DCE-derived cerebral hemodynamic indices are significantly similar to the magnitudes achieved based on the DSC-MRI (P < 0.001). Furthermore, an acceptable agreement was observed between DSC- and DCE-derived cerebral hemodynamic indices. Conclusion: Based on the measurement of the cerebral hemodynamic and blood–brain barrier permeability using DCE-MRI, a more comprehensive collection of the physiological parameters cloud be achieved for tumor evaluations.

Background The present study takes place within a geriatric program, aiming at improving the diagnosis and management of geriatric syndromes in primary care. Within this program it was of prime importance to be able to rely on a robust and reproducible geriatric consultation to use as a gold standard for evaluating a primary care brief assessment tool. The specific objective of the present study was thus assessing the agreement and reliability of a comprehensive geriatric consultation. Method The study was conducted at the outpatient clinic of the Service of Geriatric Medicine, University of Lausanne, Switzerland. All community-dwelling older persons aged 70 years and above were eligible. Patients were excluded if they hadn’t a primary care physician, they were unable to speak French, or they were already assessed by a geriatrician within the last 12 months. A set of 9 geriatricians evaluated 20 patients. Each patient was assessed twice within a 2-month delay. Geriatric consultations were based on a structured evaluation process, leading to rating the following geriatric conditions: functional, cognitive, visual, and hearing impairment, mood disorders, risk of fall, osteoporosis, malnutrition, and urinary incontinence. Reliability and agreement estimates on each of these items were obtained using a three-way Intraclass Correlation and a three-way Observed Disagreement index. The latter allowed a decomposition of overall disagreement into disagreements due to each source of error variability (visit, rater and random). Results Agreement ranged between 0.62 and 0.85. For most domains, geriatrician-related error variability explained an important proportion of disagreement. Reliability ranged between 0 and 0.8. It was poor/moderate for visual impairment, malnutrition and risk of fall, and good/excellent for functional/cognitive/hearing impairment, osteoporosis, incontinence and mood disorders. Conclusions Six out of nine items of the geriatric consultation described in this study (functional/cognitive/hearing impairment, osteoporosis, incontinence and mood disorders) present a good to excellent reliability and can safely be used as a reference (gold standard) to evaluate the diagnostic performance of a primary care brief assessment tool. More objective/significant measures are needed to improve reliability of malnutrition, visual impairment, and risk of fall assessment before they can serve as a safe gold standard of a primary care tool. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0546-9) contains supplementary material, which is available to authorized users.

Purpose The reliability of surface electromyography (sEMG) is typically modest even with rigorous methods, and therefore further improvements in sEMG reliability are desirable. This study compared the between-session reliability (both within participant absolute reliability and between-participant relative reliability) of sEMG amplitude from single vs. average of two distinct recording sites, for individual muscle (IM) and whole quadriceps (WQ) measures during voluntary and evoked contractions. Methods Healthy males (n = 20) performed unilateral isometric knee extension contractions: voluntary maximum and submaximum (60%), as well as evoked twitch contractions on two separate days. sEMG was recorded from two distinct sites on each superficial quadriceps muscle. Results Averaging two recording sites vs. using single site measures improved reliability for IM and WQ measurements during voluntary (16–26% reduction in within-participant coefficient of variation, CVW) and evoked contractions (40–56% reduction in CVW). Conclusions For sEMG measurements from large muscles, averaging the recording of two distinct sites is recommended as it improves within-participant reliability. This improved sensitivity has application to clinical and research measurement of sEMG amplitude.

