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PURPOSE: Classifying tibial plateau fractures is paramount in determining treatment regimens and systemizing decision making. The original AO classification described by Müller in 1996 and the Schatzker classification of 1970 are the most cited classifications for tibial plateau fractures, demonstrating substantial to almost perfect agreement. The main problem with these classifications schemes is that they lack the detail required to convey the variety of fracture patterns encountered. In 2018, the AO foundation published a new classification system for proximal tibia fractures, highlighting a more complete and detailed number of categories and subcategories. We sought to independently determine inter and intraobserver agreement of the AO classification system, compared to the previous systems described by Müller and Schatzker. METHODS: One hundred seven consecutive tibial plateau fractures were screened, and a representative data set of 69 was created. Six independent evaluators (three knee surgeons, three senior orthopedic residents) classified the fractures using the original AO, the Schatzker and the new AO classifications. After six weeks, the 69 cases were randomized and reclassified by all evaluators. The Kappa coefficient (k) was calculated for inter- and intraobserver correlation and is expressed with 95% confidence intervals. RESULTS: interobserver agreement was moderate for all three classifications. k = 0.464 (0.383-0.560) for the original AO; k = 0.404 (0.337-0.489) for Schatzker; and k = 0.457 (0.371-0.545) for the base categories of the new AO classification. The inclusion of subcategories and letter modifiers to the new classification worsened agreement to k = 0.358 (0.302-0.423) and k = 0.174 (0.134-0.222), respectively. There were no significant differences between knee surgeons and residents for the new classification. Intra-observer correlation was also moderate for each of the scores: k = 0.630 (0.578-0.682) for the original AO; k = 0.623 (0.569-0.674) for Schatzker; and k = 0.621 (0.566-0.678) for the new AO base categories; without differences between knee surgeons or residents. CONCLUSIONS: This study demonstrated an adequate inter and intra-observer agreement for the new AO tibial plateau fractures classification system for its base categories, but not at the subcategory or letter modifier levels.

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PURPOSE: Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. METHODS: Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). CONCLUSION: The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

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OBJECTIVE: To investigate the intraindividual agreement of the sperm chromatin dispersion (SCD) assay results to assess sperm DNA fragmentation (SDF) in men with infertility. DESIGN: Diagnostic test reliability study. SETTING: Andrology laboratories. PATIENT(S): A total of 219 men with infertility. INTERVENTION(S): Sperm DNA fragmentation assessment in two ejaculates of the same subjects within a 3-month interval, using the SCD assay performed and analyzed by the same observers under similar testing conditions. MAIN OUTCOME MEASURE(S): Cohen's κ statistics to assess the degree of agreement between the pairs of results after converting the nominal SCD values into categorical data, that is, normal (<20%), intermediate (21%-29%), and high (≥30%) SDF rates. We also assessed the pairs of results using reliability measures for numerical variables (intraclass correlation coefficient for consistency using the two-way mixed-effects model and Bland-Altman plots). RESULT(S): The degree of agreement in classifying patients according to normal and pathological SDF classes was overall substantial (κ = 0.632; 95% confidence interval [CI], 0.546-0.718). A total of 76.7% of individuals were classified under the same class using paired ejaculates. The agreement rate was highest (approximately 80%) in ejaculates initially classified as either normal or high and lowest (approximately 60%) among those with intermediate SDF levels. The frequency of intermediate SDF ejaculates downgraded to normal or upgrade to high SDF classes in the second test was similar (approximately 20%). The intraclass correlation coefficient was 0.856 (95% CI, 0.812-0.887), and the mean difference between the pairs of observations was 0.80% (95% CI, -0.72 to 2.23), indicating no systematic difference between paired observations. CONCLUSION(S): Our study indicates a substantial intraindividual agreement of paired SCD assay results to classify men with infertility into three SDF categories: normal, intermediate, and high. The reliability of the SCD assay was adequate and exceeded 0.80 using two ejaculates analyzed within a 3-month interval under similar conditions. Although this evidence overall supports a single SCD test for patient classification using predefined SDF thresholds, particularly when the first test shows normal or high SDF levels, one in four men will have discordant values in paired ejaculates. Clinicians should be judicious when using SDF test results in decision-making.

