Vertical Scar Breast Reduction: Does Gathering the Incision Matter?

BACKGROUND: The vertical scar bilateral breast reduction is a highly effective technique to reduce breast volume and create long-lasting aesthetic improvements. A cited disadvantage is the inability to adequately shorten the vertical scar, leading to chest wall scars or inframammary puckers. Gathering or cinching sutures have been described as a strategy to confront this issue. This article aims to determine if suture gathering is an effective methods to (1) reduce the incision length, (2) shorten the areola-to-inframammary fold (IMF) distance, and (3) reduce the pucker revision rate. METHODS: All patients undergoing vertical breast reduction performed by the senior author (E.H.F.) from 2001 to 2007 were included. The patient population was divided into "gather" and "no gather" groups depending on how the vertical incision was closed. RESULTS: There were 203 patients in the "no gather" group and 193 in the "gather" group. Age, body mass index, and resection weight were statistically but not clinically different. The percent reduction in vertical incision length was significantly greater in the "gather" group (34.2 ± 9.9% vs. 12.2 ± 5.9%). Both groups showed a gradual lengthening of areola-to-IMF distance postoperatively. Suture gathering had no impact on the pucker revision rate but increased healing complications. CONCLUSION: Gathering sutures significantly reduce the incision length in the operating room but do not change the areola-to-IMF distance or pucker revision rate. Gathering negatively influences skin vascularity and wound healing. It is acceptable and necessary to have a longer areola-to-IMF distance in a vertical reduction to accommodate increased projection.

Applying generalizability theory to high-stakes objective structured clinical examinations in a naturalistic environment.

PURPOSE: The purpose of this project was to determine if generalizability theory could be successfully applied to a high-stakes licensure objective structured clinical examination as part of its normal administrative procedures and whether the analysis could yield useful information with regard to sources of variance. METHODS: The anonymized data received from the Canadian Chiropractic Examining Board for its June 2005 Clinical Skills Examination were analyzed with generalizability theory. Variance components were estimated with SPSS 11.5 (SPSS Inc, Chicago, Ill) as partially nested data. The data included 182 candidates, 43 raters, 40 standardized patient actors, and 18 individual cases. RESULTS: Internal consistency estimates (Cronbach alpha) were .86 for day 1 and .91 for day 2. The alpha estimates for stations averaged .68 for day 1 and .74 for day 2. The generalizability-coefficient for the day 1 exam was .65 and for the day 2 was .42. G-coefficients for stations averaged .63 for day 1 and .74 for day 2. On day 1, the raters contributed 7% of the variance, and on day 2, the raters contributed 8%. CONCLUSIONS: Generalizability theory can contribute to the understanding of sources of variance and provide direction for the improvement of individual stations. The size of the rater variance in a station may also indicate the need for increased training in that station or the need to make the scoring checklist more clear and definitive. Generalizability theory, however, must be cautiously applied, and it requires careful selection of the floating raters and vigorous training of the raters in each station.

Applying the item response theory to classroom examinations.

OBJECTIVE: The purpose of this research project was to determine if the item response theory (IRT) can successfully be applied to smaller-sized class examinations. METHODS: The Rasch mathematical model (RMM) was selected from the family of IRT models because of its ability to work with smaller sample sizes. Two simulated examinations were created for 100 students by 100-item dichotomous examinations. Examination 2 contained 20 items common with those in examination 1. Examination 1 was systematically exposed to randomly missing student responses and to entire items being removed to determine the robustness of the RMM to missing data. The two examinations were then analyzed with the RMM individually and then in combination. Student scores and IRT measures were compared to determine if the IRT could successfully place the students from the two examinations on the same metric of measure. RESULTS: The student measures were not affected when up to 20% of the student responses were randomly missing. Student measures continued to have high reliability and correlated with full matrix measures for up to 40% of items being dropped from the examination. Student scores and IRT measures correlated highly when the two examinations were combined. CONCLUSIONS: The RMM can be successfully applied to small-sized class examinations, such as those at chiropractic, medical, and other health profession institutions. It is possible to place candidates from different administrations on the same metric of measure if there is as little as a 20% overlap of items between examinations. The RMM could assist faculty in determining if differences in candidate scores are caused by ability or item difficulty.

Predictors of performance of students from the Canadian Memorial Chiropractic College on the licensure examinations of the Canadian Chiropractic Examining Board.