Objective: Although clinical guidelines on arteriovenous fistula (AVF) creation advocate minimum luminal arterial and venous diameters, assessed by duplex ultrasonography (DUS), the clinical value of routine DUS examination is under debate. DUS might be an insufficiently repeatable and/or reproducible imaging modality because of its operator dependency. The present study aimed to assess intra-and inter-observer agreement of DUS examination in support of AVF surgery planning.Methods: Ten end stage renal disease patients were included, to assess intra-and inter-observer agreement of pre-operative DUS measurements. All measurements were performed by two trained and experienced vascular technicians, blinded to measurement readings. From the routine DUS protocol, representative measurements (venous diameters, and arterial diameters and volume flow in the upper arm and forearm) were selected. For intra-observer agreement the measurements were performed in triplicate, with the probe released from the skin between each. Intraclass correlation coefficients were calculated for intra-and inter-observer agreement, and Bland-Altman plots used to graphically display mean measurement differences and limits of agreement.Results: Ten patients (6 male, 59.4 +/- 19.7 years) consented to participate, and all predefined measurements were obtained. Intraclass correlation coefficients for intra-observer agreement of diameter measurements were at least 0.90 (95% CI 0.74-0.97; radial artery). Inter-observer agreement was at least 0.83 (0.46-0.96; lateral diameter upper arm cephalic vein). The Bland-Altman plots showed acceptable mean measurement differences and limits of agreement.Conclusion: In experienced hands, excellent intra-and inter-observer agreement can be reached for the discrete pre-operative DUS measurements advocated in clinical guidelines. DUS is therefore a reliable imaging modality to support AVF surgery planning. The content of DUS protocols, however, needs further standardisation. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Category: Sports, Ankle Introduction/Purpose: No previous study has performed a quantitative analysis of the site of acute Achilles tendon rupture. The purpose of this study was to investigate the site of acute Achilles tendon rupture via magnetic resonance imaging (MRI). Methods: The medical records and MRIs of 201 patients with acute Achilles tendon rupture were retrospectively reviewed. The rupture site was measured as the distance from the calcaneal insertion of the Achilles tendon to the proximal end of the distal stump. The relationship between the site of the rupture and patient demographics was analyzed, and the intra- and interobserver reliability scores of the measurements were assessed using intraclass correlation coefficients. Results: The rupture site had a mean size of 6.1 cm with a standard deviation of 1.6. The median was 6.3 cm, and the range of the 10th–90th percentile was 5.0–8.1 cm. There was no significant difference in rupture site according to patient demographics. All of the intra- and interobserver reliability scores of the measurements of the rupture site were excellent. Conclusion: Most acute Achilles tendon ruptures that were visible on MRI occurred 5–8 cm above the calcaneal insertion, which is greater than the previously reported 2–6 cm location.

Background: The 30 s chair stand test is often used to evaluate physical fitness in chronic pain populations. In patients with fibromyalgia, physical fitness is closely related to pain, quality of life, and fear of falling. However, the reliability of this test has only been evaluated concerning the number of repetitions. Objective: To evaluate the test&ndash, retest reliability of the 30 s chair stand test in women with fibromyalgia (n = 30), using data from the contact and non-contact time registered with an automatic chronometer (chronojump). Methods: Participants carried out the 30 s chair stand test twice with five minutes as a rest period, while an automatic chronometer recorded the time elapsed in contact with the chair (impulse phase) and not in contact (non-contact phase). Number and fear of falls in the last year and in the last six weeks were also recorded. Results: The reliability of duration of both phases was good. A relationship between these results and the number and fear of falling was also found. Conclusion: The analysis of movement phases in the 30 s chair stand test showed a good reliability in females with fibromyalgia, providing further useful information about the onset of muscle fatigue during the test.

OBJECTIVE The Japanese translation of the Berg balance scale (BBS) has previously been published; however, its reliability has not yet been validated. This study aimed to evaluate its reliability. METHODS Patients took the BBS test three times; two neurologists monitored the results. The intraclass correlation coefficients (ICCs) and Cronbach's alpha (α) coefficients were calculated, and the inter-rater and intra-rater reliability were determined. Patients Thirty-three patients with balance disturbance were recruited. RESULTS The study participants included 15 men and 18 women with a mean age of 62.8 years (SD, 14.8). For the total BBS score, the inter-rater ICC and Cronbach's α coefficient were 0.9337 and 0.9493, respectively, while the intra-rater ICC and Cronbach's α coefficient were 0.9772 and 0.9416, respectively. Most items had a relatively high ICC. The Cronbach's α coefficients were more than 0.9 for all items. CONCLUSION The Japanese version of the BBS was found to have a high inter-rater and intra-rater reliability and internal consistency. Language: en

