Interobserver agreement for the assessment of handicap in stroke patients

Interobserver agreement for the assessment of handicap in stroke patients was investigated in a group of 10 senior neurologists and 24 residents from two centers. One hundred patients were separately interviewed by two physicians in different combinations. The degree of handicap was recorded by each observer on the modified Rankin scale, which has six grades (0-5). The agreement rates were corrected for chance (kappa statistics). Both physicians agreed on the degree of handicap in 65 patients; they differed by one grade in 32 patients and by two grades in 3 patients. Kappa for all pairwise observations was 0.56; the value for weighted kappa (with quadratic disagreement weights) was 0.91. Our results confirm the value of the modified Rankin scale in the assessment of handicap in stroke patients; nevertheless, further improvements are possible.

Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis

BACKGROUND

The value of intensive combination therapy in early rheumatoid arthritis is unproven. In a multicentre, double-blind, randomised trial (COBRA), we compared the combination of sulphasalazine (2 g/day), methotrexate (7.5 mg/week), and prednisolone (initially 60 mg/day, tapered in 6 weekly steps to 7.5 mg/day) with sulphasalazine alone.

METHODS

155 patients with early rheumatoid arthritis (median duration 4 months) were randomly assigned combined treatment (76) or sulphasalazine alone (79). Prednisolone and methotrexate were tapered and stopped after 28 and 40 weeks, respectively. The main outcomes were the pooled index (a weighted change score of five disease activity measures) and the Sharp/Van der Heijde radiographic damage score in hands and feet. Independent health-care professionals assessed the main outcomes without knowledge of treatment allocation.

FINDINGS

At week 28, the mean pooled index was 1.4 (95% CI 1.2-1.6) in the combined treatment group and 0.8 (0.6-1.0) in the sulphasalazine group (p < 0.0001). At this time, 55 (72%) and 39 (49%) patients, respectively, were improved according to American College of Rheumatology criteria. The clinical difference between the groups decreased and was no longer significant after prednisolone was stopped, and there were no further changes after methotrexate was stopped. At 28 weeks, the radiographic damage score had increased by a median of 1 (range 0-28) in the combined-therapy group and 4 (0-44) in the sulphasalazine group (p < 0.0001). The increases at week 56 (2 [0-43] vs 6 [0-54], p = 0.004), and at week 80 (4 [0-80] vs 12 [0-72], p = 0.01) were also significant. Further analysis suggests that combined therapy immediately suppressed damage progression, whereas sulphasalazine did so less effectively and with a lag of 6 to 12 months. There were fewer withdrawals in the combined therapy than the sulphasalazine group (6 [8%] vs 23 [29%]), and they occurred later.

INTERPRETATION

This combined-therapy regimen offers additional disease control over and above that of sulphasalazine alone that persists for up to a year after corticosteroids are stopped. Although confirmatory studies and long-term follow-up are needed, this approach may prove useful in the treatment of early rheumatoid arthritis.

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

OBJECTIVE

To review the diagnostic accuracy of D-dimer testing in older patients (>50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values.

DESIGN

Systematic review and bivariate random effects meta-analysis.

DATA SOURCES

We searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies.

STUDY SELECTION

Primary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age × 10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2 × 2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level.

RESULTS

13 cohorts including 12,497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged >80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories.

CONCLUSIONS

The application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability.

Comparison of doxorubicin and mitoxantrone in the treatment of elderly patients with advanced diffuse non-Hodgkin's lymphoma using CHOP versus CNOP chemotherapy

PURPOSE AND METHODS

A prospective, randomized, multicenter phase III trial was performed to investigate the feasibility of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in elderly patients ( > or = 60 years) with advanced non-Hodgkin's lymphoma (NHL) of intermediate- and high-grade malignancy, and to compare the tolerance and efficacy of doxorubicin versus mitoxantrone (CHOP v CNOP).

RESULTS

Of 157 enrolled patients, 148 were eligible and 145 were assessable for response. Thirty-one percent of CNOP and 45% of CHOP patients completed six cycles without dose reduction. The cumulative normalized dose-intensity (NDI) was 92% with CHOP and 90% with CNOP after six cycles. The overall complete response (CR) rates were 49% and 31% in CHOP- and CNOP-treated patients, respectively (P = .03). Survival with CNOP was significantly worse as compared with CHOP (P = .03). Lymphoma-specific survival was significantly better in CHOP-treated patients (P = .034) At 3 years, 42% of CHOP and 26% of CNOP patients were alive. Additional unfavorable prognostic factors at diagnosis were high serum lactate dehydrogenase (LDH) level, bulky mass, and low performance status, but not age. The median disease-free intervals of complete responders were 27 (CHOP) and 15 (CNOP) months, respectively. Considering the complete group of patients, at 3 years 17% of CHOP and 13% of CNOP patients were alive and disease-free (P = .12). Common toxicity criteria (CTC) grade > or = 2 with CNOP and CHOP was not different.

