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1.  Critical Evaluation of Diagnostic Aids for the Detection of Oral Cancer 
Oral oncology  2007;44(1):10-22.
Historically, the screening of patients for signs of oral cancer and precancerous lesions has relied upon the conventional oral examination. A variety of commercial diagnostic aids and adjunctive techniques are available to potentially assist in the screening of healthy patients for evidence of otherwise occult cancerous change or to assess the biologic potential of clinically abnormal mucosal lesions. This manuscript systematically and critically examines the literature associated with current oral cancer screening and case-finding aids or adjuncts such as toluidine blue, brush cytology, tissue chemiluminescence and autofluorescence. The characteristics of an ideal screening test are outlined and the authors pose several questions for clinicians and scientists to consider in the evaluation of current and future studies of oral cancer detection and diagnosis. Although the increased public awareness of oral cancer made possible by the marketing of recently-introduced screening adjuncts is commendable, the tantalizing implication that such technologies may improve detection of oral cancers and precancers beyond conventional oral examination alone has yet to be rigorously confirmed.
PMCID: PMC2424250  PMID: 17825602
Oral Cancer; premalignancy; screening; diagnosis
2.  Correlation between histological grading and ploidy status in potentially malignant disorders of the oral mucosa: A flow cytometric analysis 
Histopathological grading of oral dysplastic lesions is the method of choice for evaluating malignant and potentially malignant disorders. Owing to inter- and intra-observer variability, determination of the DNA ploidy status of lesions may serve as an adjunct in the prediction of malignant transformation.
To correlate histopathological grading and ploidy status in potentially malignant and malignant disorders of the oral mucosa.
Settings and Design:
A pilot study was done with 30 patients (10 patients with oral potentially malignant disorders predominantly leukoplakia, 10 patients with oral malignant lesions and 10 patients with normal mucosa).
Materials and Methods:
Incisional biopsy was done after isolating the biopsy site with 1% Toluidine blue staining. Two sections of the tissue were removed and sent for histopathological and Flow-cytometric analysis respectively. Histopathological diagnosis was obtained and compared with Flow-cytometric results which were graded as diploid and aneuploid. Further, the S – phase fraction, DNA index were also calculated to evaluate the severity of malignant transformation or malignancy.
Statistical Analysis:
The results were analyzed using Pearson Chi-Square Test.
There exists a significant correlation between histopathology and ploidy status in both potentially malignant and malignant group. (P = 0.002).
The data from this study has shown that DNA Ploidy analysis can be used as a valuable tool in assessing the carcinomatous progression of potentially malignant and malignant lesions.
PMCID: PMC3830221  PMID: 24250073
Deoxyribonucleic acid index; flow cytometer; histopathology; oral cancer; potentially malignant disorder; S-phase fraction
3.  Assessment of oral mucosa in normal, precancer and cancer using chemiluminescent illumination, toluidine blue supravital staining and oral exfoliative cytology 
Carcinoma in an early stage of development is hard to detect clinically because the lesion may not be palpable and color of the lesional tissue is not necessarily different from the color of the surrounding mucosa. In order to improve the efficacy of the diagnosis, techniques are being developed to complement clinical examination and to facilitate the identification of initial carcinomas.
To find out the efficacy of chemiluminescent illumination (ViziLite™) for the diagnosis in precancer and cancer patients and compare this result to toluidine blue staining and oral exfoliative cytology.
Materials and Methods:
This study was done in 3 groups. Each group consists of 10 cases. Group I consists of normal appearing mucosa. Group II and III consist of clinically diagnosed pre-cancer and clinically suggestive of cancer respectively. Chemiluminescent illumination, toluidine blue supravital staining, oral exfoliative cytology and biopsy were performed in all cases.
Statistical analysis used:
SPSS version 10.05 was used to calculate positive and negative predictive values.
In Group I, all 10 patients showed negative result to ViziLite™. 8 patients showed positivity and 2 patients showed negativity to ViziLite™ test in Group II. 9 patients were positive and one patient was negative for ViziLite™.
Chemiluminescent illumination test was sensitive for precancerous and cancerous lesions, which presented as keratotic lesions and red-white lesions. It showed negative result to erosive lesions. Toluidine blue staining test was reliable in precancerous and cancerous lesions, which present as erosive and red-white lesions. It showed negative result to keratotic lesions. Oral exfoliative cytology has diagnostic value in cancer patients than in precancer patients. These Results indicate that chemiluminescent illumination test is relatively reliable and accurate than toluidine blue staining test and useful chair side diagnostic test.