Prenatal exposure to bisphenol A (BPA) may be associated with adverse health effects in the developing fetus; however, little is known about predictors of BPA exposure during pregnancy. We examined BPA exposure in 491 pregnant women from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) cohort and explored the role of living in the United States on significant dietary predictors of BPA exposure. Women provided urine samples up to two times during pregnancy (n = 866 total samples). We computed the intraclass correlation coefficient (ICC) to evaluate variability in concentrations between collections and used generalized estimating equation (GEE) models to assess predictors of exposure. Geometric mean (GSD) BPA concentrations were 0.9 (2.8) μg/L and 1.0 (2.6) μg/L at the first and second prenatal visits, respectively. We observed greater within- than between-woman variability in urinary BPA concentrations (ICC = 0.22). GEE models suggest that women who lived in the United States their entire life had 38% (CI: −0.1, 89.3) higher urinary BPA concentrations compared with other immigrant women. Additionally, women who consumed ≥3 sodas per day or hamburgers three times a week or more had 58% (CI: 18.0, 112.1) and 20% (CI: −0.2, 45.2) higher urinary BPA concentrations, respectively, compared with women who consumed no sodas or hamburgers. A higher percentage of women who lived their entire life in the United States reported increased consumption of sodas and hamburgers compared with other immigrant women. Independent of other factors, BPA urinary concentrations were slightly higher when the sample was collected later in the day. As in previous studies, high within-woman variability in urinary BPA concentrations confirms that several samples are needed to properly characterize exposure during pregnancy. Results also suggest that some factors could be modified to minimize exposures during pregnancy in our study participants (e.g., reducing soda and hamburger intake) and that factors associated with acculturation might increase BPA concentrations. Keywords: Bisphenol A, Prenatal, Pregnancy, Mexican–American

OBJECTIVE: This study assessed the agreement between self-reported and measured weight and stature in adolescents. METHODS: Ninety-seven students from public and private high schools of Cuiabá, in the state of Mato Grosso, Brazil (14 to 19 years old), were examined to assess the validity of self-reported weight and stature. The adolescents reported their weight and stature, which were subsequently measured by standard procedures. The body mass index was calculated from both self-reported and measured data. Weight status was classified according to body mass index Z-score and World Health Organization criteria. The differences between the self-reported and measured means were tested by the Student's paired t-test. Weighted Kappa's coefficient of agreement was used to assess the variations in weight status categorization using informed and measured data. Agreement between measurements was assessed by the Bland-Altman method and intraclass correlation coefficient. RESULTS: The means of self-reported and measured weights (p=0.30), statures (p=0.76) and body mass index (p=0.47) were not significantly different. There was high agreement between self-reported and measured measurements according to intraclass correlation coefficient (weight: r=0.99; stature: r=0.96; body mass index: r=0.97) and the mean agreements estimated by the Bland-Altman method were 99% for weight and 100% for stature. CONCLUSION: Given the excellent agreement with measured data, self-reported weight and stature are considered valid to be used in epidemiological studies on adolescents of Cuiabá, Mato Grosso, Brazil. OBJETIVO: Avaliar a concordância entre as medidas de peso e estatura autorreferidas e aferidas em adolescentes. MÉTODOS: Noventa e sete estudantes de 14 a 19 anos de idade do ensino médio público e privado de Cuiabá, (Mato Grosso) foram examinados a fim de se avaliar a validade de medidas de peso e estatura autorreferidas. Os adolescentes referiram o peso e a estatura e, na sequência, as respectivas medidas foram aferidas com base em procedimentos padronizados. O índice de massa corporal foi determinado a partir das medidas estimadas e aferidas. O status de peso foi classificado com base no escore-Z do índice de massa corporal segundo proposta da Organização Mundial da Saúde. Utilizou-se o teste t de Student pareado para avaliar as diferenças entre as médias das medidas autorreferidas e aferidas. O coeficiente de concordância Kappa ponderado foi utilizado para se avaliarem as variações na categorização do status de peso estimado a partir de medidas informadas e aferidas. A concordância entre as medidas foi avaliada pelo método de Bland-Altman e pelo coeficiente de correlação intraclasse. RESULTADOS: Não se observaram diferenças entre as médias das medidas autorreferidas e aferidas de peso (p=0,30),: estatura (p=0,76) e índice de massa corporal (p=0,47). Houve elevada concordância entre as medidas autorreferidas e aferidas de acordo com o coeficiente de correlação intraclasse (peso: r=0,99; estatura: r=0,96; índice de massa corporal; r=0,97) e segundo o método de Bland-Altman (concordância média: peso=99%; estatura=100%). CONCLUSÃO: Dada a excelente concordância com as medidas aferidas, o peso e a estatura autorreferidos são considerados válidos para serem utilizados em estudos epidemiológicos com adolescentes de Cuiabá.

Background Radiographic examination is the gold standard to evaluate spine curves, but ionising radiations limit routine use. Non-invasive methods, such as skin-surface goniometer (IncliMed®) should be used instead. Objective To evaluate intra- and interrater reliability to assess sagittal curves and mobility of the spine with IncliMed®. Methods a reliability study on agonistic football players. Thoracic kyphosis, lumbar lordosis and mobility of the spine were assessed by IncliMed®. Measurements were repeated twice by each examiner during the same session with between-rater blinding. Intrarater and interrater reliability were measured by Intraclass Correlation Coefficient (ICC), 95% Confidence Interval (CI 95%) and Standard Error of Measurement (SEM). Results Thirty-four healthy female football players (19.17 ± 4.52 years) were enrolled. Statistical results showed high intrarater (0.805-0.923) and interrater (0.701-0.886) reliability (ICC > 0.8). The obtained intra- and interrater SEM were low, with overall absolute intrarater values between 1.39° and 2.76° and overall interrater values between 1.71° and 4.25°. Conclusions IncliMed® provides high intra- and interrater reliability in healthy subjects, with limited Standard Error of Measurement. These results encourage its use in clinical practice and scientific research.