CONCLUSION

CHOP is well tolerated in elderly patients with advanced intermediate- or high-grade NHL and its NDI is not seriously impaired. Treatment with CHOP (doxorubicin) results in better CR and survival rates than CNOP (mitoxantrone). CHOP should be recommended for elderly patients with high-risk NHL.

Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: definitions and current practice in Europe

The Accreditation Subcommittee of the EBMT regularly publishes special reports on current practice of haemopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders in Europe. Major changes have occurred since the first report was published in 1996. Haemopoietic stem cell transplantation today includes grafting with allogeneic and autologous stem cells derived from bone marrow, peripheral blood and cord blood. With reduced intensity conditioning regimens in allogeneic transplantation, the age limit has increased, permitting the inclusion of older patients. New indications have emerged such as autoimmune disorders and AL amyloidosis for autologous, and solid tumours for allogeneic transplants. The introduction of alternative therapies has challenged well-established indications such as imatinib for chronic myeloid leukaemia. An updated report with revised tables and operating definitions is presented here.

Work status and productivity costs due to ankylosing spondylitis: comparison of three European countries

OBJECTIVE

To compare work disability, sick leave, and productivity costs due to ankylosing spondylitis (AS) of three European countries.

METHODS

216 patients with AS from the Netherlands, France, and Belgium participated in a two year observational study. Employment and work disability rates at baseline were adjusted for age and sex. Productivity costs were calculated by both the friction cost method and the human capital approach. The adjusted contributions of country to employment, work disability, and having an episode of sick leave were assessed by logistic regression and the contribution of the country to days of sick leave and costs by Cox proportional hazard analysis.

RESULTS

209 patients completed the two years' follow up with sufficient data for cost analysis. Adjusted employment was 55% in the Netherlands as compared with 72% in both other countries and only in the Netherlands was it lower than expected in the general population. Adjusted work disability was 41%, 23%, and 9% in the Netherlands, France, and Belgium and in all countries was higher than expected in the general population. In those with a paid job, the mean number of days of sick leave per patient per year because of AS was 19 (range 0-130), six (range 0-77), and nine (range 0-60 ) in the Netherlands, France, and Belgium respectively. Applying the friction cost method to those with a paid job resulted in mean costs per patient per year of 1257 euros (range 0-7356), 428 euros (range 0-5979), and 476 euros (range 0-2354) in the Netherlands, France, and Belgium. Applying the human capital approach to the whole group resulted in mean costs per patient per year of 8862 euros (range 0-46 818), 3188 euros (range 0-43 550), and 3609 euros (range 0-34 320) in the three countries, respectively. After adjusting for sociodemographic and disease characteristics, living in the Netherlands, as compared with both other countries, was associated with a higher chance of being work disabled (odds ratio (OR)=3.82; 95% confidence interval (CI) 1.33 to 11.01), but not with the risk of having an episode of sick leave. Similarly, living in the Netherlands contributed independently to the number of days sick leave (OR=0.65; 95% CI 0.43 to 0.97), a higher amount of friction costs (OR=0.63; 95% CI 0.42 to 0.96), and a higher amount of human capital costs (OR=0.46; 95% CI 0.32 to 0.68).

CONCLUSION

There are remarkable differences in work status and productivity costs between the three European countries. This has implications for the generalisability of health economic studies.

Kupffer cell depletion by CI2MDP-liposomes alters hepatic cytokine expression and delays liver regeneration after partial hepatectomy

BACKGROUND

Although Kupffer cells (KCs) are capable of producing important growth-stimulating cytokines, their role in liver regeneration following partial hepatectomy (PH) remains poorly understood.

METHODS

In the present study liver regeneration was studied after KC-depletion by intravenous administration of liposome-encapsulated dichloromethylene-diphosphonate (C12MDP), a method known to physically eliminate KCs. Furthermore, splenectomy was performed one week prior to PH to exclude the effect of C12MDP-liposomes on macrophage populations in the spleen.

