Improvement of agreement in TCM diagnosis among TCM practitioners for persons with the conventional diagnosis of rheumatoid arthritis: effect of training

Comparing the Effects of Short-Term Liuzijue Exercise and Core Stability Training on Balance Function in Patients Recovering From Stroke: A Pilot Randomized Controlled Trial

Aims

Liuzijue Qigong (LQG) exercise is a traditional Chinese exercise method in which breathing and pronunciation are combined with movement guidance. Breathing is closely related to balance, and LQG, as a special breathing exercise, can be applied to balance dysfunction after stroke. The purpose of this study was to observe the clinical effects of short-term LQG exercise on balance function in patients recovering from stroke.

Methods

Stroke patients were randomly divided into an Intervention Group (IG) (n = 80) and a Control Group (CG) (n = 80). The IG received conventional rehabilitation training plus LQG and the CG received conventional rehabilitation training plus Core Stability Training (CST). All patients received treatment once a day, 5 times a week for 2 weeks. The primary outcome was Berg Balance Scale (BBS). Secondary outcome measures were static standing and sitting balance with eyes open and closed, Fugl-Meyer Assessment (FMA), Maximum Phonation Time (MPT), Modified Barthel Index (MBI) and diaphragm thickness and mobility during quiet breath (QB) and deep breath (DB).

Results

Compared with the CG, the IG showed significant improvement in the BBS (10.55 ± 3.78 vs. 9.06 ± 4.50, P = 0.039), MPT (5.41 ± 4.70 vs. 5.89 ± 5.24, P = 0.001), MBI (12.88 ± 6.45 vs. 10.00 ± 4.84, P = 0.003), diaphragmatic mobility during QB (0.54 ± 0.73 vs. 0.33 ± 0.40, P = 0.01) and diaphragmatic mobility during DB (0.99 ± 1.32 vs. 0.52 ± 0.77, P = 0.003), Cop trajectory in the standing position with eyes open (−108.34 ± 108.60 vs. −89.00 ± 140.11, P = 0.034) and Cop area in the standing positions with eyes open (−143.79 ± 431.55 vs. −93.29 ± 223.15, P = 0.015), Cop trajectory in the seating position with eyes open (−19.95 ± 23.35 vs. −12.83 ± 26.64, P = 0.001) and Cop area in the seating position with eyes open (−15.83 ± 9.61 vs. −11.29 ± 9.17, P = 0.002).

Conclusions

The short-term LQG combined with conventional rehabilitation training significantly improved the balance functions of stroke patients. It also improved static standing and sitting balance with the eyes open, diaphragm functions, maximum phonation time and the quality of daily life for stroke patients.

Clinical Trial Registration

http://www.chictr.org.cn/edit.aspx?pid=25313&htm=4, Identifier: ChiCTR1800014864.

Experimental Studies of Inter-Rater Agreement in Traditional Chinese Medicine: A Systematic Review

Objectives: It has been recommended that clinical trials of Traditional Chinese Medicine (TCM) would be more ecologically valid if its characteristic mode of diagnostic reasoning were integrated into their design. In that context, however, it is also widely held that demonstrating a high level of agreement on initial TCM diagnoses is necessary for the replicability that the biomedical paradigm requires for the conclusions from such trials. Our aim was to review, summarize, and critique quantitative experimental studies of inter-rater agreement in TCM, and some of their underlying assumptions. Design: Systematic electronic searches were conducted for articles that reported a quantitative measure of inter-rater agreement across a number of rating choices based on examinations of human subjects in person by TCM practitioners, and published in English language peer-reviewed journals. Publications in languages other than English were not included, nor those appearing in other than peer-reviewed journals. Predefined categories of information were extracted from full texts by two investigators working independently. Each article was scored for methodological quality. Outcome measures: Design features across all studies and levels of inter-rater agreement across studies that reported the same type of outcome statistic were compared. Results: Twenty-one articles met inclusion criteria. Fourteen assessed inter-rater agreement on TCM diagnoses, two on diagnostic signs found upon traditional TCM examination, and five on novel rating schemes derived from TCM theory and practice. Raters were students of TCM colleges or graduates of TCM training programs with 3 or more years experience and licensure. Type of outcome statistic varied. Mean rates of pairwise agreement averaged 57% (median 65, range 19-96) across the 9 studies reporting them. Mean Cohen's kappa averaged 0.34 (median 0.34, range 0.07-0.59) across the seven studies reporting them. Meta-analysis was not possible due to variations in study design and outcome statistics. High risks of bias and confounding, and deficits in statistical reporting were common. Conclusions: With a few exceptions, the levels of agreement were low to moderate. Most studies had significant deficits of both methodology and reporting. Results overall suggest a few design features that might contribute to higher levels of agreement. These should be studied further with better experimental controls and more thorough reporting of outcomes. In addition, methods of complex systems analysis should be explored to more adequately model the relationship between clinical outcomes, and the series of diagnoses and treatments that are the norm in actual TCM practice.

Changes in Heart Rate Variability in Patients with Spleen-Qi Deficiency Syndrome

Many functional diseases are related to dysautonomia, and heart rate variability has been used to assess dysautonomia. However, heart rate variability has not been studied in Spleen-Qi deficiency syndrome (SQDS). Healthy volunteers (n = 37) and patients with SQDS (n = 67), recruited from the Clinic of the State University of Ecatepec Valley were included in the study. Outcome measures were average heart rate, standard deviation of the normal-to-normal heartbeat intervals, low frequency (LF), high frequency (HF) power, and the LF/HF ratio. Also, intestinal peristalsis, gastrointestinal symptoms (GSs), fatigue, and level of attention were measured. Standard deviation of the normal-to-normal heartbeat intervals (17 ± 2.3%) and HF (14 ± 3.1%) were lower in SQDS patients (17 ± 1.3%) than in healthy volunteers. SQDS patients had higher heart rate, LF power, LF/HF ratio, and fatigue scores (9.6 ± 1.12%, 16 ± 2.1%, 22 ± 3.8%, and 21 ± 4.1%). The fatigue correlated positively with the LF/HF ratio and negatively with HF power. The SQDS group had lower concentration performance (16.2 ± 1.9%) in the d2 test. The intestinal peristalsis showed a reduction (15 ± 1.3%) as compared with control. GS score and peristalsis correlated negatively with HF. Our results suggest that the pathology of SDQS could be associated with a low vagal tone which causes a decrease in peristalsis, increased fatigue, reduced attention, and appearance of GSs.

