Scientific Literature on the Reliability and Validity of the Manchester Triage System (MTS) Protocol: A Integrative Literature Review

OBJECTIVE To analyze the scientific production about the validity and reliability of the Manchester Triage System (MTS) protocol. METHOD A descriptive study of an integrative literature review. Articles on the validity and reliability of the MTS developed with children and adults published between 1999 and 2013 were included. RESULTS 14 articles were selected from a total of 8438, nine of validity and five of reliability. The reliability of the MTS ranged from moderate to almost perfect, with higher intra-evaluation. Regarding validity, the results seem to point to equivalent and satisfactory sensibility and specificity levels of the MTS. The instrument proved to be a good predictor of the need for hospitalization and of hospital mortality. CONCLUSION The reliability and validity of the MTS obtained in the studies is varied. It is recommended that new studies indicate necessary modifications to the MTS so that it is more safely used by nurses.

Absence of ectopic epithelial inclusions in 3,904 axillary lymph nodes examined in sentinel technique.

Intraoperative examination of sentinel axillary lymph nodes can be done by imprint cytology, frozen section, or, most recently, by PCR-based amplification of a cytokeratin signal. Using this technique, benign epithelial inclusions, representing mammary tissue displaced along the milk line, will likely generate a positive PCR signal and lead to a false-positive diagnosis of metastatic disease. To better appreciate the incidence of ectopic epithelial inclusions in axillary lymph nodes, we have performed an autopsy study, examining on 100 μm step sections 3,904 lymph nodes obtained from 160 axillary dissections in 80 patients. The median number of lymph nodes per axilla was 23 (15, 6, and 1 in levels 1, 2, and 3, respectively). A total of 30,450 hematoxylin-eosin stained slides were examined, as well as 8,825 slides immunostained with pan-cytokeratin antibodies. Despite this meticulous work-up, not a single epithelial inclusion was found in this study, suggesting that the incidence of such inclusions is much lower than the assumed 5% reported in the literature.

Interrater reliability of Nursing Activities Score among Intensive Care Unit health professionals

ABSTRACT Objective To analyze the interrater reliability of NAS among critical care nurses and managers in an ICU. Method This was a methodological study performed in an adult, general ICU in Norway. In a random selection of patients, the NAS was scored on 101 patients by three raters: a critical care nurse, an ICU physician and a nurse manager. Interrater reliability was analyzed by agreement between groups and kappa statistics. Results The mean NAS were 88.4 (SD=16.2) and 88.7 (SD=24.5) respectively for the critical care nurses and nurse managers. A lower mean of 83.7 (SD=21.1) was found for physicians. The 18 medical interventions showed higher agreement between critical care nurses and physicians (85.6%), than between critical care nurses and nurse managers (78.7). In the five nursing activities the Kappa-coefficients were low for all activities in all compared groups. Conclusion The study indicated a satisfactory agreement of nursing workload between critical care nurses and managers.

Reliability of panel-based guidelines for colonoscopy: an international comparison.

BACKGROUND: This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method. METHODS: The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland. RESULTS: Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications. CONCLUSIONS: Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

Relative and absolute reliability of the clinical version of the Narrow Path Walking Test (NPWT) under single and dual task conditions.