RESULTS

KC-depletion was confirmed in cryostat liver sections stained with the monoclonal antibody ED2, a marker for resident tissue macrophages. Forty-eight hours after PH, the cumulative hepatocyte DNA synthesis, as determined in liver sections by the hepatocyte bromodeoxyuridine labeling index, was significantly decreased in KC-depleted rats when compared to control-rats. The weight of the remnant liver, expressed as a percentage of the initial liver weight, was significantly less at 96 h after PH in KC-depleted rats. KC-depletion abolished the hepatic interleukin-6 (IL-6) and interleukin-10 (IL-10) mRNA synthesis and decreased hepatic expression of tumor necrosis factor-alpha (TNF-alpha), hepatocyte growth factor (HGF) and transforming growth factor-beta1(TGF-beta1) mRNA after PH, as was assessed by reverse-transcriptase polymerase chain reaction (RT-PCR). Moreover, at 4 h after PH the systemic release of IL-6 was significantly decreased in KC-depleted rats.

CONCLUSION

We conclude that KCs are important for hepatocyte regeneration after PH. Delayed liver regeneration in KC-depleted rats can be explained, at least in part, by an imbalanced hepatic cytokine expression, thereby suppressing important growth-stimulating cytokines.

Megadose steroids in severe head injury. Results of a prospective double-blind clinical trial

A prospective double-blind clinical trial was performed on 161 patients to determine the effectiveness of high-dose steroid therapy in patients admitted comatose after a non-missile-related head injury. Patients were randomized into a high-dose dexamethasone phosphate group and a placebo group. The initial dose of 100 mg of dexamethasone was administered within 6 hours of the accident. For statistical analysis, a sequential test was chosen, using survival at 1 month as a basic criterion of effectiveness. No significant difference was found in the 1-month survival rate or in the distribution of outcome after 6 months, either within the group as a whole, or in subgroups with varying severity of brain damage on admission. The authors conclude that dexamethasone in high doses has no statistically significant effect on morbidity or mortality in head-injured patients who are comatose on admission.

Primary prevention of arterial thromboembolism in non-rheumatic atrial fibrillation in primary care: randomised controlled trial comparing two intensities of coumarin with aspirin

OBJECTIVE

To investigate the effectiveness of aspirin and coumarin in preventing thromboembolism in patients with non-rheumatic atrial fibrillation in general practice.

DESIGN

Randomised controlled trial.

PARTICIPANTS

729 patients aged >/=60 years with atrial fibrillation, recruited in general practice, who had no established indication for coumarin. Mean age was 75 years and mean follow up 2. 7 years.

SETTING

Primary care in the Netherlands.

INTERVENTIONS

Patients eligible for standard intensity coumarin (international normalised ratio 2.5-3.5) were randomly assigned to standard anticoagulation, very low intensity coumarin (international normalised ratio 1.1-1.6), or aspirin (150 mg/day) (stratum 1). Patients ineligible for standard anticoagulation were randomly assigned to low anticoagulation or aspirin (stratum 2).

MAIN OUTCOME MEASURES

Stroke, systemic embolism, major haemorrhage, and vascular death.

RESULTS

108 primary events occurred (annual event rate 5.5%), including 13 major haemorrhages (0.7% a year). The hazard ratio was 0.91 (0.61 to 1.36) for low anticoagulation versus aspirin and 0.78 (0.34 to 1.81) for standard anticoagulation versus aspirin. Non-vascular death was less common in the low anticoagulation group than in the aspirin group (0.41, 0.20 to 0.82). There was no significant difference between the treatment groups in bleeding incidence. High systolic and low diastolic blood pressure and age were independent prognostic factors.

CONCLUSION

In a general practice population (without established indications for coumarin) neither low nor standard intensity anticoagulation is better than aspirin in preventing primary outcome events. Aspirin may therefore be the first choice in patients with atrial fibrillation in general practice.

Withdrawal from labour force due to work disability in patients with ankylosing spondylitis

OBJECTIVE

To investigate withdrawal from the labour force because of inability to work owing to ankylosing spondylitis (AS) and to determine the characteristics of patients with no job because of work disability attributable to AS.

METHODS

A postal questionnaire was sent to 709 patients with AS aged 16-60 years followed up by a rheumatologist. Kaplan-Meier survival statistics were used to assess the time lapse between diagnosis and withdrawal from work. Standardised incidence ratios were calculated to compare withdrawal from the labour force in patients with AS and the general population. Determinants of withdrawal were assessed by Cox's proportional hazard regression analysis using variables assumed to be time independent. Cross sectional characteristics of patients without a job owing to disability were further analysed by simple and multiple regression analyses.