Background: Intra-class correlation coeffi cients (ICCs) provide a statistical means of testing the reliability. However, their interpretation is not well documented in the orthopedic fi eld. The purpose of this study was to investigate the use of ICCs in the orthopedic literature and to demonstrate pitfalls regarding their use. Methods: First, orthopedic articles that used ICCs were retrieved from the Pubmed database, and journal demography, ICC models and concurrent statistics used were evaluated. Second, reliability test was performed on three common physical examinations in cerebral palsy, namely, the Thomas test, the Staheli test, and popliteal angle measurement. Thirty patients were assessed by three orthopedic surgeons to explore the statistical methods testing reliability. Third, the factors affecting the ICC values were examined by simulating the data sets based on the physical examination data where the ranges, slopes, and interobserver variability were modifi ed. Results: Of the 92 orthopedic articles identifi ed, 58 articles (63%) did not clarify the ICC model used, and only 5 articles (5%) described all models, types, and measures. In reliability testing, although the popliteal angle showed a larger mean absolute difference than the Thomas test and the Staheli test, the ICC of popliteal angle was higher, which was believed to be contrary to the context of measurement. In addition, the ICC values were affected by the model, type, and measures used. In simulated data sets, the ICC showed higher values when the range of data sets were larger, the slopes of the data sets were parallel, and the interobserver variability was smaller. Conclusions: Care should be taken when interpreting the absolute ICC values, i.e., a higher ICC does not necessarily mean less variability because the ICC values can also be affected by various factors. The authors recommend that researchers clarify ICC models used and ICC values are interpreted in the context of measurement.

Objective The Scales for Outcomes in Parkinson's Disease-Autonomic (SCOPA-AUT) questionnaire was used to assess autonomic dysfunction in patients with neurological disorders. The aim of this study was to evaluate the reliability of the Japanese version of the SCOPA-AUT. Methods We translated the SCOPA-AUT from English to Japanese. Thirty-one patients with diseases involving autonomic symptoms completed the form twice. The reliability was assessed by Cronbach's coefficient alphas and intraclass correlation coefficients (ICCs). Results The average (standard deviation, SD) total scores of the first and second assessments of the SCOPA-AUT were 15.7 (SD, 7.1) and 13.6 (SD, 6.5), respectively. The Cronbach's coefficient alphas were globally high, but the ICCs were moderately high. The valid response rates for the questions about sexual dysfunction were 36.7% in men and 26.6% in women. Conclusions The Japanese version of the SCOPA-AUT had high internal consistency. However, the questions about sexual dysfunction showed less valid response rates.

Background: The Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow outcome score is a functional assessment tool for the upper extremity of the overhead athlete, which is currently validated for administration in person. Purpose/Hypothesis: The purpose of this study was to validate the KJOC score for administration over the phone. The hypothesis was that no difference will exist in KJOC scores for the same patient between administration in person versus over the phone. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Fifty patients were randomized to fill out the KJOC questionnaire either over the phone first (25 patients) or in person first (25 patients) based on an a priori power analysis. One week after the patients completed the initial KJOC on the phone or in person, they then filled out the score via the opposite method. Results were compared per question and for overall score. Results: There was a mean ± SD of 8 ± 5 days between when patients completed the first and second questionnaires. There were no significant differences in the overall KJOC score between the phone and paper groups ( P = .139). The intraclass correlation coefficient comparing paper and phone scores was 0.802 (95% CI, 0.767-0.883; P < .001), with a Cronbach alpha of 0.89. On comparison of individual questions, there were significant differences for questions 1, 3, and 8 ( P = .013, .023, and .042, respectively). Conclusion: The KJOC questionnaire can be administered over the phone with no significant difference in overall score as compared with that from in-person administration.

