Inter-Rater Reliability of Hounsfield Units as a Measure of Bone Density: Applications in the Treatment of Thoracolumbar Fractures.

OBJECTIVE: The study sought to investigate the reliability of computed tomography (CT)-derived Hounsfield unit (HU) measurements and ascertain the correlation between HU with quantitative CT (qCT)-derived bone mineral density (BMD) in cases of traumatic thoracolumbar fracture, based on native CT scans. METHODS: This study is a retrospective cross-sectional analysis of data sets from patients who received native CT scans and bone mineral density measurements (qCT) of the same vertebral body. Two different CT scanner models were used. The inter-rater reliability of 4 raters, which measured HU in native CT scans, was calculated using intraclass correlation coefficient for absolute agreement (ICC(3,1)). For the correlation between HU and qCT values, respectively the prediction of qCT based on HU, linear regression was used. Bland-Altman plots were used for visual comparison of predicted and measured qCT values. RESULTS: In total 305 data sets were analyzed. CT scanner model was found to have no significant impact on HU (P = 0.125). The inter-rater reliability for HU measurements from native CT scans was ICC(3,1)=0.932 (95% confidence interval 0.919-0.943, P < 0.001). The linear regression showed significant correlation of HU and qCT values for each rater (P < 0.001). The equation for qCT prediction with averaged coefficient and constant is qCT = 0.8 HU + 5. In the Bland-Altman plots no bias of predicted qCT values could be found, but a trend to overestimate predicted higher qCT values and underestimate lower qCT values, respectively. CONCLUSIONS: HU measurement shows very high inter-rater reliability. The HU values correlate closely with qCT BMD values. In summary, it seems that HU measurement is a suitable tool to readily and accurately assess bone quality without further scans or effort in cases of thoracolumbar spinal trauma.

Real-time assessment of perioperative behaviors in children and parents: development and validation of the perioperative adult child behavioral interaction scale.

BACKGROUND: Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments. METHODS: The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (kappa(w)) and multiple validations using Spearman correlation coefficients were analyzed. RESULTS: The PACBIS demonstrated good to excellent interrater reliability, with kappa(w) ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities. CONCLUSIONS: The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

Insufflation vs intubation during esophagogastroduodenoscopy in children.

OBJECTIVES: We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation. BACKGROUND: Optimum airway management during EGD in children remains undecided. METHODS/MATERIALS: Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi-square contingency tables or Fisher's exact test as appropriate. RESULTS: Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD. CONCLUSIONS: Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.