Pragmatic Combinations of Acupuncture Points for Lateral Epicondylalgia are Unreliable in the Physiotherapy Setting

This study describes the reliability of pragmatic combinations of acupuncture points for lateral epicondylalgia (LE) as prescribed by physiotherapists who were experts in acupuncture. Raters (n = 14; 33-59 years) independently prescribed acupuncture points for 30 simulated human patients with LE who were surveyed via a printed questionnaire. The frequency and cooccurrence of acupuncture points prescribed for patients with lateral epicondylitis were assessed. Absolute agreement and Light's kappa (κ_Light) with 95% confidence interval (CI) were used to quantify the interrater agreement. Raters prescribed 103 unique acupuncture points in different combinations with a median (min-max) of 5 (0-11) acupuncture points. The most prescribed acupuncture point was LI-11 (297 of 420; 71%), and the most common cooccurring acupuncture points were LI-11 and LI-4 (160 of 420; 38%). The absolute agreement for prescribing the acupuncture points ranged from 70% (point GB-20) to 0% (points LI-10, SP-6, LI-11, GB-34, LI-12, and LI-4). Point LR-3 showed the highest interrater reliability for prescribing the acupuncture points [κ_Light = 0.112, 95% CI = (0.055-0.194)], whereas point LI-4 showed the lowest reliability [κ_Light = -0.003, 95% CI = (-0.024 to 0.024)]. These findings suggest that pragmatic prescriptions of acupuncture points for LE are unreliable among physiotherapists who are experts in acupuncture. Explicit, high-level evidence-based rules for prescribing and teaching combinations of acupuncture points for LE are warranted.

Key symptoms selection for two major syndromes diagnosis of Chinese medicine in chronic hepatitis B

OBJECTIVE

To identify key symptoms of two major syndromes in chronic hepatitis B (CHB), which can be the clinical evidence for Chinese medicine (CM) doctors to make decisions.

METHODS

Standardization scales on diagnosis for CHB in CM were designed including physical symptoms, tongue and pulse appearance. The total of 695 CHB cases with dampness-heat (DH) syndrome or Pi (Spleen) deficiency (SD) syndrome were collected for feature selection and modeling, another 275 CHB patients were collected in different locations for validation. Key symptoms were selected based on modified information gain (IG), and 5 classifiers were applied to assist with models training and validation. Classification accuracy and area under receiver operating characteristic curves (AUC) were evaluated.

RESULTS

(1) Thirteen DH syndrome key symptoms and 13 SD syndrome key symptoms were selected from original 125 symptoms; (2) The key symptoms could achieve similar or better diagnostic accuracy than the original total symptoms; (3) In the validation phase, the key symptoms could identify syndromes effectively, especially in DH syndrome, which average prediction accuracy on 5 classifiers could achieve 0.864 with the average AUC 0.772.

CONCLUSION

The selected key symptoms could be simple DH and SD syndromes diagnostic elements applied in clinical directly. (Registration N0.: ChiCTR-DCC-10000759).

TCM tongue diagnosis index of early-stage breast cancer

OBJECTIVES

This paper investigates discriminating tongue features to distinguish between early stage breast cancer (BC) patients and non-breast cancer individuals through non-invasive traditional Chinese medicine (TCM) tongue diagnosis.

DESIGN

The tongue features for 67 patients with 0 and 1 stages of BC, and 70 non-breast cancer individuals are extracted by the automatic tongue diagnosis system (ATDS). A total of nine tongue features, namely, tongue color, tongue quality, tongue fissure, tongue fur, red dot, ecchymosis, tooth mark, saliva, and tongue shape are identified for each tongue. Features extracted are further sub-divided according to the areas located, i.e., spleen-stomach, liver-gall-left, liver-gall-right, kidney, and heart-lung areas. This study focuses on deriving significant tongue features (p<0.05) to discriminate early-stage BC patients from non-breast cancer individuals.

RESULTS

The Mann-Whitney test shows that the amount of tongue fur (p=0.024), maximum covering area of tongue fur (p=0.009), thin tongue fur (p=0.009), the average area of red dot (p=0.049), the maximum area of red dot (p=0.009), red dot in the spleen-stomach area (p=0.000), and red dot in the heart-lung area (p=0.000) demonstrate significant differences. The data collected are further classified into two groups. The training group consists of 57 early-stage BC patients and 60 non-breast cancer individuals, while the testing group is composed of 10 early-stage BC patients and 10 non-breast cancer individuals. The logistic regression by utilizing these 7 tongue features with significant differences in Mann-Whitney test as factors is performed. In order to reduce the number of tongue features employed in prediction, tongue features with the least amount of significant difference, namely, maximum area of red dot and average area of red dot, are removed progressively. The tongue features of the testing group are employed in the aforementioned three models to test the power of significant tongue features identified in predicting early-stage BC. An accuracy of 80%, 80% and 90% is reached on non-breast cancer individuals by applying the 7, 6 and 5 significant tongue features obtained through Mann-Whitney test, respectively, while 60%, 60% and 50% is reached on the corresponding early-stage BC patients.

CONCLUSION

The TCM tongue diagnosis can serve as a preliminary screening procedure in the early detection of BC in light of its simple and non-invasive nature, followed by other more accurate testing process. To the best of our knowledge, this is the first attempt in applying non-invasive TCM tongue diagnosis to the discrimination of early-stage BC patients and non-breast cancer individuals.

Extraction of Clinical Indicators That Are Associated with the Heat/Nonheat and Excess/Deficiency Patterns in Pattern Identifications for Stroke

The aim of this study is to extract indicators that are associated with the heat/nonheat and excess/deficiency patterns in stroke pattern identification through the large-scale analysis of clinical data. Two experts, who had more than three years of clinical experience with stroke, independently performed the pattern identification. We analyzed indicators of clinical data with two doctors' concurrent diagnoses on the patient's pattern identification. To verify heat/nonheat and excess/deficiency patterns, which are the basic elements of pattern identification, we grouped 960 patients diagnosed as the fire-heat pattern, the Yin deficiency pattern, and the Qi deficiency pattern in to two groups, the heat/nonheat group and the excess/deficiency group. We then extracted significant indicators using univariate and multivariate analysis. As a result of the comparison of 65 indicators, we were able to extract 10 indicators for the heat pattern, 6 for the nonheat pattern, 9 for the excess pattern, and 10 for the deficiency pattern. Extracted indicators in this study can be used for pattern identification in the context of stroke. These are positive indicators from large-scale clinical studies and are greatly expected to be crucial discriminant indicators in individual pattern identification henceforth.

Education of Chinese medicine tongue diagnosis by automatic tongue diagnosis system

OBJECTIVE

To investigate the efficacy of applying automatic tongue diagnosis system (ATDS) to the training of novice Chinese medicine (CM) doctors in the tongue diagnosis.

METHOD

A two-round experiment composed of pre- and after-training tests was performed. Two groups of CM doctors were formed by experienced doctors (ED) and novice doctors (ND). The intra- and inter-observer agreements for the ED and ND groups, and the inter-observer agreements between ATDS and ED, and ATDS and ND were derived first. After a 1-month training of the ND, the intra- and inter-observer agreements of the ND group, and the inter-observer agreement between ATDS and ND were obtained.

RESULT

The kappa value of agreement data for ND after training was significantly higher than ND before training with a level of P<0.05, indicating an obvious improvement of intra-observer agreement for ND after training with ATDS. The inter-observer agreements for the ED group, and ND group after training were significantly higher (P<0.05) than the ND group before training. In contrast, no significance is observed between the ED group and the ND group after training, indicating that physicians in the ND group achieve an inter-observer agreement to the same level as that of ED after 1-month training.