Decline in gait stability has been associated with increased fall risk in older adults. Reliable and clinically feasible methods of gait instability assessment are needed. This study evaluated the relative and absolute reliability and concurrent validity of the testing procedure of the clinical version of the Narrow Path Walking Test (NPWT) under single task (ST) and dual task (DT) conditions. Thirty independent community-dwelling older adults (65-87 years) were tested twice. Participants were instructed to walk within the 6-m narrow path without stepping out. Trial time, number of steps, trial velocity, number of step errors, and number of cognitive task errors were determined. Intraclass correlation coefficients (ICCs) were calculated as indices of agreement, and a graphic approach called "mountain plot" was applied to help interpret the direction and magnitude of disagreements between testing procedures. Smallest detectable change and smallest real difference (SRD) were computed to determine clinically relevant improvement at group and individual levels, respectively. Concurrent validity was assessed using Performance Oriented Mobility Assessment Tool (POMA) and the Short Physical Performance Battery (SPPB). Test-retest agreement (ICC1,2) varied from 0.77 to 0.92 in ST and from 0.78 to 0.92 in DT conditions, with no apparent systematic differences between testing procedures demonstrated by the mountain plot graphs. Smallest detectable change and smallest real change were small for motor task performance and larger for cognitive errors. Significant correlations were observed for trial velocity and trial time with POMA and SPPB. The present results indicate that the NPWT testing procedure is highly reliable and reproducible.

Assessment of a new MRI classification of spinal stenosis based on cross-sectional morphology of the dural sac : FM2

Introduction: Quantitative measures of degree of lumbar spinal stenosis (LSS) such as antero-posterior diameter of the canal or dural sac cross sectional area vary widely and do not correlate with clinical symptoms or results of surgical decompression. In an effort to improve quantification of stenosis we have developed a grading system based on the morphology of the dural sac and its contents as seen on T2 axial images. The grading comprises seven categories ranging form normal to the most severe stenosis and takes into account the ratio of rootlet/CSF content. Material and methods: Fifty T2 axial MRI images taken at disc level from twenty seven symptomatic lumbar spinal stenosis patients who underwent decompressive surgery were classified into seven categories by five observers and reclassified 2 weeks later by the same investigators. Intra- and inter-observer reliability of the classification were assessed using Cohen's and Fleiss' kappa statistics, respectively. Results: Generally, the morphology grading system itself was well adopted by the observers. Its success in application is strongly influenced by the identification of the dural sac. The average intraobserver Cohen's kappa was 0.53 ± 0.2. The inter-observer Fleiss' kappa was 0.38 ± 0.02 in the first rating and 0.3 ± 0.03 in the second rating repeated after two weeks. Discussion: In this attempt, the teaching of the observers was limited to an introduction to the general idea of the morphology grading system and one example MRI image per category. The identification of the dimension of the dural sac may be a difficult issue in absence of complete T1 T2 MRI image series as it was the case here. The similarity of the CSF to possibly present fat on T2 images was the main reason of mismatch in the assignment of the cases to a category. The Fleiss correlation factors of the five observers are fair and the proposed morphology grading system is promising.

Absence of intestinal PPARγ aggravates acute infectious colitis in mice through a lipocalin-2-dependent pathway.

To be able to colonize its host, invading Salmonella enterica serovar Typhimurium must disrupt and severely affect host-microbiome homeostasis. Here we report that S. Typhimurium induces acute infectious colitis by inhibiting peroxisome proliferator-activated receptor gamma (PPARγ) expression in intestinal epithelial cells. Interestingly, this PPARγ down-regulation by S. Typhimurium is independent of TLR-4 signaling but triggers a marked elevation of host innate immune response genes, including that encoding the antimicrobial peptide lipocalin-2 (Lcn2). Accumulation of Lcn2 stabilizes the metalloproteinase MMP-9 via extracellular binding, which further aggravates the colitis. Remarkably, when exposed to S. Typhimurium, Lcn2-null mice exhibited a drastic reduction of the colitis and remained protected even at later stages of infection. Our data suggest a mechanism in which S. Typhimurium hijacks the control of host immune response genes such as those encoding PPARγ and Lcn2 to acquire residence in a host, which by evolution has established a symbiotic relation with its microbiome community to prevent pathogen invasion.