RESULTS

A total of 658 patients returned the questionnaire. Of 529 patients with a paid job before diagnosis of AS, 5% had left the labour force within the first year after the diagnosis, 13% after 5 years, 21% after 10 years, 23% after 15 years, and 31% after 20 years. Age and sex adjusted risk for withdrawal was 3.1 (95% CI 2.5 to 3.7) times higher than in the general population. In patients with AS, determinants of withdrawal from work were older age at diagnosis, manual work, and coping strategies characterised by limiting or adapting activities. Patients with work disability at the time of the study were older, came from a lower social class, and were more likely to have total hip replacement, peripheral arthritis, or comorbidity. Moreover, they reported worse physical function (BAS-FI), experienced lower quality of life, and more often had extraspinal disease than those with a job.

CONCLUSION

Withdrawal from work is 3.1 times higher in patients with AS than expected in the general population. Within patients, higher age at diagnosis, manual work, and unfavourable coping strategies are important determinants of withdrawal. Patients without a job experience a lower quality of life.

Interobserver agreement for the diagnosis of transient ischemic attacks

The interobserver agreement for the diagnosis of a cerebral transient ischemic attack (TIA) was investigated in a pool of eight senior and interested neurologists from the same department. They interviewed 56 patients in alternating pairs. The diagnosis was based on internationally accepted criteria. The agreement rates were corrected for chance (kappa statistics). Both neurologists agreed that 36 patients had a TIA and 12 had not, but they disagreed about 8 patients (kappa = 0.65; for perfect agreement kappa would be 1.0). The vascular territory (carotid or vertebrobasilar) was agreed upon in only 24 of the 36 patients in whom both diagnosed TIA's (kappa = 0.31). We concluded that currently the diagnosis of a TIA, made by a single neurologist, is a poorly defined entity.

Interobserver and intraobserver variation in the assessment of antepartum cardiotocograms

Five experienced observers assessed 100 antepartum cardiotocograms from 100 pregnant women by means of three different systems: two commonly used scoring systems and a close look at a 1-minute recording period (window). Variation between observers (interobserver) and within one observer (intraobserver) was determined by calculating the weighted kappa coefficients. Weighted kappa coefficients for interobserver variation in the Visser/Huisjes score and the Fischer score were 0.41 and 0.37, respectively. Weighted kappa coefficients for interobserver variation in a close look at a 1-minute window ranged from 0.09 to 0.69. Thus, a low level of agreement between observers was shown to exist for all three systems tested. The level of intraobserver agreement was shown to be much higher for virtually all three systems. Since the level of interobserver agreement is low, the results of different studies that describe visually assessed antepartum cardiotocograms by means of these scoring systems or 1-minute windows are not comparable, and reproducibility will be low.

Agreement between physicians on assessment of outcome following severe head injury

This study describes inter-observer agreement between physicians and consistency of one observer on repeated scoring in the assessment of outcome 6 to 12 months after severe head injury. Observer agreement is expressed by Kappa, taking chance agreement into account. The study was conducted in "live" and "non-live" situations, using five- and eight-category outcome scales. Kappa values were considerably higher when the five-category scale was used. However, even with the five-category scale, disagreement was considerable, and the results indicate that accurate predictions of the quality of survival will be difficult to attain. Observer agreement should be taken into account in prognosis studies, and when different therapeutic regimens are evaluated on the basis of outcome.

Maternal volume homeostasis in early pregnancy in relation to fetal growth restriction

OBJECTIVE

To test the hypothesis that volume adaptation in pregnancies complicated by fetal growth restriction (FGR) is already abnormal very early in pregnancy.

METHODS

In six pregnancies later complicated by FGR, volume homeostasis in the first 8 weeks was compared to that in ten normal pregnancies. Creatinine clearance, volume-dependent hormones, hemodilution-related variables, and ultrasonic cardiovascular dimensions were measured weekly between weeks 5 and 10, in the second and third trimesters, and postpartum. Differences between the two groups were analyzed by nonparametric tests.

RESULTS

Very early in pregnancy, pregnancies complicated by FGR differed from normal pregnancies in the following ways: smaller left atrial diameter, smaller collapsible part of the inferior vena cava, lower serum sodium concentration, and smaller fall in serum creatinine and urea.

CONCLUSION

Fetal growth restriction is preceded by defective volume adaptation very early in pregnancy. It appears that the maternal compensation mechanisms are unable to resolve the transient state of vascular underfill seen in this period in normal gestation.