Background Non-technical skills (NTS) such as leadership and team work are important in providing good quality of care. One system to assess physicians’ NTS is the Anesthesiologists’ Non-Technical Skills (ANTS) system. The present study evaluates the ANTS system on the interrater reliability and usability for research purposes. Methods Ten anesthesiologists and 20 anesthesiology residents performed two resuscitation scenarios (with and without the presence of distractors) in a simulation room with a full-scale patient simulator. The scenarios were videotaped. Two independent raters rated the NTS of the anesthesiologists using the ANTS system. The intraclass correlation coefficients (ICC) were calculated to determine the interrater reliability of both the total NTS score and the measured differences between the two scenarios. The raters filled out a questionnaire to obtain insights in the usability of the ANTS system for research purposes. Results The ICC for the total score of the NTS was substantial (0.683), and the ICC of the elements varied between 0.371 for assessing capabilities and 0.670 for providing and maintaining standards. The intraclass correlation coefficient of measuring differences was fair (0.502). The raters judged the usability as good. Conclusions The ANTS system was reliable for the total score and usable to measure physicians’ NTS in a research setting. However, there was variation between the reliability of the elements. We recommend that if the ANTS is used for research, a pilot study should determine elements not applicable or observable in the scenario of interest; these elements should be excluded from the study. Electronic supplementary material The online version of this article (doi:10.1186/s41077-016-0013-2) contains supplementary material, which is available to authorized users.

To quantify reliability and validity of plain radiographs for assessing the degree of small finger metacarpal neck fracture angulation, we created typical two-fragments fractures in 30 adult cadaveric specimens. Reliability and validity of different radiographic measurement methods were determined by the intraclass correlation coefficient (ICC) and the Bland and Altman graphical approach. Intraobserver and interobserver reliability was high with any radiographic measurement method. Mean ICCs values (95% confidence intervals) varied from 0.76 (0.56-0.88) to 1.00 (0.99-1.00). The graphical approach confirmed good agreement. Validity was substantial when the fracture angle was measured between the line along the longitudinal axis of the metacarpal shaft and the line from the center of the metacarpal head to the fracture site on lateral radiographs. Mean ICCs values varied from 0.70 (0.36-0.86) to 0.79 (0.5-0.90). The graphical analysis also indicated good agreement. In contrast, considerable lack of validity was observed when the angle was measured on oblique radiographs. Although the mean ICCs values varied from 0.68 (0.12-0.88) to 0.74 (0.05-0.90), suggesting substantial correlation, the graphical analysis provided evidence for poor validity. There was systematic bias with oblique radiographs consistently producing higher readings (up to 35 degrees ). In summary, reliability and validity are good only when the degree of small finger metacarpal neck fracture angulation is measured after drawing lines on lateral radiographs. Oblique radiograph measurements consistently produce higher readings.

The potential purpose of near-infrared spectroscopy (NIRS) as a clinical application in patients with chronic heart failure (CHF) is the identification of limitations in O2 delivery or utilization during exercise. The objective of this study was to evaluate absolute and relative test–retest reliability of skeletal muscle oxygenation measurements in patients with CHF. Thirty patients with systolic heart failure (left ventricular ejection fraction 31 ± 8%) performed 6-min constant-load cycling tests at 80% of the anaerobic threshold (AT) with tissue saturation index (TSI) measurement at the vastus lateralis. Tests were repeated after 10 ± 5 days to evaluate reliability. Absolute reliability was assessed with limits of agreement (LoA, expressed as bias ± random error) and coefficients of variation (CV) for absolute values (LoA range: 0·4 ± 6·2% to 0·6 ± 7·9%; CV range: 4·7–7·1%), amplitudes (LoA range −0·5 ± 5·8% to −0·7 ± 6·8%; CV range: 26·2–42·1%), onset and recovery kinetics (mean response times; LoA 0·4 ± 9·5 s, CV 23·5% and LoA −5·8 ± 50·8 s, CV 67·4% respectively) and overshoot characteristics (CV range 45·7–208·6%). Relative reliability was assessed with intraclass correlation coefficients for absolute values (range 0·74–0·90), amplitudes (range 0·85–0·92), onset and recovery kinetics (0·53 and 0·51, respectively) and overshoot characteristics (range 0·17–0·74). In conclusion, absolute reliability of absolute values and onset kinetics seems acceptable for serial within-subject comparison, and as such, for evaluation of treatment effects. Absolute reliability of amplitudes and recovery kinetics is considered unsatisfactory. Relative reliability of absolute values and amplitudes is sufficient for purposes of physiological distinction between patients with CHF. Despite lower relative reliability, kinetics may still be useful for clinical application.

