Karate Training Improves Metabolic Health in Overweight and Obese Adolescents: A Randomized Clinical Trial.

PURPOSE: This study evaluated the effects of 12 weeks of karate training on cardiometabolic parameters, oxidative stress, and inflammation in adolescents with overweight and obesity. METHOD: Seventy adolescents were randomized into 2 groups: control received nutritional and psychological interventions once a week for 12 weeks, and treatment received nutritional and psychological interventions once a week, plus 3 karate sessions per week, for 12 weeks. The main outcome measure was improvement in cardiometabolic parameters, oxidative stress, and inflammation. RESULTS: After the intervention period, the treatment group showed a reduction in resting heart rate (77.86 [10.89]), high-density lipoprotein cholesterol (40.86 [8.31]), and triglycerides (75.18 [32.29]) and an increase in low-density lipoprotein cholesterol (95.64 [42.53]) in relation to pretraining. Regarding oxidative stress markers, there was a reduction in protein carbonylation (0.07 [0.06]) and nitric oxide (1.39 [1.11]) and an increase in superoxide dismutase (0.68 [0.31]) and glutathione (0.11 [0.08]) compared with pretraining. With respect to inflammation, adiponectin increased (14.54 [5.36]) after the intervention when compared with preintervention. CONCLUSION: The study concluded that the intervention may improve cardiometabolic parameters, oxidative stress, and inflammation in adolescents with overweight and obesity. Long-term effects need to be evaluated.

Inexpensive and nonconventional fabrication of microfluidic devices in PMMA based on a soft-embossing protocol.

This study describes an inexpensive and nonconventional soft-embossing protocol to produce microfluidic devices in poly(methyl methacrylate) (PMMA). The desirable microfluidic structure was photo-patterned in a poly(vinyl acetate) (PVAc) film deposited on glass substrate to produce a low-relief master. Then, this template was used to generate a high-relief pattern in stiffened PDMS by increasing of curing agent /monomer ratio (1:5) followed by thermal aging in a laboratory oven (200°C for 24 h). The stiffened PDMS masters were used to replicate microfluidic devices in PMMA based on soft embossing at 220-230°C and thermal sealing at 140°C. Both embossing and sealing stages were performed by using binder clips. The proposed protocol has ensured the replication of microfluidic devices in PMMA with great fidelity (>94%). Examples of MCE devices, droplet generator devices and spot test array were successfully demonstrated. For testing MCE devices, a mixture containing inorganic cations was selected as model and the achieved analytical performance did not reveal significant difference from commercial PMMA devices. Water droplets were successfully generated in an oil phase at rate of ca. 60 droplets/min (fixing the continuous phase flow rate at 100 µL/h) with size of ca. 322 ± 6 µm. Glucose colorimetric assay was performed on spot test devices and good detectability level (5 µmol/L) was achieved. The obtained results for two artificial serum samples revealed good agreement with the certified concentrations. Based on the fabrication simplicity and great analytical performance, the proposed soft-embossing protocol may emerge as promising approach for manufacturing PMMA devices.

Effectiveness of martial arts exercise on anthropometric and body composition parameters of overweight and obese subjects: a systematic review and meta-analysis.

BACKGROUND: Obesity is considered a top public health concern, and its prevalence is growing every day. Thus, interventions to address this problem should be encouraged and further studied. In this regard, the aim of this review was to summarize the evidence of martial arts interventions to evaluate their effectiveness on the anthropometric and body composition parameters of overweight and obese subjects. METHODS: A systematic literature search was conducted on January 26, 2020 using the PubMed, Medline, Lilacs, Cochrane, and Scielo databases. Reference lists of eligible articles and relevant reviews have also been examined. All randomized clinical trials on martial arts that evaluated the anthropometric and body composition parameters of overweight and obese subjects were included, and a narrative synthesis of eligible studies was conducted in accordance with PRISMA guidelines. The Downs & Black checklist was used to assess the quality of the studies. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42018086116). RESULTS: A total of 82 articles were identified from the initial search strategy. A further 2 articles were identified from the review of relevant bibliographies. Six studies encompassing 258 participants who were overweight or obese were included. Four studies reported Tai Chi practice, one study reported Kung Fu exercise, and another study reported martial arts exercise. The examined meta-analyses did not reveal significant benefits from martial arts practice over control groups after the experiment period for body mass index (- 1.34 kg/m2; 95% CI: - 2.72, 0.05), waist circumference (1.41 cm; 95% CI: - 0.72, 3.54) and percentage of body fat (- 0.75%; 95% CI: - 5.58, 4.08). CONCLUSION: The scarcity, heterogeneity, short intervention time, small sample size, and significant methodological limitations of the available studies do not allow to conclude whether martial arts are effective in the anthropometric and body composition parameters of overweight and obese individuals. This study highlights the need for more research to assess the benefits of martial arts for overweight and obese individuals.

