Effect of Reader and Patient Parameters on the Performance of Last-Image-Hold for Fluoroscopic Grading of Vesicoureteric Reflux.

OBJECTIVE. The purpose of this study is to determine the effect of different reader and patient parameters on the degree of agreement and the rate of misclassification of vesicoureteric reflux grading on last-image-hold frames in relation to spot-exposed frames from voiding cystourethrography (VCUG) as well as to determine the nature of reflux misclassification on last-image-hold frames. MATERIALS AND METHODS. Blinded readers conducted a retrospective evaluation of last-image-hold and spot-exposed frames of the renal fossae from 191 sequential VCUG examinations performed during a five-year period. Kappa tests were used to determine the agreement between reflux gradings and to assess the impact of reader and patient parameters. Pearson product-moment correlations were used to evaluate the effect of patient parameters on reader level of certainty regarding reflux grading. RESULTS. We measured almost perfect overall agreement for more experienced readers and substantial overall agreement for less experienced readers. Point estimates of overall misclassification were less than 2% for more experienced readers and less than 4% for less experienced readers. The readers' level of certainty about reflux grading had a positive impact on agreement values and misclassification rates. Experienced readers' most common misclassification was assigning reflux a grade of 3 on a spot-exposed frame and a grade of 2 on an equivalent last-image-hold frame. Inexperienced readers' most common misclassification involved missing reflux altogether. CONCLUSION. Instances of grade 2 reflux on last-image-hold frames may warrant supplemental evaluation with spot-exposed frames. Otherwise, a reader's level of certainty regarding reflux grading on a last-image-hold frame may help determine whether a supplemental spot-exposed frame would be beneficial.

Abusive fracture incidence over three decades at a level 1 pediatric trauma center.

Few studies have examined the incidence of abusive fractures in children. Only one study to date, from a single pediatric trauma center,has reported on the incidence of abusive fractures over time. That study showed a decrease in abusive fractures over a 24-year period. Our objective for this current study was to compare these published data with recent data from this same trauma center, allowing for a detailed comparison of the incidence of abusive fractures over a 30-year period. We included children <36months of age who presented to the emergency department of a level 1 pediatric trauma center (2007-2010) with≥1 fracture. Six experts from 3 different fields rated each case on the likelihood the fracture(s) was caused by abuse using an established 7- point scale, and a consensus rating was agreed upon for each case. The incidence of abusive fractures was calculated per 10,000 children <36months of age living in the geographic region and per 10,000 ED visits and was compared to previously published data for three prior time periods (1979-1983, 1991-1994, and 1999-2002) at the same pediatric trauma center. From 2007-2010, 551 children were identified, including 31 children who were rated as abused. The incidence of a child presenting with an abusive fracture in the county per year was 2.7/10,000 children <36months of age. The previous three time periods showed a countywide incidence of 3.2/10,000 (1979-1983), 1.7/10,000 (1991-1994), and 2.0/10,000 (1999-2002) (p for trend 0.34). The incidence per ED visit was 2.5/10,000 in the recent time period compared to 6.0/10,000 (1979-1983), 3.4/10,000 (1991-1994), and 2.5/10,000 (1999-2002) (p for trend <0.001). In this single institution review of fractures in children <36months of age, the incidence of abusive fractures has remained relatively constant over a 30-year period.

Inter-rater reliability of physical abuse determinations in young children with fractures.

As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children <36months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7-point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (κ=0.78) and CAPs (κ=0.67) had substantial within-specialty agreement, while radiologists (κ=0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (κ=0.81), while agreement was much lower for orthopaedists and radiologists (κ=0.37) and CAPs and radiologists (κ=0.42). More-experienced clinicians had substantial between-specialty agreement (κ=0.80) versus less-experienced clinicians who had moderate agreement (κ=0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.