Background: Ultrasound is frequently used to measure activity in the lumbar multifidus muscle (LMM). However previous reliability studies on diagnostic ultrasound and LMM have included a limited number of subjects and few have used Bland-Altman's Limits of Agreement (LOA). Further one does not know if activity affects the subjects' ability to contract the LMM. Methods: From January 2012 to December 2012 an inter- and intra-examiner reliability study was carried out in a clinical setting. It consisted of a total of four experiments with 30 subjects in each study. Two experienced examiners performed all measurements. Ultrasound measurements were made of: 1. the LMM in the resting state, 2. during a contracted state, 3. on subsequent days, and, before and after walking. Reliability and agreement was tested for 1. resting LMM, 2. contracted LMM, and 3. thickness change in the LMM. Mean values of three measurements were used for statistical analysis for each spinal level. The intra-class correlation coefficient (ICC) 3.1 and 3.2 was used to test for reliability, and Bland-Altman's LOA method to test for agreement. Results: All of the studies indicate high levels of reliability, but as the LMM thickness increased (increasing contraction) the agreement between examiners was poorer than for low levels of contraction. Conclusions: The use of diagnostic ultrasound to measure the LMM seems to be reliable in subjects who have little or no change in thickness of the LMM with contraction.

Background There is a shortage of agreement studies relevant for measuring changes over time in lumbar intervertebral disc structures. The objectives of this study were: 1) to develop a method for measurement of intervertebral disc height, anterior and posterior disc material and dural sac diameter using MRI, 2) to evaluate intra- and inter-rater agreement and reliability for the measurements included, and 3) to identify factors compromising agreement. Methods Measurements were performed on MRIs from 16 people with and 16 without lumbar disc herniation, purposefully chosen to represent all possible disc contours among participants in a general population study cohort. Using the new method, MRIs were measured twice by one rater and once by a second rater. Agreement on the sagittal start- and end-slice was evaluated using weighted Kappa. Length and volume measurements were conducted on available slices between intervertebral foramens, and cross-sectional areas (CSA) were calculated from length measurements and slice thickness. Results were reported as Bland and Altman’s limits of agreement (LOA) and intraclass correlation coefficients (ICC). Results Weighted Kappa (K w (95% CI)) for start- and end-slice were: intra-: 0.82(0.60;0.97) & 0.71(0.43;0.93); inter-rater: 0.56(0.29;0.78) & 0.60(0.35;0.81). For length measurements, LOA ranged from [−1.0;1.0] mm to [−2.0;2.3] mm for intra-; and from [−1.1; 1.4] mm to [−2.6;2.0] mm for inter-rater. For volume measurements, LOA ranged from [−293;199] mm3 to [−582;382] mm3 for intra-, and from [−17;801] mm3 to [−450;713] mm3 for inter-rater. For CSAs, LOA ranged between [−21.3; 18.8] mm2 and [−31.2; 43.7] mm2 for intra-, and between [−10.8; 16.4] mm2 and [−64.6; 27.1] mm2 for inter-rater. In general, LOA as a proportion of mean values gradually decreased with increasing size of the measured structures. Agreement was compromised by difficulties in identifying the vertebral corners, the anterior and posterior boundaries of the intervertebral disc and the dural sac posterior boundary. With two exceptions, ICCs were above 0.81. Conclusions Length measurements and calculated CSAs of disc morphology and dural sac diameter from MRIs showed acceptable intra- and inter-rater agreement and reliability. However, caution should be taken when measuring very small structures and defining anatomical landmarks.

Background While the assessment of analytical precision within medical laboratories has received much attention in scientific enquiry, the degree of as well as the sources causing variation between them remains incompletely understood. In this study, we quantified the variance components when performing coagulation tests with identical analytical platforms in different laboratories and computed intraclass correlations coefficients (ICC) for each coagulation test. Methods Data from eight laboratories measuring fibrinogen twice in twenty healthy subjects with one out of 3 different platforms and single measurements of prothrombin time (PT), and coagulation factors II, V, VII, VIII, IX, X, XI and XIII were analysed. By platform, the variance components of (i) the subjects, (ii) the laboratory and the technician and (iii) the total variance were obtained for fibrinogen as well as (i) and (iii) for the remaining factors using ANOVA. Results The variability for fibrinogen measurements within a laboratory ranged from 0.02 to 0.04, the variability between laboratories ranged from 0.006 to 0.097. The ICC for fibrinogen ranged from 0.37 to 0.66 and from 0.19 to 0.80 for PT between the platforms. For the remaining factors the ICC’s ranged from 0.04 (FII) to 0.93 (FVIII). Conclusions Variance components that could be attributed to technicians or laboratory procedures were substantial, led to disappointingly low intraclass correlation coefficients for several factors and were pronounced for some of the platforms. Our findings call for sustained efforts to raise the level of standardization of structures and procedures involved in the quantification of coagulation factors.