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

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STUDY QUESTION: What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria? SUMMARY ANSWER: Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used. WHAT IS KNOWN ALREADY: According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population. STUDY DESIGN, SIZE, DURATION: A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield. MAIN RESULTS AND THE ROLE OF CHANCE: The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80. LIMITATIONS, REASONS FOR CAUTION: Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification. WIDER IMPLICATIONS OF THE FINDINGS: Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting. STUDY FUNDING/COMPETING INTEREST(S): Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose. TRIAL REGISTRATION NUMBER: not applicable.

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BACKGROUND: A new AO classification for intertrochanteric fractures was recently published; no studies have evaluated its inter- and intra-observer agreement. METHODS: Six evaluators (three hip subspecialists and three residents) assessed radiographs of 68 intertrochanteric fractures; fractures were classified using the original and the new AO classifications. The cases were displayed in a random sequence after a six-week interval for repeat evaluation. We used the Kappa coefficient (k) to determine inter- and intra-observer agreement. RESULTS: Inter-observer agreement was slight (k = 0.128 [0.092-0.170]) using the original and fair (k = 0.250 [0.186-0.327]), with the new AO classification. Orthopedic residents exhibited better agreement than hip surgeons using the original classification (k = 0.302 [0.210-0.416] and k= -0.018 [-0.058-0.029], respectively) and the new classification (k = 0.388 [0.294-0.514] and k = 0.109 [0.031-0.192], respectively). Using both classifications as dichotomous variables (stable or unstable patterns), the agreement was slight (k = 0.158 [0.074-0.246]) using the original classification and moderate (k = 0.425 [0.308-0.550]) with the new AO classification. INTRA-OBSERVER: The agreement was fair using the original (k = 0.350 [0.278-0.424]) and the new (k = 0.295 [0.239 to 0.353]) AO classifications, respectively. Residents had better agreement than hip specialists using the original (k = 0.405 [0.303-0.512]) versus (k = 0.292 [0.193-0.293]) and the new classification (k = 0.449 [0.370 to 0.528] versus k = 0.129 [0.064 to 0.208]). CONCLUSION: The inter-observer agreement using the new AO classification was significantly better than using its original version. Also, the new AO classification system allowed better agreement when distinguishing stable from unstable patterns.

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OBJECTIVE: To assess the degree of agreement between the model for maternal nutritional assessment proposed by Rosso-Mardones and the one proposed by Atalah. METHODS: Diagnostic agreement study. Pregnant women between the ages of 19 and 37 years with a gestational age of 10 or more weeks were incuded; patients with diabetes, thyroid disease, pregnancy-associated hypertension, twin pregnancy, severe fetal malformation, fetal death and hydrops fetalis were excluded. Non-probabilistic sampling. Sociodemographic, obstetrical and nutritional status variables were measured. RESULTS: Overall, 98 pregnant women were included. With the use of the Rosso-Mardones scale, 33% of the patients were classified as having a normal nutritional status, 22% as low weight, and 44% as overweight or obese. With the Atalah scale, 41% of the women were classified as having a normal nutritional status, 10% as low weight and 48% as overweight or obese. The weighted kappa value was 0.74 with a standard error of 0.04, a 95% CI of 0.66-0.82 and a p value < 0.05. CONCLUSIONS: There is substantial agreement between nutritional assessment scales used in pregnancy, namely the Rosso-Mardones nomogram and the Atalah scale. Further studies to assess the agreement of these scales in the pregnant population are required.