Uncovering the Formation of Color Gradients for Glucose Colorimetric Assays on Microfluidic Paper-Based Analytical Devices by Mass Spectrometry Imaging.

This study describes the use of mass spectrometry imaging with matrix-assisted laser desorption/ionization (MALDI) and desorption electrospray ionization (DESI) to understand the color gradient generation commonly seen in microfluidic paper-based analytical devices (µPADs). The formation of color gradients significantly impacts assay sensitivity and reproducibility with µPADs but the mechanism for formation is poorly understood. The glucose enzymatic assay using potassium iodide (KI) as a chromogenic agent was selected to investigate the color gradient generated across a detection spot. Colorimetric measurements revealed that the relative standard deviation for the recorded pixel intensities ranged between 34 and 40%, compromising the analytical reliability. While a variety of hypotheses have been generated to explain this phenomenon, few studies have attempted to elucidate the mechanisms associated with its formation. Mass spectrometry imaging using MALDI and DESI was applied to understand the nonuniform color distribution on the detection zone. MALDI experiments were first explored to monitor the spatial distribution of the glucose oxidase and horseradish peroxidase mixture, before and after lateral flow assay with and without KI. MALDI(+)-TOF data revealed uniform enzyme distribution on the detection spots. On the other hand, after the complete assay DESI(-) measurements revealed a heterogeneous shape indicating the presence of iodide and triiodide ions at the zone edge. The reaction product (I3-) is transported by lateral flow toward the zone edge, generating the color gradient. Mass spectrometry imaging has been used for the first time to prove that color gradient forms as result of the mobility small molecules and not the enzyme distribution on µPAD surface.

Clinical complications in renal biopsy using two different needle gauges: The impact of large hematomas, a random clinical trial study.

OBJECTIVE: To compare complications of ultrasound-guided percutaneous renal biopsy using two needle gauges (16-G and 18-G). METHODS: A total of 238 individuals with renal biopsy indication were included and randomly separated into two groups: ultrasound-guided percutaneous renal biopsy procedure carried out with a 16-G or 18-G needle. The adequacy of biopsy samples and post-procedure complications were compared between the two groups. RESULTS: The procedures carried out with a 16-G needle collected fragments with a mean of 22.1 ± 10.8 glomeruli, and those carried out with an 18-G needle had a mean of 17.5 ± 9.4 glomeruli. Patients submitted to renal biopsies with a 16-G needle had a higher likelihood of having a complication (OR5.1, 95% CI 1.7-15.4, P = 0.001). The overall mean volume of post-biopsy hematoma in patients with complications was significantly larger than those without complications (44 ± 56.1 mL vs 5.9 ± 6.6 mL; P < 0.001). CONCLUSIONS: Renal biopsies carried out by ultrasonography using an 18-G needle provide adequate histological analysis, showing a lower amount of glomeruli but with similar clinical quality as a 16-G needle. Furthermore, it is associated with a lower risk of procedure-related complications.

Simple, rapid and, cost-effective fabrication of PDMS electrophoresis microchips using poly(vinyl acetate) as photoresist master.

This study describes a simple, rapid, and cost-effective fabrication of PDMS electrophoresis microchips using poly(vinyl acetate) (PVAc) emulsion as photoresist master. High-relief microfluidic structures were defined on poly(vinyl acetate) previously deposited on printed circuit boards surfaces without cleanroom facilities and sophisticated instrumentation. After a UV exposure, channels with heights ranging from 30 to 140 µm were obtained by controlling the emulsion mass deposited on the master surface. The developing stage was performed using water rather than the organic solvents that are applied for conventional masks. The surface morphology was characterized by optical imaging, profilometry, and SEM. Based on the achieved results, the proposed method offers suitable reproducibility for the prototyping of electrophoresis microchips in PDMS. The feasibility of the resulting PDMS electrophoresis chips was successfully demonstrated with the separation of major inorganic cations within 100 s using a contactless conductivity detection system. The separation efficiencies ranged from ca. 67 900 to 125 600 plates/m. Due to the satisfactory performance and simplified instrumentation, we believe this fabrication protocol presents potential to be implemented in any chemical, biochemical, or biological laboratory.