Objective: Electrical stimulation by a cochlear implant (CI) induces maturation of the auditory system and reorganization of the auditory cortex in deaf children. Cortical reorganization produces an interhemispheric asymmetry in auditory evoked brain potentials associated with sound stimulation after unilateral implantation. To objectively determine the onset of this phenomenon and follow this process over time, the interhemispheric symmetry needs to be quantified. In this paper, the intraclass correlation coefficient (ICC) between mean global field powers (MGFPs) of each hemisphere is proposed to quantify ong latency auditory evoked potential (LLAEP) interhemispheric symmetries as a measure of auditory cortex reorganization in Cl recipients.Design: An LLAEP, in response to a simple tone, was recorded in 5 juvenile unilateral Cl recipients at less and at more than two years post-implantation and the ICC between MGFPs was calculated for both recordings. The cross correlation coefficients (CC) between MGFPs of each hemisphere were also calculated and compared with the ICC.Results: The experience-related visually observed increases in amplitude and shape asymmetries of the LLAEP topographic map (around the LLAEP P, peak), were reflected in a considerable reduction of ICC values (on average 41.4%), at more than two years post-implantation surgery. In contrast, CC values only showed much smaller decreases (on average 20.0%), at more than two years post-implantation.Conclusions: The ICC is a better descriptor of symmetry than the CC because it reflects both shape and amplitude similarity between left and right LLAEP MGFPs instead of only shape similarity. The decrease in ICC values at more than two years post-implantation is likely associated with a lateralization of the auditory response as a result of cortical reorganization. Our results show that the ICC between the MGFPs for each hemisphere can be useful to objectively determine the auditory cortex reorganization process and also to evaluate the performance of cochlear implant users without the necessity to use expensive technologies such as high density EEG recordings and/or fMRI scans. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Background Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways. Methods To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1. Results ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively. Conclusion Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.

Background The purpose of the study was to evaluate intraclass correlation coefficients (ICC) of variables concerning personal characteristics, structure, outcome and process in the Brazilian Network for Surveillance of Severe Maternal Morbidity study conducted to identify severe maternal morbidity/near miss cases using the World Health Organization criteria. Method It was a cross-sectional, multicenter study involving 27 hospitals providing care for pregnant women in Brazil. Cluster size and the mean size of the primary sampling unit were described. Estimated prevalence rates, ICC, their respective 95% confidence intervals, the design effect and the mean cluster size were presented for each variable. Results Overall, 9,555 cases of severe maternal morbidity (woman admitted with potentially life-threatening conditions, near miss events or death) were included in the study. ICC ranged from < 0.001 to 0.508, with a median of 0.035. ICC was < 0.1 for approximately 75% of the variables. For process-related variables, median ICC was 0.09, with 0.021 for those related to outcome. These findings confirm data from previous studies. Homogeneity may be considered minor, thus increasing reliability of these findings. Conclusions These results may be used to design new cluster trials in maternal and perinatal health and to help calculate sample sizes.

Context Good Clinical Practice regulates monitoring activities in clinical research. Due to question and design diversity, and limited resources, on-site monitoring is often less intensive in the academic context, and variable. Standardization is needed, and relies on definition and validation of tools accounting for risk. Objective To define, and validate tools, to implement a risk-based monitoring strategy for academic clinical research. Methods Working groups of experienced professionals searched the literature, and built a consensus risk-assessment scale (RAS), and a risk-adapted monitoring plan (RAMP). We allocated 200 protocols to 49 assessors. We assessed the RAS relevance vs. a visual analogue scale (VAS), and its reproducibility through Kraemer's kappa, and intraclass correlation coefficient (ICC) from a random proportional odds model. We identified sources of disagreement through a logistic regression. We described assessors' difficulties during assessment. We applied the RAMP to 10 protocols per risk level, and rated its feasibility (0 = easy to 4 = impossible). Results RAS and RAMP were defined in 4 levels. RAS relevance was good: RAS-risk levels were evenly distributed on VAS-risk (0.6, 2.6, 5.6, and 7.9). Reproducibility was moderate to good: kappa = 0.48, ICC = 0.70. Major disagreements (36%) arose from decision-makers, rather than hands-on managers. Most difficulties occurred in ill-written protocols (17%). RAMP was easily feasible for most protocols (mean score: 0.2 to 0.9). We proposed a standard synopsis for evaluation purpose. Conclusion We defined, and validated risk-based tools. This risk-adapted strategy will be compared to an intensive one in a randomized trial, Optimon, to define a standard of practice for academic clinical research.