CONCLUSION

This finding validates the utilization of ATDS as a mean of education in forging consensus during the learning process of tongue diagnosis.

Herb Network Analysis for a Famous TCM Doctor's Prescriptions on Treatment of Rheumatoid Arthritis

Traditional Chinese Medicine (TCM) doctors always prescribe various herbal formulae tailored to individual patients. However, there is still a lack of appropriate methods to study the rule and potential biological basis underlying the numerous prescriptions. Here we developed an Herb-Compound-Target-Disease coherent network approach to analyze 871 herbal prescriptions from a TCM master, Mr. Ji-Ren Li, in his clinical practice on treatment of rheumatoid arthritis (RA). The core herb networks were extracted from Mr. Li's prescriptions. Then, we predicted target profiles of compounds in core herb networks and calculated potential synergistic activities among them. We further found that the target sets of core herbs overlapped significantly with the RA related biological processes and pathways. Moreover, we detected a possible connection between the prescribed herbs with different properties such as Cold and Hot and the Western drugs with different actions such as immunomodulatory and hormone regulation on treatment of RA. In summary, we explored a new application of TCM network pharmacology on the analysis of TCM prescriptions and detected the networked core herbs, their potential synergistic and biological activities, and possible connections with drugs. This work offers a novel way to understand TCM prescriptions in clinical practice.

Effects of diagnostic errors in pattern differentiation and acupuncture prescription: a single-blinded, interrater agreement study

This study compared the interrater agreement for pattern differentiation and acupoints prescription between two groups of human patients simulated with different diagnostic outcomes. Patients were simulated using a dataset about zangfu patterns and separated into groups (n = 30 each) according to the diagnostic outcome determined by a computational model. A questionnaire with 90 patients was delivered to 6 TCM experts (4-year minimal of clinic experience) who were asked to indicate a single pattern (among 73) and 8 acupoints (among 378). Interrater agreement was higher for pattern differentiation than for acupuncture prescription. Interrater agreement on pattern differentiation was slight for both groups with correct (Light's κ = 0.167, 95% CI = [0.108; 0.254]) and incorrect diagnosis (Light's κ = 0.190, 95% CI = [0.120; 0.286]). Interrater agreement on acupuncture prescription was slight for both groups of correct (ι = 0.029, 95% CI = [0.015; 0.057]) and incorrect diagnosis (ι = 0.040, 95% CI = [0.023; 0.058], P = 0.075). Diagnostic performance of raters yielded the following: accuracy = 60.9%, sensitivity = 21.7%, and specificity = 100%. An overall improvement in the interrater agreement and diagnostic accuracy was observed when the data were analyzed using the internal systems instead of the pattern's labels.

Interobserver reliability of four diagnostic methods using traditional korean medicine for stroke patients

Objective. The aim of this study is to evaluate the consistency of pattern identification (PI), a set of diagnostic indicators used by traditional Korean medicine (TKM) clinicians. Methods. A total of 168 stroke patients who were admitted into oriental medical university hospitals from June 2012 through January 2013 were included in the study. Using the PI indicators, each patient was independently diagnosed by two experts from the same department. Interobserver consistency was assessed by simple percentage agreement as well as by kappa and AC₁ statistics. Results. Interobserver agreement on the PI indicators (for all patients) was generally high: pulse diagnosis signs (AC₁ = 0.66–0.89); inspection signs (AC₁ = 0.66–0.95); listening/smelling signs (AC₁ = 0.67–0.88); and inquiry signs (AC₁ = 0.62–0.94). Conclusion. In four examinations, there was moderate agreement between the clinicians on the PI indicators. To improve clinician consistency (e.g., in the diagnostic criteria used), it is necessary to analyze the reasons for inconsistency and to improve clinician training.

Tongue diagnosis system for quantitative assessment of tongue coating in patients with functional dyspepsia: a clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Tongue diagnosis is a significant procedure to examine the physiological and pathological changes of the human body in oriental medicine. However, the conventional method of tongue diagnosis including direct observation of tongue has limitations because of various external factors and subjective factors. Therefore, the current study investigated the usefulness of the tongue diagnosis system (TDS) as a diagnostic tool for evaluating tongue coating thickness (TCT) by assessing the agreement between the TDS and a gold standard established by assessors using the conventional method.

MATERIALS AND METHODS

The present study was designed as a prospective clinical trial including 60 patients with functional dyspepsia. The TDS was used to capture tongue images twice within a 30-min interval to assess its reproducibility. Tongue coating percentage was measured by the TDS, and TCT was classified as either no coating, thin coating, or thick coating according to the existing diagnostic criteria. After both TDS examinations, the weight of tongue coating was quantitatively measured, and the correlation between the actual quantity of tongue coating and the percentage of the coating measured by the TDS was analyzed using Pearson׳s correlation. After collecting tongue images in all 60 patients, tongue coating was evaluated using a conventional method by 5 well-trained assessors to establish the gold standard for evaluating TCT, which allowed us to assess the diagnostic agreement between the TDS and the gold standard. After 2 weeks, TCT evaluation was repeated by the same assessors using the same images but in a random order.

RESULTS

The agreement between the TDS and the gold standard for evaluating TCT was almost perfect (weighted kappa, 0.840), as was the reproducibility of the TDS (weighted kappa, 0.851). The percentage of tongue coating measured by the TDS was significantly correlated with the weight of tongue coating (r=0.442, p <0.001). The levels of intra-rater reliability ranged from substantial to almost perfect (range of weighted kappa, 0.777-0.923). The inter-rater reliability of 5 assessors was moderate (weighted kappa, 0.563).

CONCLUSIONS

The present study demonstrated that the TDS can be used as a diagnostic tool for the objective and standardized evaluation of TCT in actual clinical practice.

Traditional East Asian medicine: how to understand and approach diagnostic findings and patterns in a modern scientific framework?

Research into the diagnostic methods and patterns of traditional East Asian medical (TEAM) systems of practice such as acupuncture and herbal medicine face certain challenges due to the nature of thinking in TEAM and the subjective basis of judgments made in practice. The TEAM-based diagnosis can take into account various findings and signs such as the appearance of the tongue, palpable qualities of the radial pulses, palpable qualities and findings on the abdomen, the complexion of the patient and so on. Both diagnostic findings and the patterns of diagnosis cannot be assumed to have objective bases or to be causally related to the complaints of the patient. However, the diagnoses of TEAM based acupuncture and herbal medicine have tended to look at pictures of the whole patient and rather than focus on a particular symptom, they have looked across a myriad of signs and symptoms to decide or identify the 'pattern' of diagnosis according to the theory in question. Although open for selective and subjective biases each diagnosis pattern always comes with a prescribed treatment tailored to the pattern. Further, the same research requirements needed for the validation of the diagnoses are needed also for these clinical observations and judgments. Hence, it is necessary, albeit challenging for research on TEAM diagnoses to first address these issues before proceeding to more complex investigations such as the development of instruments for making diagnostic observations, instruments for forming diagnostic conclusions or studies investigating the physiological bases of the diagnostic patterns. Preliminary work has started and instruments have been made, but we suggest that any instrumentation must necessarily be first validated by matching of the calibrated or scaled observations or judgments to observations made and agreed upon by relevant experts. Reliability of all observations and judgments are needed before any other tool, technology or more advanced approach can proceed and also whenever the natural system of diagnosis-treatment is applied in clinical trials. In this paper the authors highlight the core problems and describe a step wise process for addressing them.