TITULO: ESTUDIO DE CONCORDANCIA ENTRE LAS ESCALAS DE ROSSO-MARDONES Y ATALAH PARA LA EVALUACIÓN NUTRICIONAL EN EMBARAZADAS. CLÍNICA LA ERMITA DE CARTAGENA, 2017. OBJETIVO: evaluar el grado de concordancia entre el modelo de evaluación del estado nutricional materna propuesto por Rosso-Mardones con el propuesto por Atalah. METODOS: estudio de concordancia diagnóstica. Se incluyeron gestantes entre los 19 y 37 años, con una edad gestacional de 10 o más semanas; se excluyeron gestantes con: diabetes, enfermedad tiroidea, hipertensión asociada al embarazo, embarazos gemelares, malformaciones fetales graves, muerte fetal e hidrops fetalis. Muestreo no probabilístico. Se midieron las variables sociodemográficas, obstétricas y el estado nutricional. Se calculó el valor de kappa de concordancia entre las dos escalas de evaluación nutricional. RESULTADOS: se incluyeron 98 gestantes. La escala de Roso-Mardones clasificó al 33 % de las pacientes en estado nutricional normal, al 22 % con bajo peso y al 44 % con sobrepeso u obesidad. La escala de Atalah clasificó al 41 % de las gestantes en estado nutricional normal, al 10 % con bajo peso y al 48 % con sobrepeso u obesidad. El valor kappa ponderado obtenido fue 0,74 con un error estándar de 0,04 y un IC 95 %: 0,66-0,82 con valor p < 0,05. CONCLUSIONES: las escalas de evaluación nutricional en gestantes, nomograma de Rosso-Mardones y de Atalah, tienen un acuerdo considerable. Se requieren más estudios que evalúen la concordancia entre estas escalas en población gestante.

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RESUMEN Objetivo: evaluar el grado de concordancia entre el modelo de evaluación del estado nutricional materna propuesto por Rosso-Mardones con el propuesto por Atalah Materiales y métodos: estudio de concordancia diagnóstica. Se incluyeron gestantes entre los 19 y 37 años, con una edad gestacional de 10 o más semanas; se excluyeron gestantes con: diabetes, enfermedad tiroidea, hipertensión asociada al embarazo, embarazos gemelares, malformaciones fetales graves, muerte fetal e hidrops fetalis. Muestreo no probabilístico. Se midieron las variables sociodemográficas, obstétricas y el estado nutricional. Se calculó el valor de kappa de concordancia entre las dos escalas de evaluación nutricional. Conclusiones: las escalas de evaluación nutricional en gestantes, nomograma de Rosso-Mardones y de Atalah, tienen un acuerdo considerable. Se requieren más estudios que evalúen la concordancia entre estas escalas en población gestante.

ABSTRACT Objective: To assess the degree of agreement between the model for maternal nutritional assessment proposed by Rosso-Mardones and the one proposed by Atalah. Materials and methods: Diagnostic agreement study. Pregnant women between the ages of 19 and 37 years with a gestational age of 10 or more weeks were included; patients with diabetes, thyroid disease, pregnancy-associated hypertension, twin pregnancy, severe fetal malformation, fetal death and hydrops fetalis were excluded. Non-probabilistic sampling. Sociodemographic, obstetrical and nutritional status variables were measured. Results: Overall, 98 pregnant women were included. With the use of the Rosso-Mardones scale, 33% of the patients were classified as having a normal nutritional status, 22% as low weight, and 44% as overweight or obese. With the Atalah scale, 41% of the women were classified as having a normal nutritional status, 10% as low weight and 48% as overweight or obese. The weighted kappa value was 0.74 with a standard error of 0.04, a 95% CI of 0.66-0.82 and a p value < 0.05. Conclusions: There is substantial agreement between nutritional assessment scales used in pregnancy, namely the Rosso-Mardones nomogram and the Atalah scale. Further studies to assess the agreement of these scales in the pregnant population are required.