The reliability of graph metrics calculated in network analysis is essential to the interpretation of complex network organization. These graph metrics are used to deduce the small-world properties in networks. In this study, we investigated the test-retest reliability of graph metrics from functional magnetic resonance imaging (fMRI) data collected for two runs in 45 healthy older adults. Graph metrics were calculated on data for both runs and compared using intraclass correlation coefficient (ICC) statistics and Bland-Altman (BA) plots. ICC scores describe the level of absolute agreement between two measurements and provide a measure of reproducibility. For mean graph metrics, ICC scores were high for clustering coefficient (ICC=0.86), global efficiency (ICC=0.83), path length (ICC=0.79), and local efficiency (ICC=0.75); the ICC score for degree was found to be low (ICC=0.29). ICC scores were also used to generate reproducibility maps in brain space to test voxel-wise reproducibility for unsmoothed and smoothed data. Reproducibility was uniform across the brain for global efficiency and path length, but was only high in network hubs for clustering coefficient, local efficiency and degree. BA plots were used to test the measurement repeatability of all graph metrics. All graph metrics fell within the limits for repeatability. Together, these results suggest that with exception of degree, mean graph metrics are reproducible and suitable for clinical studies. Further exploration is warranted to better understand reproducibility across the brain on a voxel-wise basis.

Background The aims of this study were to evaluate the construct validity (known group), concurrent validity (criterion based) and test-retest (intra-rater) reliability of manual goniometers to measure passive hip range of motion (ROM) in femoroacetabular impingement patients and healthy controls. Methods Passive hip flexion, abduction, adduction, internal and external rotation ROMs were simultaneously measured with a conventional goniometer and an electromagnetic tracking system (ETS) on two different testing sessions. A total of 15 patients and 15 sex- and age-matched healthy controls participated in the study. Results The goniometer provided greater hip ROM values compared to the ETS (range 2.0-18.9 degrees; P < 0.001); good concurrent validity was only achieved for hip abduction and internal rotation, with intraclass correlation coefficients (ICC) of 0.94 and 0.88, respectively. Both devices detected lower hip abduction ROM in patients compared to controls (P < 0.01). Test-retest reliability was good with ICCs higher 0.90, except for hip adduction (0.82-0.84). Reliability estimates did not differ between the goniometer and the ETS. Conclusions The present study suggests that goniometer-based assessments considerably overestimate hip joint ROM by measuring intersegmental angles (e.g., thigh flexion on trunk for hip flexion) rather than true hip ROM. It is likely that uncontrolled pelvic rotation and tilt due to difficulties in placing the goniometer properly and in performing the anatomically correct ROM contribute to the overrating of the arc of these motions. Nevertheless, conventional manual goniometers can be used with confidence for longitudinal assessments in the clinic., BMC Musculoskeletal Disorders, 11, ISSN:1471-2474

Question What is the inter-rater reliability of the Assessment of Physiotherapy Practice (APP) instrument, and what is the error associated with individual scores? Design Cross-sectional inter-rater reliability study. Thirty pairs of clinical educators each assessed one student after observing student practice over a 5-week clinical placement. Participants Sixty clinical educators from five Australian universities formed 30 independent pairs of assessors. Outcome measures Each pair completed two independent assessments of one student, providing 60 completed APP assessments and an associated Global Rating Scale score for analysis. Analysis Correlational coefficients and measurement error expressed in APP scale units were computed to provide a comprehensive analysis of the likely utility of APP scores and to enable score and change score interpretation. Results Percentage of agreement between assessors for each item ranged from 56% (Item 19, evidence-based practice) to 83% (Item 20, risk management) and across all items averaged 70% (SD 7). The ICC(2,1) was 0.92 (95% CI 0.84 to 0.96) for the total APP score and 0.72 (95% CI 0.50 to 0.86) for the Global Rating Scale. The standard error of measurement for the total score (scale width 0–80) was 3.2 APP points and the MDC 90 was 7.86 representing 9% of the scale width. Bland-Altman analyses identified no systematic differences between raters. Conclusion Clinical educators demonstrated a high level of reliability when using the APP instrument to assess physiotherapy students' level of professional competence in workplacebased practice. [Dalton M, Davidson M, Keating JL (2012) The Assessment of Physiotherapy Practice (APP) is a reliable measure of professional competence of physiotherapy students: a reliability study. Journal of Physiotherapy 58: 49–56]