Reliability of the image evaluation system PGMI

Purpose: Many countries used the PGMI (P=perfect, G=good, M=moderate, I=inadequate) classification system for assessing the quality of mammograms. Limits inherent to the subjectivity of this classification have been shown. Prior to introducing this system in Switzerland, we wanted to better understand the origin of this subjectivity in order to minimize it. Our study aimed at identifying the main determinants of the variability of the PGMI system and which criteria are the most subjected to subjectivity. Methods and Materials: A focus group composed of 2 experienced radiographers and 2 radiologists specified each PGMI criterion. Ten raters (6 radiographers and 4 radiologists) evaluated twice a panel of 40 randomly selected mammograms (20 analogic and 20 digital) according to these specified PGMI criteria. The PGMI classification was assessed and the intra- and inter-rater reliability was tested for each professional group (radiographer vs radiologist), image technology (analogic vs digital) and PGMI criterion. Results: Some 3,200 images were assessed. The intra-rater reliability appears to be weak, particularly in respect to inter-rater variability. Subjectivity appears to be largely independent of the professional group and image technology. Aspects of the PGMI classification criteria most subjected to variability were identified. Conclusion: Post-test discussions enabled to specify more precisely some criteria. This should reduce subjectivity when applying the PGMI classification system. A concomitant, important effort in training radiographers is also necessary.

Complete Nucleotide Sequence of Mouse Mammary Tumor Virus from JYG Chinese Wild Mice: Absence of Bacterial Insertion Sequences in the Cloned Viral gag Gene.

Mammary tumors of a newly isolated strain of Chinese wild mouse (JYG mouse) harbor exogenous mouse mammary tumor virus (MMTV). The complete nucleotide sequence of exogenous JYG-MMTV was determined on the proviral 5' long terminal repeat (LTR)(partial)-gag-pol-env-3' LTR (partial) fragment cloned into a plasmid vector and the cDNA sequence from JYG-MMTV producing cells. Similarly to the other MMTV species the LTR of JYG-MMTV contains an open reading frame (ORF). The amino acid sequence of the JYG-MMTV ORF resembles that of SW-MMTV (92% identity) and endogenous Mtv-7 (93% identity) especially at the C-terminal region. Thus, a functional similarity in T-cell receptor V beta recognition as a superantigen is implicated among these MMTV species. Analysis of the viral gag nucleotide sequence revealed that this gene is not disrupted by the bacterial insertion sequence IS1 or IS2, which have been reported to be present in the majority of the plasmids containing the gag region. Comparison of amino acid sequences of JYG-MMTV with those of BR6-MMTV showed that over 96% of the amino acids of gag, pol, protease and env products are identical. These results suggest the intact nature of the nucleotide sequence of the near full-length MMTV genome cloned in the plasmid.

Experimental conversion of colony social organization in fire ants (Solenopsis invicta): worker genotype manipulation in absence of queen effects

Colony social organization in the fire ant Solenopsis invicta appears to be under strong genetic control. In the invasive USA range, polygyny (multiple queens per colony) is marked by the presence of the Gp-9(b) allele in most of a colony's workers, whereas monogyny (single queen per colony) is associated with the exclusive occurrence of the Gp-9(B) allele. Ross and Keller, Behav Ecol Sociobiol 51:287-295 (2002) experimentally manipulated social organization by cross-fostering queens into colonies of the alternate form, thereby changing adult worker Gp-9 genotype frequencies over time. Although these authors showed that social behavior switched predictably when the frequency of b-bearing adult workers crossed a threshold of 5-10%, the possibility that queen effects caused the conversions could not be excluded entirely. We addressed this problem by fostering polygyne brood into queenright monogyne colonies. All such treatment colonies switched social organization to become polygyne, coincident with their proportions of b-bearing workers exceeding 12%. Our results support the conclusion that polygyny in S. invicta is induced by a minimum frequency of colony workers carrying the b allele, and further confirm that its expression is independent of queen genotype or history, worker genotypes at genes not linked to Gp-9, and colony genetic diversity.

Ancient kings of Peru : the reliability of the Chronicle of Fernando de Montesinos

Doctoral dissertation, University of Turku