Does cell phone use increase the chances of parotid gland tumor development? A systematic review and meta-analysis.

BACKGROUND: Prior epidemiological studies had examined the association between cell phone use and the development of tumors in the parotid glands. However, there is no consensus about the question of whether cell phone use is associated with increased risk of tumors in the parotid glands. We performed a meta-analysis to evaluate the existing literature about the mean question and to determine their statistical significance. METHODS: Primary association studies. Papers that associated cell phone use and parotid gland tumors development were included, with no restrictions regarding publication date, language, and place of publication. Systematic literature search using PubMed, SciELO and Embase followed by meta-analysis. RESULTS AND CONCLUSION: Initial screening included 37 articles, and three were included in meta-analysis. Using three independent samples including 5087 subjects from retrospective case-control studies, cell phone use seems to be associated with greater odds (1.28, 95%- confidence interval: 1.09-1.51) to develop salivary gland tumor. Results should be read with caution due to the limited number of studies available and their retrospective design.

Cell phone use is associated with an inflammatory cytokine profile of parotid gland saliva.

BACKGROUND: There is controversy on the effects of the non-ionizing radiation emitted by cell phones on cellular processes and the impact of such radiation exposure on health. The purpose of this study was to investigate whether cell phone use alters cytokine expression in the saliva produced by the parotid glands. METHODS: Cytokine expression profile was determined by enzyme linked immuno sorbent assay (ELISA) in the saliva produced by the parotid glands in healthy volunteers, and correlated with self-reported cell phone use and laterality. RESULTS: The following parameters were determined, in 83 Brazilian individuals in saliva produced by the parotid glands comparing the saliva from the gland exposed to cell phone radiation (ipsilateral) to that from the contralateral parotid: salivary flow, total protein concentration, interleukin 1 ß (IL-1 ß), interleukin 6 (IL-6), interleukin 10 (IL-10), interferon γ (IFN-γ), and tumor necrosis factor α (TNF-α) salivary levels by ELISA. After multiple testing correction, decreased IL-10 and increased IL-1ß salivary levels in the ipsilateral side compared with the contralateral side (P < 0.05) were detected. Subjects who used cell phones for more than 10 years presented higher differences between IL-10 levels in ipsilateral versus contralateral parotids (P = 0.0012). No difference was observed in any of the tested parameters in correlation with cell phone monthly usage in minutes. CONCLUSION: The exposure of parotid glands to cell phones can alter salivary IL-10 and IL-1ß levels, consistent with a pro-inflammatory microenvironment that may be related to heat production.

Association between cell cycle gene transcription and tumor size in oral squamous cell carcinoma.

Higher tumor size correlates with poor prognosis and is an independent predictive survival factor in oral squamous cell carcinoma (OSCC) patients. However, the molecular events underlining OSCC tumor evolution are poorly understood. We aimed to investigate if large OSCC tumors show different cell cycle gene transcriptional signature compared to small tumors. Seventeen fresh OSCC tumor samples with different tumor sizes (T) were included in the study. Tumors were from the tongue or from the floor of the mouth, and only three patients were nonsmokers. Samples were categorized according to clinical tumor size in tumors ≤2 cm (T1, n = 5) or tumors >2 cm (T2, n = 9; T3, n = 2; T4, n = 1). The group of tumors ≤2 cm was considered the reference group, while the larger tumors were considered the test group. We assessed the expression of 84 cell cycle genes by qRT-PCR array and normalized it to the expression of two housekeeping genes. Results were analyzed according to the formula 2(^-DeltaCt). A five-fold change cutoff was used, and p values <0.05 were considered statistically significant. Ki-67 immunohistochemistry was performed to estimate cell proliferation index. Twenty-nine genes were downregulated in the test group (larger tumors) compared to the reference group (smaller tumors). Among these genes, 13 reached statistical significance: ANAPC4, CUL1, SUMO1, KPNA2, MAD2L2, CCNG2, E2F4, NBN, CUL2, PCNA, TFDP1, KNTC1, and ATR. Ki-67 labeling index was similar in both tumor groups. Our findings suggest that the transcriptional activity of specific cell cycle genes varies according to the size of OSCC tumor, which probably reflects tumor molecular evolution and adaptation to the microenvironment.