Using a questionnaire among patient, resident doctor and senior supervisor: Are their answers the same?

OBJECTIVES

This study aims to contribute to the development of objective diagnostic standards in Traditional Chinese Medicine (TCM), in order to improve the training of physicians.

METHODS

We devised a questionnaire study to evaluate the accuracy of resident doctors' diagnostic skills by comparing their assessment of patients with those of their senior supervising physician and the patients themselves. We selected 39 patients with systemic lupus erythematosus (SLE) at Chang Gung Memorial Hospital, Taiwan, between November 1, 2008 and June 30, 2012, and had the resident doctors (R), their senior supervisor (S) and their patients (P) fill out questionnaires before treatment (V1), immediately after treatment (V5) and two months after treatment (V6), in order to record their assessments on the patients' condition. The R and S questionnaires covered subjective symptoms, tongue, and pulse, while the P questionnaires only included general symptoms. We then compared the assessment records to determine the level of agreement between them.

RESULTS

The agreements of inquiry during the study for P and S were 0.78 (V1) to 0.84 (V6) and 0.87 (V1) to 0.94 (V6) for R and S, respectively, the agreements between R and S for tongue diagnosis and pulse diagnosis were 0.87 (V1) to 0.90 (V6) and 0.91 (V1) to 0.95 (V6), respectively. All the above agreements improved with time from V1 to V6.

CONCLUSIONS

The results show that the patient input was feasible and effective and that the questionnaire method provided an objective assessment standard to determine how successfully the resident doctor was trained. Furthermore, it facilitated a training process that could help resident doctors improve their skills.

Breast cancer index: a perspective on tongue diagnosis in traditional chinese medicine

Breast cancer (BC) ranks second in the cancer fatality rate among females worldwide. Mammogram, ultrasound, magnetic resonance imaging (MRI), blood testing, and fine needle aspiration biopsy are usually applied to discriminate BC patients from normal persons. False-negative results, undetectable calcifications, movement-incurred blurry image, infection, and sampling error are commonly associated with these traditional means of diagnosis. Traditional Chinese medicine (TCM) covers a broad range of medical practices sharing common theoretical concepts. Tongue diagnosis plays an important role in TCM. Organ conditions, properties, and variation of pathogens can be revealed through observation of tongue. In light of this observation, this paper investigates discriminating tongue features to distinguish between BC patients and normal people, and establishes differentiating index to facilitate the non-invasive detection of BC. The tongue features for 60 BC patients and 70 normal persons were extracted by the Automatic Tongue Diagnosis System (ATDS). The Mann-Whitney test showed that the amount of tongue fur (P = 0.007), tongue fur in the spleen-stomach area, maximum covering area of tongue fur, thin tongue fur, the number of tooth marks, the number of red dots, red dot in the spleen-stomach area, red dot in the liver-gall-left area, red dot in the liver-gall-right area, and red dot in the heart-lung area demonstrated significant differences (P < 0.05). The tongue features of the testing group were employed to test the power of significant tongue features identified in predicting BC. An accuracy of 80% was reached by applying the seven significant tongue features obtained through Mann–Whitney test. To the best of our knowledge, this is the first attempt in applying TCM tongue diagnosis to the discrimination of BC patients and normal persons.

Reliability and Validity Assessment of Mizaj Questionnaire: A Novel Self-report Scale in Iranian Traditional Medicine

BACKGROUND

In Iranian Traditional Medicine, mizaj (temperament) plays a key role in preventive, therapeutic and lifestyle recommendations. A reliable self-reported scale for mizaj identification is critically needed to introduce ITM into the official medical and health care system especially in the case of designing national preventive protocols.

OBJECTIVES

The present study aimed to design a preliminary self-administered mizaj questionnaire and assessed its reliability and validity in Iran.

PATIENTS AND METHODS

In this cross-sectional study, a questionnaire with 52 items was designed based on mizaj-related indices. Subsequent to content and face validity assessment, using qualitative and quantitative method, 47 items remained. Based on the non-randomly sampling, the test-retest reliability of each question and internal consistency of the questionnaire was examined by the participation of 35 volunteers. The reliable version questionnaire was filled up by 52 volunteers wherein they were divided into warm/cold and wet/dry groups based on their mizaj which was predetermined by a team of expert practitioners. Logistic regression analysis was performed for validity process between the experts' assessment of mizaj and each of the items in the questionnaire that resulted to the final ten-item questionnaire divided into two subscales. By using ANOVA and post Hoc with Dunnet statistics, the optimum cut-off points were defined and their sensitivity and specificity was assessed.

RESULTS

The weighted kappa coefficients of the 39 items were between 0.40 and 0.82 showing their acceptable reliability and the Cronbach's α coefficient was 0.71 showing the internal consistency. The sensitivity and specificity of the final questionnaire cut-off points were 65% and 93% for the warm group, 52% and 97% cold group, 53% and 67% dry group and finally 53% and 76% wet group.

CONCLUSIONS

Our results suggested that many of the designed questions according to the literature's mizaj identification indices had satisfactory reliability and the final ten-item questionnaire could discriminate the different groups of mizaj, therefore, this can be used as the first version of a brief self-report mizaj estimating scale.

Availability of tongue diagnosis system for assessing tongue coating thickness in patients with functional dyspepsia

Tongue diagnosis is an important procedure in traditional Korean medicine (TKM). In particular, tongue coating thickness (TCT) is deemed to show the progression of the disease. However, conventional tongue diagnosis has limitations because of various external factors. Therefore, it is necessary to investigate the availability of tongue diagnosis system (TDS) in the assessment of TCT. This study has been designed as a prospective clinical trial involving 60 patients with functional dyspepsia. Tongue images will be obtained by TDS twice with a 30 min interval. The system will measure the percentage of TCT and classify it as either no coating, thin coating, or thick coating according to the existing diagnostic criteria. After finishing the collection of 60 patients' tongue images, TCT on the images will be simultaneously evaluated by the conventional method to establish the gold standard for assessing TCT by 5 well-trained clinicians. The evaluation will be repeated by the same clinicians after 2 weeks, but the order of the images will be changed. This trial is expected to provide clinical evidence for the availability of TDS as a diagnostic tool and to contribute to the standardization of the diagnosis system used in TKM. This trial is registered with ClinicalTrials.gov NCT01864837.

Intrarater and interrater reliability of pulse examination in traditional Indian Ayurvedic medicine

Background

In Ayurveda, pulse examination (nadipariksha) is an important tool to assess the status of three doshas: vata, pitta, and kapha. Long historical use has been seen as a documentation of its efficacy; however, there is a lack of a quantitative measure of the reliability of the pulse examination method. The objective of this study was to test the intrarater and interrater reliability of pulse examination in Ayurveda.