Direct costs of ankylosing spondylitis and its determinants: an analysis among three European countries

OBJECTIVE

To assess direct costs associated with ankylosing spondylitis (AS). To determine which variables, including country, predict costs.

METHODS

216 patients with AS from the Netherlands, France, and Belgium participated in a two year observational study and filled in bimonthly economic questionnaires. Disease related healthcare resource use was measured and direct costs were calculated from a societal perspective (true cost estimates) and from a financial perspective (country-specific tariffs). Predictors of costs were assessed using Cox's regression analysis.

RESULTS

209 patients provided sufficient data for cost analysis. Mean annual societal direct costs for each patient were euro;2640, of which 82% were direct healthcare costs. In univariate analysis costs were higher in the Netherlands than in Belgium, but this difference disappeared after adjusting for baseline differences in patients' characteristics among countries. Longer disease duration, lower education, worse physical function, and higher disease activity were predictors of costs. Mean annual direct costs from a financial perspective were euro;2122, euro;1402, and euro;941 per patient in the Netherlands, France, and Belgium, respectively. For each country, costs from a financial perspective were significantly lower than costs from a societal perspective.

CONCLUSION

Direct costs for AS are substantial in three European countries but not significantly different after adjusting for baseline characteristics among countries. Worse physical function and higher disease activity are important determinants of costs, suggesting better disease control might reduce the costs of AS. The difference in costs from a societal and financial perspective emphasises the importance of an economic analysis.

Tumor angiogenesis: an independent prognostic parameter in cervical cancer

OBJECTIVE

The purpose of this study was to investigate whether the intensity of tumor angiogenesis, expressed as microvessel density, is a parameter predicting the probability of lymph node metastasis and survival in patients with cervical cancer stages IB and IIA.

STUDY DESIGN

In a retrospective study of 114 patients with cervical cancer stages IB and IIA, microvessel density, lymph node status, and several other prognostic parameters were correlated with disease-free survival by a multivariate analysis according to Cox proportional-hazards model.

RESULTS

There was a significant difference in mean microvessel density between tumors with and without pelvic lymph node metastasis (p = 0.002). Both microvessel density (vessels per square millimeter of stroma). (p = 0.05) and pelvic lymph node metastasis (p = 0.007) correlated significantly and independently with disease-free survival.

CONCLUSION

This study demonstrates that microvessel density is an independent prognostic parameter for disease-free survival in patients with cervical cancer stages Ib and IIa.

Predictive value of signs and symptoms for colorectal cancer in patients with rectal bleeding in general practice

The aim of the study is to determine the diagnostic value of (combinations of) signs, symptoms and simple laboratory test results for colorectal cancer in patients with rectal bleeding presenting in general practice. Initial complaints and findings were compared with the final diagnoses based on clinical follow-up after at least 1 year. Patients studied were those presenting overt rectal bleeding to the general practitioner (83 GPs in the South of the Netherlands). Outcome measures are sensitivity, specificity, predictive values, odds ratios and a prediction model derived from multiple logistic regression analysis. Age, change in bowel habit and blood mixed with or on stool show a statistically significant independent value in the discrimination between patients with a low and those with a high probability of colorectal cancer. Many other variables did not show predictive value. The prediction model has a sensitivitiy of 100% and a specificity of 90%. Although the number of patients with colorectal cancer is small (n = 9) it was possible to identify three characteristics which can be helpful in the prediction of presence or absence of colorectal cancer in general practice. Application of the model presented might prevent 90% of 'unnecessary' invasive diagnostic procedures for patients with rectal bleeding who do not have colorectal cancer (true negative). Testing the performance of the model in other general practice populations is recommended.

Inter observer agreement in the assessment of the motor response of the Glasgow 'coma' scale

The motor response of the Glasgow 'coma' scale is readily learned by nurses and doctors. It can be used as a reliable indicator of changes in the state of a comatose patient, as there is a high agreement rate between different observers.

Frailty is associated with in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands: the COVID-OLD study

BACKGROUND

During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting.

OBJECTIVE

The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands.

METHODS

This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality.

RESULTS

A total of 1,376 patients were included (median age 78 years (interquartile range 74-84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6-9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1-3, patients with CFS 4-5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3-3.0)) and patients with CFS 6-9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8-4.3)).

CONCLUSIONS

The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.