The association of openness personality trait with stress-related salivary biomarkers in burning mouth syndrome.

BACKGROUND: Burning mouth syndrome (BMS) is a chronic disorder defined as a burning sensation in the oral mucosa without evidence of pathological findings. Its pathophysiology is largely unknown, but psychiatric disorders and personality traits have been implicated. OBJECTIVE: This study investigated whether there is any association between salivary biomarkers and personality traits in BMS patients. METHODS: It was a cross-sectional, controlled study that evaluated 30 individuals with BMS and 32 controls. All subjects were assessed with a structured psychiatric interview (Mini International Neuropsychiatric Interview) and the Big Five inventory. Salivary levels of brain-derived neurotrophic factor (BDNF), neural growth factor, tumor necrosis factor-α, interleukin (IL)-6, IL-10 and cortisol were determined. RESULTS: We found that BMS patients exhibited more traits of neuroticism and lower openness than controls. Openness showed a moderate and negative correlation with cortisol, BDNF and IL-6. CONCLUSION: Personality traits are associated with salivary biomarkers in BMS.

Capillary-driven toner-based microfluidic devices for clinical diagnostics with colorimetric detection.

The fabrication of toner-based microfluidic devices to perform clinical diagnostics with capillary action and colorimetric detection is described in this report. Test zones and microfluidic channels were drawn in a graphic software package and laser printed on a polyester film. The printed layout and its mirror image were aligned with an intermediary cut-through polyester film and then thermally laminated together at 150 °C at 60 cm/min to obtain a channel with ca. 100-µm depth. Colorimetric assays for glucose, protein, and cholesterol were successfully performed using a desktop scanner. The limit of detection (LD) values found for protein, cholesterol, and glucose were 8, 0.2, and 0.3 mg/mL, respectively. The relative standard deviation (RSD) values for an interdevices comparison were 6%, 1%, and 3% for protein, cholesterol, and glucose, respectively. Bioassays were successfully performed on toner-based devices stored at different temperatures during five consecutive days without loss of activity.

Burning mouth syndrome: a therapeutic approach involving mechanical salivary stimulation.

OBJECTIVE: The study aimed to evaluate the effects of salivary stimulation therapy on the salivary flow, quality of saliva, and symptoms in patients with burning mouth syndrome (BMS). BACKGROUND: BMS is a chronic disorder characterized by a burning sensation. Some reports have proposed a role for saliva in the pathogenesis of BMS. METHODS: Twenty-six BMS patients underwent treatment with salivary mechanical stimulation. Resting and stimulated saliva were collected before and after therapy. Salivary levels of total protein, brain-derived neurotrophic factor, interleukin-10, tumor necrosis factor-α, interleukin-6, and nerve growth factor were assessed before and 90 days after therapy by enzyme-linked immunosorbent assay. RESULTS: A significant reduction in the burning sensation and number of burning sites as well as an improvement of taste disturbances and xerostomia were observed after therapy. The salivary flow was not significantly modified. However, the therapy resulted in a significant decrease in salivary levels of total protein and an increase of tumor necrosis factor-α. CONCLUSION: Salivary mechanical stimulation therapy is effective in reducing clinical symptoms of BMS.

Mixed laryngocele mimicking thyroid nodule.

Laryngocele is defined as a dilation of the laryngeal saccule forming an air sac. Some differential diagnoses for laryngocele have been reported. The aim of the present paper was to describe a case of a patient referred for the evaluation a suspected thyroid nodule that was subsequently diagnosed as a mixed laryngocele. A 31-year-old male with no clinical manifestations was referred by an endocrinologist to undergo Doppler ultrasonography and fine-needle aspiration biopsy due to a preliminary ultrasonographic diagnosis of a nodule apparently in the thyroid. The diagnosis of laryngocele was raised considering the cytopathological analysis and imaging exam. Computed tomography of the neck confirmed this hypothesis. The patient was counseled to consult a surgeon, but, up to the end of this report, continued asymptomatic and in follow-up. We report a mixed laryngocele with different clinical behavior, showing that laryngocele may appear to be another entity and drawing the attention of clinicians to imaging similarities.

Fabrication of microwell plates and microfluidic devices in polyester films using a cutting printer.