PURPOSE: The purpose of this study was to determine if the Canadian Memorial Chiropractic College (CMCC) structured admissions interview and other student measures predict success on the Canadian Chiropractic Examining Board (CCEB) examinations. METHODS: An independent researcher combined CMCC and CCEB data by student name and then anonymized the data and destroyed the linking information. Backward stepwise multiple linear regressions were applied to external dependent variables from the CCEB and internal independent variables from the CMCC. RESULTS: Forty percent of the variance in the basic science examination (R2 = 0.405) was explained by the independent variables of third year objective structured clinical examination practical and second-year grade point average (chi rhoGPA). Forty-five percent of the variance in the applied science examination (R2 = 0.448) was explained by the fourth year final examination and chi rhoGPA for years 4, 2, and 3. Twenty-four percent of the variance in the clinical decision making examination (R2 = 0.239) was explained by chi rhoGPAs of years 4, 1, 2, and 3. Sixteen percent of the variance in the clinical skills examination (R2 = 0.160) was explained by the third year objective structured clinical examination theory and chi rhoGPA for year 2. CONCLUSION: For this educational institution, the admissions interview is not a predictor of success on the outcome measures of the CCEB. Student chi rhoGPA in year 2 is critical to success on CCEB licensure examinations. This information infers that students should only continue in their education after they have demonstrated a mastery level at the end of year 2.

The presence and impact of local item dependence on objective structured clinical examinations scores and the potential use of the polytomous, many-facet Rasch model.

OBJECTIVE: The purpose of this research project was to extend the research on the robustness of the dichotomous Rasch model to violations of the local independence assumption to the polytomous many-facet Rasch model (MFRM). Candidate scores from oral examinations and objective structured clinical examinations (OSCEs) have been shown to contain variance due to rater error/bias. If the MFRM is robust to local item dependence (LID), then the MFRM could theoretically be applied to medical OSCEs. METHODS: Five OSCEs were used in the study: 3 chiropractic licensure OSCEs and 2 nursing licensure OSCEs. Items were assigned to split-halves based on common stimulus. Split-half correlations were compared with Spearman-Brown estimates of reliability based on Cronbach alpha with all items contributing. Two- and 3-facet MFRM analyses were performed, first with individual items contributing and second with station totals contributing. Correlations were estimated between the 2 MFRM estimates. RESULTS: Cronbach alpha estimates with all items contributing were all very high (>.87). Spearman-Brown estimates were all considerably higher than split-half correlations. Correlations between MFRM by items and by stations were all very high (>.993). CONCLUSIONS: The research project provided evidence that OSCEs violate the local item independence assumption. The project also showed that the MFRM is quite robust to such violations. The authors recommend that the MFRM be applied to OSCEs by station totals for estimates of candidate ability, and by items for item performance measures and quality control programs.

Validation of Persian rapid estimate of adult literacy in dentistry.

AIM: The aim of the present study was to establish the psychometric properties of the Rapid Estimate of adult Literacy in Dentistry-99 (REALD-99) in the Persian language for use in an Iranian population (IREALD-99). METHODS: A total of 421 participants with a mean age of 28 years (59% male) were included in the study. Participants included those who were 18 years or older and those residing in Quazvin (a city close to Tehran), Iran. A forward-backward translation process was used for the IREALD-99. The Test of Functional Health Literacy in Dentistry (TOFHLiD) was also administrated. The validity of the IREALD-99 was investigated by comparing the IREALD-99 across the categories of education and income levels. To further investigate, the correlation of IREALD-99 with TOFHLiD was computed. A principal component analysis (PCA) was performed on the data to assess unidimensionality and strong first factor. The Rasch mathematical model was used to evaluate the contribution of each item to the overall measure, and whether the data were invariant to differences in sex. Reliability was estimated with Cronbach's α and test-retest correlation. RESULTS: Cronbach's alpha for the IREALD-99 was 0.98, indicating strong internal consistency. The test-retest correlation was 0.97. IREALD-99 scores differed by education levels. IREALD-99 scores were positively related to TOFHLiD scores (rh = 0.72, P < 0.01). In addition, IREALD-99 showed positive correlation with self-rated oral health status (rh = 0.31, P < 0.01) as evidence of convergent validity. The PCA indicated a strong first component, five times the strength of the second component and nine times the third. The empirical data were a close fit with the Rasch mathematical model. There was not a significant difference in scores with respect to income level (P = 0.09), and only the very lowest income level was significantly different (P < 0.01). CONCLUSIONS: The IREALD-99 exhibited excellent reliability on repeated administrations, as well as internal consistency. The IREALD-99 can be used for the basic screening of oral health literacy among the Iranian population.

Intra- and inter-observer reliability of the Cobb measurement by chiropractic interns using digital evaluation methods.