Methods

Fifteen registered Ayurvedic doctors with 3–15 years of experience examined the pulse of 20 healthy volunteers twice, for a total of 600 examinations. The examinations were performed blind and in a random order. Only the current status of dosha-specific methods of pulse examination were considered. Cohen's weighted κ statistic was used as a measure of intrarater and interrater reliability, and a hypothesis of homogeneous diagnosis (random rating) was tested. Following this, we tested whether proportions of ratings were equal between doctors.

Results

According to the Landis and Koch scale, the level of reliability ranged from poor to moderate. It was observed that the doctors more frequently diagnosed a combination of two doshas than a single dosha. The κ values were generally larger for experienced doctors (p = 0.04).

Conclusion

Experience and proper training have important roles in pulse examination.

Patterns of traditional chinese medicine diagnosis in thermal laser acupuncture treatment of knee osteoarthritis

Knee osteoarthritis (OA) manifests with pain, joint stiffness, and limited function. In traditional Chinese medicine, knee OA is differentiated into three patterns: yang deficiency and cold coagulation, kidney deficiency, and blood stasis. The objective of this study was to determine whether yang deficiency cold coagulation patients respond better to thermal laser acupuncture treatment than do non-yang deficient patients. Fifty-two patients with OA were allocated to group A (yang deficient, n = 26) or B (non-yang deficient, n = 26). All patients received a 20-min thermal laser acupuncture treatment at acupoint Dubi (ST 35) three times a week for two weeks and twice a week for another four weeks. Outcome assessments were performed immediately after the first treatment, and at weeks 2, 6, and 10. Group A function scores were significantly better than those of Group B at weeks 2 (P = 0.049), 6 (P = 0.046), and 10 (P = 0.042), but no significant differences were found between the two groups in pain and stiffness scores at any time point. No significant adverse effect was observed. The combined 10.6 μm–650 nm laser treatment might be most beneficial to yang deficiency cold coagulation knee OA patients, particularly in improving function.

Tongue diagnosis of traditional Chinese medicine for rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease with unknown aetiology that causes the immune system to attack the joints (synoviums), leading to chronic inflammation. According to the traditional Chinese medicine (TCM), RA falls into the category of Impediment disease ("Bi" syndrome), that is, poor circulation of qi and blood (stasis). Tongue diagnosis is an important method of TCM to detect blood stasis. In this study, 74 RA patients, meeting the pre-set criteria, were recruited via rheumatology outpatient clinic and examined by experienced rheumatology physicians. Two images-one of the tongue and the other, sublingual vessels-of the same patient were taken by a Canon digital camera in a darkroom with uniform lighting conditions. Relevant features of the tongue were extracted by utilising image processing techniques. Every tongue was classified into corresponding patterns based on the features identified. The subjects included 62 females and 12 males with an average age of 49.86 ± 13.81 years old, an average morbidity period of 4.56 ± 3.92 years, an average rheumatoid factor (RF) of 225.3 ± 373.8 IU/mL and an average erythrocyte sedimentation rate of (ESR) 40.9 ± 31.9 m/hr. According to our study, 86% of the patients with RA have tongues with sublingual vessels with a width of more than 2.7 mm, a length of more than 3/5 from tongue tipto sublingual caruncle, or a count of sublingual vessels more than 2. Moreover, since RA index is highly correlated with blood stasis in TCM, a logistic regression is conducted to predict the probability of presence of RA using RF and ESR as explanatory variables. Also, the logistic regression analysis of RA with respect to the conventional tongue diagnosis criteria was performed. Based on the aforementioned studies, we concluded that tongue diagnosis is helpful in detecting blood stasis of RA.

Histone modifications and traditional Chinese medicinals

Background

Chromatin, residing in the nuclei of eukaryotic cells, comprises DNA and histones to make up chromosomes. Chromatin condenses to compact the chromosomes and loosens to facilitate gene transcription and DNA replication/repair. Chemical modifications to the histones mediate changes in chromatin structure. Histone-modifying enzymes are potential drug targets. How herbs affect phenotypes through histone modifications is interesting.

Methods

Two public traditional Chinese medicine (TCM) databases were accessed to retrieve the chemical constituents and TCM natures of 3,294 TCM medicinals. NCBI taxonomy database was accessed to build the phylogenetic tree of the TCM medicinals. Statistical test was used to test if TCM natures of the medicinals cluster in the phylogenetic tree. A public chemical-protein interaction database was accessed to identify TCM medicinals whose constituent chemicals interact with human histone-modifying enzymes. For each histone modification, a correlation coefficient was calculated between the medicinals’ TCM natures and modification modulabilities. Information of the ingredient medicinals of 200 classical TCM formulas was accessed from a public database.

Results

It was found that 1,170 or 36% of the 3,294 TCM medicinals interact with human histone-modifying enzymes. Among the histone-modifying medicinals, 56% of them promote chromatin condensation. The cold-hot natures of TCM medicinals were found to be phylogenetically correlated. Furthermore, cold (hot) TCM medicinals were found to be associated with heterochromatinization (euchromatinization) through mainly H3K9 methylation and H3K4 demethylation. The associations were weak yet statistically significant. On the other hand, analysis of TCM formulas, the major form of TCM prescriptions in clinical practice, found that 99% of 200 government approved TCM formulas are histone-modifying. Furthermore, in formula formation, heterochromatic medicinals were found to team up with other heterochromatic medicinals to enhance the heterochromatinization of the formula. The synergy was mainly through concurrent DNMT and HDAC inhibition, co-inhibition of histone acetylation and H3S10 phosphorylation, or co-inhibition of H3K4 demethylation and H3K36 demethylation.

Conclusions

TCM prescriptions’ modulation of the human epigenome helps elucidation of phyto-pharmacology and discovery of epigenetic drugs. Furthermore, as TCM medicinals’ properties are closely tied to patient TCM syndromes, results of this materia-medica-wide, bioinformatic analysis of TCM medicinals may have implications for molecular differentiation of TCM syndromes.

Interrater reliability of chinese medicine diagnosis in people with prediabetes

Background. Achieving reproducibility in research design is challenging when patient cohorts under study are inconsistently defined. Traditional Chinese medicine (TCM) diagnosis is one example where inconsistency between practitioners has been found. We hypothesise that the use of a validated instrument may improve consistency. Biochemical biomarkers may also be used enhance reliability. Methods. Twenty-seven participants with prediabetes were assessed by two TCM practitioners using a validated instrument (TEAMSI-TCM). Inter-rater reliability was summarised using percentage agreement and the kappa coefficient. One-way ANOVA and Tukey's post hoc test were used to test links between TCM diagnosis and biomarkers. Results. The two practitioners agreed on primary diagnosis of 70% of participants. kappa = 0.56 (P < 0.001). The three predominant TCM diagnostic patterns for people with prediabetes were Yin deficiency, Qi and Yin deficiency and Spleen qi deficiency. The Spleen Qi deficiency with Damp cohort had statistically significant higher fasting glucose, higher insulin, higher insulin resistance, higher HbA1c and lower HDL than those with Qi and Yin deficiency. Conclusions. Using the TEAMSI-TCM resulted in moderate interrater reliability between TCM practitioners. This study provides initial evidence of variation in the biomarkers of people with prediabetes according to the different TCM patterns which may suggest a route to further improving interrater reliability.