Anorectal function: defecographic measurement in asymptomatic subjects

A study of anorectal function during fluoroscopically monitored defecation was conducted in 32 asymptomatic subjects. Two observers independently measured various parameters on defecograms and reviewed video recordings during the subjects' squeezing, rest, and straining. There was a wide range of measurements for the anorectal angle, the position of the anorectal junction, perineal motility, and anal canal width. Interobserver variation of these measurements was large. In 17 subjects, both observers agreed that rectal emptying was incomplete. In 10 patients, there was agreement on the presence of rectal wall changes such as intussusception, rectocele, and mucosal prolapse. Defecographic measurements should be interpreted with caution and should not be used as the only criteria for treatment. Anatomic changes of the anorectal region during straining at defecation do not necessarily cause symptoms but may be a precursor of clinical disorders. Defecography is useful in the detection of these abnormalities.

Interobserver variation in histopathological grading of cervical dysplasia

In order to assess the variability among histopathologists in grading cervical dysplasia, four experienced histopathologists examined the same set of 106 biopsy specimens and assigned them to one of five diagnostic categories. These were: no dysplasia, mild dysplasia, moderate dysplasia, severe dysplasia and carcinoma in situ. The histopathologists did not discuss the grading criteria beforehand. There was considerable disagreement among the pathologists: unweighted group kappa 0.28, weighted group kappa 0.56. It appeared that all grades of dysplasia were equally difficult to distinguish from adjacent categories. Various explanations for this interobserver variation are put forward.

Interobserver agreement in assessment of ocular signs in coma

There is interobserver agreement in the assessment of various ocular signs found in coma patients. As measure for observer agreement the parameter kappa (K) was determined for (in-)equality of pupils, reaction of pupils, spontaneous eye movements, and oculocephalic responses. The agreement in the assessment of the pupils to light and in the assessment of (in-)equality of pupils appeared to be satisfactory, but more disagreement occurred in assessing spontaneous eye movements and oculocephalic responses.

Endothelium-dependent vasodilatation, plasma markers of endothelial function, and adrenergic vasoconstrictor responses in type 1 diabetes under near-normoglycemic conditions

It is unknown whether and to what extent changes in various endothelial functions and adrenergic responsiveness are related to the development of microvascular complications in type 1 diabetes. Therefore, endothelium-dependent and endothelium-independent vasodilatation, endothelium-dependent hemostatic factors, and one and two adrenergic vasoconstrictor responses were determined in type 1 patients with and without microvascular complications. A total of 34 patients with type 1 diabetes were studied under euglycemic conditions on two occasions (11 without microangiopathy, 10 with proliferative and preproliferative retinopathy previously treated by laser coagulation, 13 with microalbuminuria, and 12 healthy volunteers also were studied). Forearm vascular responses to brachial artery infusions of N(G)-monomethyl-L-arginine (L-NMMA), sodium nitroprusside, acetylcholine (ACh), clonidine, and phenylephrine were determined. The ACh infusions were repeated during coinfusion of L-arginine. Furthermore, plasminogen activator inhibitor type 1 (PAI-1) activity, tissue plasminogen activator antigen levels, von Willebrand factor antigen levels, tissue factor pathway inhibitor (TFPI) activity, and endothelin-1 levels were measured. No differences in endothelium-dependent or endothelium-independent vasodilatation or adrenergic constriction were observed between the diabetic patients and the healthy volunteers. In comparison to the first ACh infusion, the maximal response to repeated ACh during L-arginine administration was reduced in the diabetic patients, except in the patients with proliferative and preproliferative retinopathy previously treated by laser coagulation. In these patients, the combined infusion of L-arginine and ACh resulted in an enhanced response. TFPI activity was elevated, and PAI-1 activity was reduced in the type 1 diabetic patients. Furthermore, PAI-1 activity was positively correlated with urinary albumin excretion (r = 0.48, P < 0.01) and inversely correlated with the vasodilatory response to the highest ACh dose (r = -0.37, P < 0.05). The response to the highest ACh and L-NMMA dose were positively correlated with mean arterial blood pressure (r = 0.32, P < 0.01; r = 0.41, P < 0.01, respectively). Forearm endothelium-dependent and endothelium-independent vasodilatation and adrenergic responsiveness were unaltered in type 1 diabetic patients with and without microvascular complications. Relative to healthy control subjects, endothelium-dependent vasodilatation was depressed during a repeated ACh challenge (with L-arginine coinfusion) in the diabetic patients without complications or with microalbuminuria. In contrast, this vasodilatation was enhanced in the patients with retinopathy. Elevation of TFPI was the most consistent marker of endothelial damage of all the endothelial markers measured.