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PURPOSE: Differentiating osteoporotic vertebral fractures (OVF) from metastatic vertebral fractures (MVF) is difficult. A magnetic resonance imaging (MRI)-based score (META score) aiming to differentiate OVF and MVF was recently published; however, an independent agreement assessment is required before the score is used. We performed such independent agreement evaluation, including raters with different levels of training. METHODS: Sixty-four patients with confirmed OVF or MVF were evaluated by six raters (three spine surgeons and three orthopaedic residents) using the META score. We used the intra-class correlation coefficient (ICC) to evaluate inter- and intra-observer agreement and the kappa statistic (κ) to determine the agreement for individual score criteria. We calculated the area under the receiver-operating characteristic curve (AUC) to establish the score accuracy. RESULTS: The inter-observer agreement was poor [ICC = 0.22 (0.12-0.33)]; spine surgeons [ICC = 0.75 (0.66-0.83)] had better agreement than that of residents [ICC = 0.06 (- 0.07 to 0.23)]. The intra-observer agreement was poor [ICC = 0.15 (- 0.04 to 0.30)]; both spine surgeons [ICC = 0.21 (0.05-0.41)] and residents exhibited poor agreement [ICC = - 0.06 (- 0.40 to 0.20)]. The agreement for each specific criterion varied from κ = 0.24 to κ = 0.38. The AUC was 0.57 (0.64 for spine surgeons and 0.51 for residents, p < 0.01). CONCLUSION: The inter-observer agreement using the META score was adequate for spine surgeons but not for residents; the intra-observer agreement was poor. These results do not support the standard use of the META score to differentiate OVF and MVF. These slides can be retrieved under Electronic Supplementary Material.

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PURPOSE: We performed an agreement study using two subaxial cervical spine classification systems: the AOSpine and the Allen and Ferguson (A&F) classifications. We sought to determine which scheme allows better agreement by different evaluators and by the same evaluator on different occasions. METHODS: Complete imaging studies of 65 patients with subaxial cervical spine injuries were classified by six evaluators (three spine sub-specialists and three senior orthopaedic surgery residents) using the AOSpine subaxial cervical spine classification system and the A&F scheme. The cases were displayed in a random sequence after a 6-week interval for repeat evaluation. The Kappa coefficient (κ) was used to determine inter- and intra-observer agreement. RESULTS: Inter-observer: considering the main AO injury types, the agreement was substantial for the AOSpine classification [κ = 0.61 (0.57-0.64)]; using AO sub-types, the agreement was moderate [κ = 0.57 (0.54-0.60)]. For the A&F classification, the agreement [κ = 0.46 (0.42-0.49)] was significantly lower than using the AOSpine scheme. Intra-observer: the agreement was substantial considering injury types [κ = 0.68 (0.62-0.74)] and considering sub-types [κ = 0.62 (0.57-0.66)]. Using the A&F classification, the agreement was also substantial [κ = 0.66 (0.61-0.71)]. No significant differences were observed between spine surgeons and orthopaedic residents in the overall inter- and intra-observer agreement, or in the inter- and intra-observer agreement of specific type of injuries. CONCLUSION: The AOSpine classification (using the four main injury types or at the sub-types level) allows a significantly better agreement than the A&F classification. The A&F scheme does not allow reliable communication between medical professionals.

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PURPOSE: Grading inter-vertebral disc degeneration (IDD) is important in the evaluation of many degenerative conditions, including patients with low back pain. Magnetic resonance imaging (MRI) is considered the best imaging instrument to evaluate IDD. The Pfirrmann classification is commonly used to grade IDD; the authors describing this classification showed an adequate agreement using it; however, there has been a paucity of independent agreement studies using this grading system. The aim of this study was to perform an independent inter- and intra-observer agreement study using the Pfirrmann classification. METHODS: T2-weighted sagittal images of 79 patients consecutively studied with lumbar spine MRI were classified using the Pfirrmann grading system by six evaluators (three spine surgeons and three radiologists). After a 6-week interval, the 79 cases were presented to the same evaluators in a random sequence for repeat evaluation. The intra-class correlation coefficient (ICC) and the weighted kappa (wκ) were used to determine the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was excellent, with an ICC = 0.94 (0.93-0.95) and wκ = 0.83 (0.74-0.91). There were no differences between spine surgeons and radiologists. Likewise, there were no differences in agreement evaluating the different lumbar discs. Most differences among observers were only of one grade. Intra-observer agreement was also excellent with ICC = 0.86 (0.83-0.89) and wκ = 0.89 (0.85-0.93). CONCLUSIONS: In this independent study, the Pfirrmann classification demonstrated an adequate agreement among different observers and by the same observer on separate occasions. Furthermore, it allows communication between radiologists and spine surgeons.

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