Reliability studies of diagnostic methods in Indian traditional Ayurveda medicine: An overview

Recently, a need to develop supportive new scientific evidence for contemporary Ayurveda has emerged. One of the research objectives is an assessment of the reliability of diagnoses and treatment. Reliability is a quantitative measure of consistency. It is a crucial issue in classification (such as prakriti classification), method development (pulse diagnosis), quality assurance for diagnosis and treatment and in the conduct of clinical studies. Several reliability studies are conducted in western medicine. The investigation of the reliability of traditional Chinese, Japanese and Sasang medicine diagnoses is in the formative stage. However, reliability studies in Ayurveda are in the preliminary stage. In this paper, examples are provided to illustrate relevant concepts of reliability studies of diagnostic methods and their implication in practice, education, and training. An introduction to reliability estimates and different study designs and statistical analysis is given for future studies in Ayurveda.

Reliability of the Eight Guiding Principles and Syndrome Diagnosis in Chinese Medicine Diagnosis of Patients with Knee Osteoarthritis

Abstract Background: A Chinese medicine (CM) "Syndrome" or "pattern of disharmony" is a diagnostic subcategory of a disease/disorder or symptom, characterized by particular symptoms and signs, and indicative of the etiology and the state of pathogenesis at that point in time. In CM, treatment is aimed at addressing the disease/disorder and the underlying CM Syndrome. A few studies have assessed reliability of CM Syndrome diagnosis according to one of the major CM theories, Zang-Fu theory, but only 1 study has investigated the reliability of diagnosis according to a fundamental theory, that of the Eight Guiding Principles. Given that treatment follows diagnosis, if diagnosis is not reliable there will be lower confidence that optimal treatment is received. There have not yet been any reliability studies in osteoarthritis (OA). Little is known about the characteristics or Syndromes of OA with respect to the Eight Guiding Principles and Zang-Fu theory. Objectives: The objectives of this study were to characterize diagnostic subcategories of OA according to the Eight Guiding Principles and Zang-Fu theory and to investigate the inter-rater reliability of CM diagnosis according to these two theories. Methods: An inter-rater reliability study was conducted as a substudy of a clinical trial investigating the treatment of knee OA with Chinese herbal medicine. Two (2) experienced CM practitioners conducted a CM examination separately, within 2 hours of each other, of 40 participants. A CM assessment form was utilized to record the diagnostic data. Cohen's κ coefficient was used as a measure of reliability. Results: Results support the concept that knee OA is more likely a disease with characteristics of Interior, Deficiency, and Yin according to the Eight Guiding Principles. There was no clear agreement on CM Syndromes of knee OA according to Zang-Fu theory. The main Zang Organs involved were broadly agreed on; they were Kidney, Liver, and Spleen. Conclusions: Results lend some empirical evidence to support to the argument that OA of the knee is an Internal disease with the manifestations of Deficient symptoms according to CM theories. To establish if Syndrome diagnosis is reliable, more studies should be conducted for different clinical conditions.

The Study on the Agreement between Automatic Tongue Diagnosis System and Traditional Chinese Medicine Practitioners

Tongue diagnosis is an important practice in traditional Chinese medicine (TCM) for diagnosing diseases before determining proper means of treatments. Traditionally, it depends solely on personal knowledge and experience of the practitioner, thereby being criticized as lacking of objectivity. Currently, no research regarding intra- and inter-agreements of automatic tongue diagnosis system (ATDS) and TCM doctors has been conducted. In this study, the ATDS is developed to extract a variety of tongue features and provide practitioners with objective information to assist diagnoses. To evaluate the ATDS clinical stability, 2 sets of tongue images taken 1 hour apart from 20 patients with possible variations in lighting and extruding tongue, are employed to investigate intra-agreement of the ATDS, intra-agreement of the TCM doctors, and the inter-agreement between the ATDS and TCM doctors. The ATDS is shown to be more consistent with significantly higher intra-agreement than the TCM doctors (kappa value: 0.93 ± 0.06 versus 0.64 ± 0.13) with P < 0.001 (Student's t-test). Inter-agreements between the ATDS and TCM doctors, as well as among the TCM doctors are both moderate. The high agreement of the ATDS can provide objective and reliable tongue features to facilitate doctor in making effective observation and diagnosis of specific diseases.

Reducing interrater variability and improving health care: a meta-analytical review

OBJECTIVES

In the scientific literature about reliability, the main approach to increasing reliability seems to involve increasing the number of observers and improving the instrument used. Other aspects for improving reliability - like the training of raters - seem to receive less notice. It is worth asking whether this technical approach could be complemented by training the user of the instrument. A systematic meta-analytical review of the research literature was performed to answer this question and examine the effectiveness of planned interventions for improving interrater reliability of health care professionals.

METHOD

The databases of PubMed (MEDLINE), Embase, Omega and PsycINFO were searched. The inclusion criteria were met by 57 studies. Details extracted from the studies included the study design, the number of observers and the number of observed cases, the intervention, the type of instrument (whether or not it was highly technical), and statistical information about the agreement before and after the intervention. Interventions were categorized into three groups: training of professionals, improving the diagnostic instrument and a combination of training and improving the instrument. A meta-analysis was performed by means of linear regression.

RESULTS

The interventions were arranged according to their effectiveness in improving the diagnostic instrument (mean change: β = 0.13), training combined with improving the instrument (mean change: β = 0.10) and training (mean change: β = 0.09).

CONCLUSION

On average, although all types of interventions are effective, improving the diagnostic instrument seems to be the most effective. Especially when highly technical instruments were concerned, improvement proved to be very effective (β = 0.52). Because instrumental variables constitute a major source of error, improving the instrument is an important approach. However, this review offers solid arguments that can complement the literature and practice, with a focus on training the user of the instrument.

Construction of a traditional Chinese medicine syndrome-specific outcome measure: the Kidney Deficiency Syndrome Questionnaire (KDSQ)

Background

Development of Traditional Chinese Medicine (TCM) syndrome-specific outcome measures is needed for the evaluation of TCM syndrome-specific therapies. We constructed a Kidney Deficiency Syndrome Questionnaire (KDSQ) for the evaluation of the common TCM syndromes Kidney-Yin Deficiency Syndrome (KDS-Yin) and Kidney-Yang Deficiency Syndrome (KDS-Yang) in middle-aged women with menopausal symptoms.