This study reports, for the first time, the possibility to manufacture analytical devices on polyester substrates using a cutting printer. The protocol involves the design of a layout in a graphical software, the cut into polyester films and the lamination against one or multiple polyester films coated with a thermosensitive layer. The feasibility of the proposed approach was demonstrated through the fabrication of 96-microwell plates, 3D microfluidic mixing and distance-based microfluidic devices. The printer has enabled cutting microchannels wider than 300 µm on polyester films and a thickness of 250 µm. Urea and glucose assays were performed on microwell plates aiming for their quantification in artificial urine and serum samples. The presented results revealed good agreement with the expected values. The complexation reaction between Fe2+ and o-phenanthroline was selected as model to investigate the feasibility of the 3D mixing device. Absorbance measurements were recorded for the reaction product performed in both on and off-chip modes. Considering the achieved data, the on-chip mixing exhibited similar behavior when compared to off-chip reaction, thus demonstrating to be efficient to perform mixtures due to the turbulence generated inside three-dimensional channels. Lastly, a distance-based device was designed to detect H2O2 based on the displacement of a dye plug promoted by the oxygen generation using a copper-modified paper sheet. The distance-based peroxymeter revealed a linear behavior in the concentration range between 1 and 5% (v/v) and a LOD equal to 0.5% (65.2 mM). Based on the results herein reported, the proposed method represents a simple and alternative protocol to produce microdevices, using affordable and inexpensive raw materials, within 10 min, and at a cost lower than US$ 0.10 per unit.

Mass spectrometry imaging as a potential technique for diagnostic of Huanglongbing disease using fast and simple sample preparation.

Huanglongbing (HLB) is a disease of worldwide incidence that affects orange trees, among other commercial varieties, implicating in great losses to the citrus industry. The disease is transmitted through Diaphorina citri vector, which inoculates Candidatus Liberibacter spp. in the plant sap. HLB disease lead to blotchy mottle and fruit deformation, among other characteristic symptoms, which induce fruit drop and affect negatively the juice quality. Nowadays, the disease is controlled by eradication of sick, symptomatic plants, coupled with psyllid control. Polymerase chain reaction (PCR) is the technique most used to diagnose the disease; however, this methodology involves high cost and extensive sample preparation. Mass spectrometry imaging (MSI) technique is a fast and easily handled sample analysis that, in the case of Huanglongbing allows the detection of increased concentration of metabolites associated to the disease, including quinic acid, phenylalanine, nobiletin and sucrose. The metabolites abieta-8,11,13-trien-18-oic acid, suggested by global natural product social molecular networking (GNPS) analysis, and 4-acetyl-1-methylcyclohexene showed a higher distribution in symptomatic leaves and have been directly associated to HLB disease. Desorption electrospray ionization coupled to mass spectrometry imaging (DESI-MSI) allows the rapid and efficient detection of biomarkers in sweet oranges infected with Candidatus Liberibacter asiaticus and can be developed into a real-time, fast-diagnostic technique.

Effects of aging on DNA hydroxymethylation and methylation in human dental follicles.

OBJECTIVE: Despite the high frequency of impacted teeth and increased frequency of lesions in dental follicles (DF) with aging, DF age-changes remain unclear. We compared the global methylation and hydroxymethylation profiles in DF in relation to age. DESIGN: DF associated with impacted lower third molars were obtained from 59 individuals. Global DNA methylation (5mC content) and hydroxymethylation (5hmC) were evaluated by ELISA. We tested the correlation between 5mC and 5hmC content, and the correlation of each with patients' age. The differences in age, 5mC, and 5hmC in DF from men/women, and location (left/right mandible) was tested. RESULTS: The mean age of the 59 individuals was 19.56 ±â€¯3.92, ranging from 13 to 31 years, and most were women (n = 39). 5hmC content and age up to 19 years were inversely correlated (Spearman's correlation coefficient=-0.552, p = 0.0003, n = 38). There was no relationship between 5hmC and 5mC content. There was no difference in the medians of age (p = 0.25), 5hmC (p = 0.33) and 5mC (p = 0.86) between men/women, nor in the medians of age (p = 0.39), 5hmC (p = 0.99) and 5mC (p = 0.22) between the left/right side of the tooth extraction. CONCLUSION: An inverse correlation between 5hmC and age was established, with no correlation between 5mC and 5hmC content in DF. The biological meaning of such a decrease of global DNA hydroxymethylation with age in DF remains to be clarified.