INTRODUCTION: It is important to create a body of evidence surrounding the reliability of certain diagnostic criteria. While the reliability of the Cobb measurement is well established with various licensed health care professionals, this study aims to determine the inter- and intra-observer reliability of the Cobb Measurement among chiropractic interns. METHODS: Fourteen chiropractic interns analyzed 10 pre-selected digital spinal radiographs on a Picture Archiving and Communication System (PACS) in two separate rounds of observation. The participants indicated their choice of end vertebra and Cobb Measurement in each round of observation. Agreement on vertebral levels selected was estimated using percentage agreement. Intra-observer reliability was estimated using the Pearson r correlation coefficient, and inter-observer correlation was estimated using the Inter-Class Coefficient (ICC). RESULTS: The range of percentage agreement on vertebral level selection was 0.36 - 0.79. The Pearson r correlation coefficient for round 1 and round 2 was 0.79. The ICC (3,1) was 0.79 (round 1), and 0.70 (round 2). CONCLUSION: Less than optimal agreement on end vertebrae selection was found between observers. Intra- and inter-observer reliability of the Cobb Measurement was 'excellent' (round 1) and 'good' (round 2).

INTRODUCTION: Il est important de créer un ensemble de preuves sur la fiabilité de certains critères de diagnostic. Bien que la fiabilité de la mesure Cobb soit bien établie chez divers professionnels de la santé, cette étude vise à déterminer la fiabilité des observations individuelles et entre ces observations de la mesure Cobb parmi des stagiaires en chiropratique. MÉTHODOLOGIE: Quatorze stagiaires en chiropratique ont analysé 10 radiographies numériques de la colonne vertébrale sur un système d'archivage et de transmission d'image (PACS) en deux séances distinctes d'observation. Les participants ont indiqué leur choix de vertèbre limite et de mesure Cobb dans chaque observation. Un consensus sur les niveaux vertébraux sélectionnés a été établi en fonction du pourcentage de concordance. La fiabilité des observations individuelles a été estimée à l'aide du coefficient de corrélation de Pearson r, et la corrélation entre les observations des stagiaires a été estimée à l'aide du coefficient interclasse (ICC). RÉSULTATS: La fourchette de pourcentage de concordance sur la sélection de niveau vertébral était de 0,36 à 0,79. Le coefficient de corrélation de Pearson r pour la première séance et la deuxième séance d'observations était de 0,79. Le coefficient interclasse (3,1) était de 0,79 (séance 1), et de 0,70 (séance 2). CONCLUSION: Le consensus sur la sélection des vertèbres limites a été moins qu'optimal entre les observateurs. La fiabilité des observations individuelles et entre ces observations de la mesure Cobb a été « excellente ¼ (séance 1) et « bonne ¼ (séance 2).

Validity and reliability of the Iranian version of the quality of recovery-40 questionnaire.

BACKGROUND: Recovery after anesthesia and surgery is a complex process and depends on many factors such as patient, anesthesia and surgery conditions as well pre-existing comorbidities. OBJECTIVES: The aims of this study were to translate the 40-item quality of recovery score (QoR-40) into Persian and evaluate its psychometric properties in Iranian patients. PATIENTS AND METHODS: We enrolled patients candidate for elective general surgery undergoing general anesthesia from July 2013 to December 2013 at Shahid Rajaee Hospital, Qazvin, Iran. Translation was performed based on Beaton's and Bullinger's recommendations. Estimates of internal consistency, test-retest reliability, concurrent validity, predictive validity and clinical validity were performed. RESULTS: All estimates of internal consistency were high (Cronbach's alpha = 0.89 for global estimates, subscales between 0.89 and 0.93). All test-retest scores and subscales were between 0.71 and 0.88.The correlation with a recovery visual analogue scale was 0.51, and all subscales correlated significantly with comparable subscales of the SF-36. An exploratory factor analysis found five-components and explained 52% of the variance. A confirmatory factor analysis based on the five-components, yielded good fit statistics (CFI = 0.93). CONCLUSIONS: Overall, the Persian version of the QoR-40 was both conceptually and linguistically equivalent to the original English QoR-40. This study revealed that the Persian version of the QoR-40 is a valid and reliable instrument to assess the recovery quality in Iranian patients after surgery.

Applying structural equation modeling to Canadian Chiropractic Examining Board measures.

The purpose of this research project was to determine if structural equation modeling (SEM) can be successfully applied to the Canadian Chiropractic Examining Board (CCEB) measures to explore the inferential nature of the "causal" relationship between academic ability and success on the CCEB examinations; specifically the ability to make correct clinical decisions. As this was a time-series study (pre-chiropractic grade-point-average to licensure examination data), a latent variable path analysis was the SEM method of choice. The Comparative Fit Index for the model to data fit was 0.98. Inferences include: 1) the need to recruit students with strong academic abilities, 2) the need to hold back students who have not achieved a high level of understanding of the first two-years of work at chiropractic college, and 3) that the CCEB extended-matching, long-format questions are a better estimate of clinical reasoning ability than 5-option short-format questions or the OSCE.