Methods

KDS-Yin and KDS-Yang were traditionally defined by expert opinion were validated by exploratory factor analysis (EFA) and structural equation modeling (SEM). Content validity was tested by EFA on a sample of 236 women from a seminar and SEM on another sample of 321 women from a postal survey. Other psychometric properties were tested on 292 women from the seminar at baseline and two systematically selected sub-samples: 54 who reported no changes in discomforts 11–12 days after the baseline and 31 who reported changes in discomforts 67–74 days after the baseline. All participants completed the KDSQ, the Greene Climacteric Scale and the standard 12-item Short Form Health Survey.

Results

The EFA and SEM established the measurement models of KDS-Yin and KDS-Yang supporting content validity of the KDSQ. Internal consistency was good (Cronbach’s Alpha >0.70). Construct validity was supported by theoretically-derived levels of correlation with the established external measures. Test–retest reliability was strong (ICC_agreement: KDS-Yin, 0.94; KDS-Yang, 0.93). The KDSQ was responsive to changes over time as tested by effect size and longitudinal validity.

Conclusions

The KDSQ was a valid and reliable measure for KDS-Yin and KDS-Yang in Hong Kong Chinese middle-aged women with menopausal symptoms.

Urine metabolomics combined with the personalized diagnosis guided by Chinese medicine reveals subtypes of pre-diabetes

The prevalence of type 2 diabetes continuously increases globally. A personalized strategy applied in the pre-diabetic stage is vital for diabetic prevention and management. The personalized diagnosis of Chinese Medicine (CM) may help to stratify the diabetics. Metabolomics is regarded as a potential platform to provide biomarkers for disease-subtypes. We designed an explorative study of 50 pre-diabetic males, combining GC-MS urine metabolomics with CM diagnosis in order to identify diagnostic biomarkers for pre-diabetic subtypes. Three CM physicians reached 85% diagnosis consistency resulting in the classification of 3 pre-diabetic groups. The urine metabolic patterns of groups 1 'Qi-Yin deficiency' and 2 'Qi-Yin deficiency with dampness' (subtype A) and group 3 'Qi-Yin deficiency with stagnation' (subtype B) were clearly discriminated. The majority of metabolites (51%), mainly sugars and amino acids, showed higher urine levels in subtype B compared with subtype A. This indicated more disturbances of carbohydrate metabolism and renal function in subtype B compared with subtype A. No differences were found for hematological and biochemical parameters except for levels of glucose and γ-glutamyltransferase that were significantly higher in subtype B compared with subtype A. This study proved that combining metabolomics with CM diagnosis can reveal metabolic signatures for pre-diabetic subtypes. The identified urinary metabolites may be of special clinical relevance for non-invasive screening for subtypes of pre-diabetes, which could lead to an improvement in personalized interventions for diabetics.

Interobserver reliability of tongue diagnosis using traditional korean medicine for stroke patients

Observation of the tongue, also known as tongue diagnosis, is an important procedure in diagnosis by inspection in Traditional Korean medicine (TKM). We investigated the reliability of TKM tongue diagnosis in stroke patients by evaluating interobserver reliability regarding tongue indicators as part of the project named the Fundamental Study for the Standardization and Objectification of Pattern Identification in TKM for Stroke (SOPI-Stroke). A total of 658 patients with stroke admitted to 9 oriental medical university hospitals participated. Each patient was independently seen by two experts from the same department for an examination of the status of the tongue. Interobserver agreement about subjects regarding pattern identification with the same opinion between the raters (n = 451) was generally high, ranging from “moderate” to “excellent”. Interobserver agreement was nearly perfect for certain signs of special tongue appearance (mirror, spotted, and bluish purple), poor for one of the tongue colors (pale) and moderate for others. Clinicians displayed measurable agreement regarding tongue indicators via both observation and pattern identification consistency. However, interobserver reliability regarding tongue color and fur quality was relatively low. Therefore, it is necessary to improve objectivity and reproducibility of tongue diagnosis through the development of detail-oriented criteria and enhanced training of clinicians.

Analysis of agreement on traditional chinese medical diagnostics for many practitioners

In Traditional Chinese Medicine (TCM) diagnostics, it is an important issue to study the degree of agreement among several distinct practitioners. In order to study the reliability of TCM diagnostics, we have to design an experiment to simultaneously deal with both of the cases when the data is ordinal and when there are many TCM practitioners. In this study, we consider a reliability measure called "Krippendorff's alpha" to investigate the agreement of tongue diagnostics in TCM. Besides, since it is not easy to obtain a large data set with patients rated simultaneously by many TCM practitioners, we use the renowned "bootstrapping" to obtain a 95% confidence interval for the Krippendorff's alpha. The estimated Krippendorff's alpha for the agreement among ten physicians that discerned fifteen randomly chosen patients is 0.7343, and the 95% bootstrapping confidence interval for the true alpha coefficient is [0.6570, 0.7349]. The data was collected and analyzed at the Department of Traditional Chinese Medicine, Changhua Christian Hospital (CCH) in Taiwan.

Misdiagnosis and undiagnosis due to pattern similarity in Chinese medicine: a stochastic simulation study using pattern differentiation algorithm

Background

Whether pattern similarity causes misdiagnosis and undiagnosis in Chinese medicine is unknown. This study aims to test the effect of pattern similarity and examination methods on diagnostic outcomes of pattern differentiation algorithm (PDA).

Methods

A dataset with 73 Zangfu single patterns was used with manifestations according to the Four Examinations, namely inspection (Ip), auscultation and olfaction (AO), inquiry (Iq) and palpation (P). PDA was applied to 100 true positive and 100 true negative manifestation profiles per pattern in simulation. Four runs of simulations were used according to the Four Examinations: Ip, Ip+AO, Ip+AO+Iq and Ip+AO+Iq+P. Three pattern differentiation outcomes were separated, namely correct diagnosis, misdiagnosis and undiagnosis. Outcomes frequencies, dual pattern similarity and pattern-dataset similarity were calculated.

Results

Dual pattern similarity was associated with Four Examinations (gamma = -0.646, P < 0.01). Combination of Four Examinations was associated (gamma = -0.618, P < 0.01) with decreasing frequencies of pattern differentiation errors, being less influenced by pattern-dataset similarity (Ip: gamma = 0.684; Ip+AO: gamma = 0.660; Ip+AO+Iq: gamma = 0.398; Ip+AO+Iq+P: gamma = 0.286, P < 0.01 for all combinations).

Conclusion

Applied in an incremental manner, Four Examinations progressively reduce the association between pattern similarity and pattern differentiation outcome and are recommended to avoid misdiagnosis and undiagnosis due to similarity.

Factor analysis on symptoms and signs of chronic low-back pain based on Traditional Chinese Medicine theory

OBJECTIVES

The objective of this study was to use factor analysis to explore patterns of symptoms and signs from patients with chronic low-back pain (CLBP) based on the Traditional Chinese Medicine (TCM) theory.

DESIGN, SETTINGS, AND SUBJECTS

A cross-sectional study was carried out among 513 patients with CLBP in four hospitals affiliated with Yunnan University of Traditional Chinese Medicine, China.

OUTCOME MEASURES

Outcome measures comprised 31 symptoms and signs on a six-level self-report questionnaire.