The long noncoding RNA KIAA0125 is upregulated in ameloblastomas.

Ameloblastoma and adenomatoid odontogenic tumor (AOT) are jaw tumors derived from the teeth forming apparatus. While ameloblastoma is a destructive, debilitating lesion, with conventional surgical treatment leading to facial deformity and morbodities, AOT shows indolent clinical behavior. The underlying molecular mechanisms associated with their biological behavior are unknown. The use of high-density whole-genome microarray analysis in ameloblastomas and AOT revealed high frequency of genomic gain at 14q32.33, which encompasses the long noncoding RNA (lncRNA) gene KIAA0125. In the present study, we aimed to investigate the expression profile of KIAA0125 in these tumors. Thirteen samples were included (five solid/multicystic ameloblastomas, four AOT, and four dental follicles). The relative quantification of KIAA0125 expression was obtained by qPCR and interactions of KIAA0125 were in silico predicted. We detected higher levels of KIAA0125 transcripts in the ameloblastoma group compared to dental follicles (p = 0.042). The expression levels of KIAA0125 in AOT were not different from that of dental follicles. KIAA0125 was predicted to interact with 41 miRNA families. Four miRNAs of these families have been previously reported differentially expressed in ameloblastoma, being miR-135a-5p, miR-204-5p and miR-205-5p upregulated, and miR-150-5p downregulated. The lncRNA KIAA0125 is likely involved in the ameloblastoma pathobiology. LncRNAs hold strong promise as therapeutic targets and experimental validation of this lncRNA functions may lead to tailored therapies targeting KIAA0125 in extensive and recurrent ameloblastoma cases.

A single molecule rectifier with strong push-pull coupling.

We theoretically investigate the electronic charge transport in a molecular system composed of a donor group (dinitrobenzene) coupled to an acceptor group (dihydrophenazine) via a polyenic chain (unsaturated carbon bridge). Ab initio calculations based on the Hartree-Fock approximations are performed to investigate the distribution of electron states over the molecule in the presence of an external electric field. For small bridge lengths (n=0-3) we find a homogeneous distribution of the frontier molecular orbitals, while for n>3 a strong localization of the lowest unoccupied molecular orbital is found. The localized orbitals in between the donor and acceptor groups act as conduction channels when an external electric field is applied. We also calculate the rectification behavior of this system by evaluating the charge accumulated in the donor and acceptor groups as a function of the external electric field. Finally, we propose a phenomenological model based on nonequilibrium Green's function to rationalize the ab initio findings.

Reliability of the Mechanical Diagnosis and Therapy System in Patients With Spinal Pain: A Systematic Review.

BACKGROUND: An updated summary of the evidence for the reliability of the Mechanical Diagnosis and Therapy (MDT) system in patients with spinal pain is needed. OBJECTIVE: To investigate the evidence on the intrarater and interrater reliability of MDT in patients with spinal pain. METHODS: Searches in MEDLINE, CINAHL, Embase, PEDro, and Scopus were conducted for this systematic review. We included any study design as long as reliability of the MDT method was tested in patients with spinal pain. We collected data on the reliability of MDT to identify main and subsyndromes, directional preference, the centralization phenomenon, and lateral shift. The methodological quality of studies was assessed using the Quality Appraisal of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement Studies checklists. RESULTS: Twelve studies were included (8 studies on back pain, pooled n = 2160 patients; 3 studies on neck pain, pooled n = 45 patients; and 3 studies recruited mixed spinal conditions, pooled n = 389 patients). Studies investigating patients with back pain reported kappa estimates ranging from 0.26 to 1.00 (main and subsyndromes), 0.27 to 0.90 (directional preference), and 0.11 to 0.70 (centralization phenomenon). Kappa estimates for studies investigating neck pain ranged from 0.47 to 0.84 (main and subsyndromes) and 0.46 (directional preference). In mixed populations, kappa estimates ranged from 0.56 to 0.96 (main and subsyndromes). CONCLUSION: The MDT system appears to have acceptable interrater reliability for classifying patients with back pain into main and subsyndromes when applied by therapists who have completed the credentialing examination, but unacceptable reliability in other therapists. We found conflicting evidence regarding the reliability of the MDT system in patients with neck pain or mixed pain locations. J Orthop Sports Phys Ther 2018;48(12):923-933. Epub 22 Jun 2018. doi:10.2519/jospt.2018.7876.