RESULTS

Four (4) factors were extracted. They were eventually interpreted as (1) "Qi and/or Blood Stagnation," which includes eight items such as piercing pain; activity limited by feeling of local heaviness, lumbar and flank stiffness with bending limitation and purple tongue, etc.; (2) "Cold/Damp," which has seven items (for example, Cold/Damp pain, pallid face and greasy coating, etc.); (3) a part of "Kidney Deficiency," which includes two items: "dull pain and recurrent vague pain"; (4) "Warmth/Heat," which is related to three items (namely, purple tongue, yellow tongue coating, and burning pain). The four factors accounted for 12.7%, 8.2%, 8.2%, and 7.8% of the total variance, respectively. There are seven items with uniqueness over 0.8.

CONCLUSIONS

Four (4) TCM major groups of pathophysiology could explain 37% of variance of 31 symptoms and signs of the CLBP patients. Thirteen (13) items are not groupable.

An evidence-based validation of traditional Chinese medicine syndromes

OBJECTIVES

A standard description regarding the diagnosis of traditional Chinese medicine (TCM) syndromes based on validated evidence is needed for education, practice and evaluation of TCM syndrome-specific treatments. We studied whether an evidence-based four-step approach proposed for the validation of TCM syndromes could validate Kidney-Yin deficiency syndrome (KDS-Yin) and Kidney-Yang deficiency syndrome (KDS-Yang) in middle-aged women with menopausal symptoms.

METHODS

TCM classic and contemporary literature were reviewed for the symptoms and the domain changes of KDS-Yin and KDS-Yang. Factor analysis was used to explore whether these symptoms could be grouped according to their mutual relationships in a sample of women. Latent tree models were constructed based on the factor loadings and justifiability by the theory, and were tested by structural equation modelling on another sample of women.

RESULTS

The symptoms and domain changes were reviewed from the TCM literature. Exploratory factor analysis (EFA) identified symptom patterns on a sample of 236 women. Based on the findings and the TCM literature, latent tree models of KDS-Yin and KDS-Yang, showing their domain changes and domain symptoms, were constructed and could be confirmed by structural equation modelling on a sample of 323 women.

CONCLUSION

KDS-Yin and KDS-Yang in middle-aged women with menopausal symptoms were validated and the four-step approach may be used to validate TCM syndromes.

Diagnostic accuracy of pattern differentiation algorithm based on Chinese medicine theory: a stochastic simulation study

Background

Clinical practice of Chinese medicine requires little information for differentiation of Zang-fu patterns. This study is to test the impact of information amount on the diagnostic accuracy of pattern differentiation algorithm (PDA) using stochastic simulation of cases.

Methods

A dataset with 69 Zang-fu single patterns was used with manifestations according to the Four Examinations, namely inspection (Ip), auscultation and olfaction (AO), inquiry (Iq) and palpation (P). A variable quantity of available information (N_%) was randomly sampled to generate 100 true positive and 100 true negative manifestation profiles per pattern to which PDA was applied. Four runs of simulations were used according to the Four Examinations: Ip, Ip+AO, Ip+AO+Iq and Ip+AO+Iq+P. The algorithm performed pattern differentiation by ranking a list of diagnostic hypotheses by the amount of explained information F_%. Accuracy, sensitivity, specificity and negative and positive predictive values were calculated.

Results

Use the Four Examinations resulted in the best accuracy with the smallest cutoff value (N_% = 28.5%), followed by Ip+AO+Iq (33.5%), Ip+AO (51.5%) and Ip (52.0%). All tested combinations provided concave-shaped curves for accuracy, indicating an optimal value subject to N_%-cutoff. Use of N_%-cutoff as a secondary criterion resulted in 94.7% (94.3; 95.1) accuracy, 89.8% (89.1; 90.6) sensitivity, and 99.5% (99.3; 99.7) specificity with the Four Examinations.

Conclusion

Pattern differentiation based on both explained and optimum available information (F_% and N_%-cutoff) is more accurate than using explained and available information without cutoff (F_% and N_%). Both F_% and N_%-cutoff should be used as PDA's objective criteria to perform Zang-fu single pattern differentiation.

Effects of questionnaire-based diagnosis and training on inter-rater reliability among practitioners of traditional Chinese medicine

OBJECTIVE

To investigate whether a training process that focused on a questionnaire-based diagnosis in Traditional Chinese Medicine (TCM), and developing diagnostic consensus, would improve the agreement of TCM diagnoses among 10 TCM practitioners evaluating patients with temporomandibular joint disorder (TMJD).

DESIGN AND SETTING

Evaluation of a diagnostic training program at the Department of Family and Community Medicine, University of Arizona, Tucson, Arizona, and the Oregon College of Oriental Medicine, Portland, Oregon.

SUBJECTS

Screened participants for a study of TCM for TMJD. PRACTITIONERS: Ten (10) licensed acupuncturists with a minimum of 5 years licensure and education in Chinese herbs.

METHODS

A training session using a questionnaire-based diagnostic form was conducted, followed by waves of diagnostic sessions. Between sessions, practitioners discussed the results of the previous round of participants with a focus on reducing variability in primary diagnosis and severity rating of each diagnosis: 3 waves of 5 patients were assessed by 4 practitioner pairs for a total of 120 diagnoses. At 18 months, practitioners completed a recalibration exercise with a similar format with a total of 32 diagnoses. These diagnoses were then examined with respect to the rate of agreement among the 10 practitioners using inter-rater correlations and kappas.

RESULTS

The inter-rater correlation with respect to the TCM diagnoses among the 10 practitioners increased from 0.112 to 0.618 with training. Statistically significant improvements were found between the baseline and 18 month exercises (p < 0.01).

CONCLUSIONS

Inter-rater reliability of TCM diagnosis may be improved through a training process and a questionnaire-based diagnosis process. The improvements varied by diagnosis, with the greatest congruence among primary and more severe diagnoses. Future TCM studies should consider including calibration training to improve the validity of results.

A review of the reliability of traditional East Asian medicine diagnoses

BACKGROUND

In the practice of forms of traditional East Asian medicine (TEAM) such as Traditional Chinese Medicine and Japanese meridian therapy, treatment follows identification of underlying "patterns of disharmony." However, little is known in an objective sense of the consistency or reliability of diagnosis within TEAM. This is important: If diagnosis is not reliable, there can be less confidence that optimal treatment is received. TEAM systems have their own diagnostic endpoints that are used as evidence of change. If these are to be incorporated into clinical studies, a prerequisite is that they are reliable. Few studies have assessed the reliability of diagnostic data collected during a TEAM examination. The majority have investigated reliability of pulse diagnosis, with results ranging from low to a very good level of agreement. Studies of reliability of tongue diagnosis and other diagnostic data collected in a Chinese Medicine examination suggest considerable variability. In general, studies of reliability of pattern diagnosis and treatment in a range of disorders have not found a high level of reliability. A range of factors may affect reliability.

OBJECTIVES

This paper reviews the current knowledge of reliability of TEAM diagnoses, including limitations of studies, and discusses the implications for practice and research and how to improve the current situation.