PMCID: PMC3519202  PMID: 23248459
Chemiluminescent illumination; Oral exfoliative cytology; Toluidine blue
4.  A comparative analysis of toluidine blue with frozen section in oral squamous cell carcinoma 
Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins.
After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section.
Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%.
Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available.
PMCID: PMC3349537  PMID: 22500814
5.  Dysplasia of the Upper Aerodigestive Tract Squamous Epithelium 
Head and Neck Pathology  2009;3(1):63-68.
Dysplasia of the oral, laryngeal and oropharyngeal stratified squamous epithelia is a microscopically defined change that may occur in clinically identifiable lesions including erythroplakia, leukoplakia and erythroleukoplakia, lesions that convey a heightened risk for carcinomatous progression. Dysplastic lesions have been classified microscopically according to degree of cytologic atypia and changes in architectural patterns, usually on a three part or four part gradation scale. Vocal cord epithelial lesions are graded according to either the Ljubljana or the World Health Organization (WHO) system whereas oral dysplasias are generally classified according to WHO criteria. Cytologically atypical cells are considered to represent precancerous changes predicting an increase risk for carcinomatous transformation. Inter- and intra-rater reliability studies among pathologists have disclosed low correlation coefficients for four part grading systems, whereas improved agreement is achieved (kappa correlation values) using the Ljubljana systems. Evidence forwarded by some studies supports the prognostic value of progressively severe dysplastic changes for carcinomatous transformation; however, some studies indicate that the presence of a clinically defined lesion without microscopic evidence of dysplasia also connotes increased risk for carcinomatous transformation. Loss of heterozygosity (LOH) at 3p and 9p microsatellite domains, DNA ploidy analysis and nuclear image analyses may have predictive value as molecular and histomorphological biomarkers.
PMCID: PMC2807542  PMID: 20596993
Dysplasia; Squamous cell carcinoma; Head and neck; Larynx; Oral mucosa; Oropharynx; Biomarkers; Precancerous lesions; DNA ploidy; Loss of heterozygosity
6.  Reliability of novice raters in using the movement system impairment approach to classify people with low back pain 
Manual therapy  2012;18(1):35-40.
Observational cross sectional study.
To examine the inter-rater reliability of novice raters in using the Movement System Impairment (MSI) approach system and to explore the patterns of disagreement in classification errors. The inter-rater reliability of individual tests items used in the MSI approach is moderate to good; however, the reliability of the classification algorithm has been tested only preliminarily.
Using previously recorded patient data (n = 21), 13 novice raters classified patients according to the MSI schema. The overall percent agreement using the kappa statistic as well as the agreement/disagreement among pair-wise comparisons in classification assignments were examined.
There was an overall 87.4% agreement in the pairs of classification judgments with a kappa coefficient of 0.81 (95% CI: 0.79, 0.83). Raters were most likely to agree on the classification of Flexion (100%) and least likely to agree on the classification of Rotation (84%).
The MSI classification algorithm can be learned by novice users and with training, their inter-rater reliability in applying the algorithm for classification judgments is good and similar to that reported in other studies. However, some degree of error persists in the classification decision-making associated with the MSI system, in particular for the Rotation category.
PMCID: PMC3618854  PMID: 22796388
Classification of low back pain; Reliability; Subgrouping of low back pain
7.  The reliability of WorkWell Systems Functional Capacity Evaluation: a systematic review 
Functional capacity evaluation (FCE) determines a person’s ability to perform work-related tasks and is a major component of the rehabilitation process. The WorkWell Systems (WWS) FCE (formerly known as Isernhagen Work Systems FCE) is currently the most commonly used FCE tool in German rehabilitation centres. Our systematic review investigated the inter-rater, intra-rater and test-retest reliability of the WWS FCE.
We performed a systematic literature search of studies on the reliability of the WWS FCE and extracted item-specific measures of inter-rater, intra-rater and test-retest reliability from the identified studies. Intraclass correlation coefficients ≥ 0.75, percentages of agreement ≥ 80%, and kappa coefficients ≥ 0.60 were categorised as acceptable, otherwise they were considered non-acceptable. The extracted values were summarised for the five performance categories of the WWS FCE, and the results were classified as either consistent or inconsistent.
From 11 identified studies, 150 item-specific reliability measures were extracted. 89% of the extracted inter-rater reliability measures, all of the intra-rater reliability measures and 96% of the test-retest reliability measures of the weight handling and strength tests had an acceptable level of reliability, compared to only 67% of the test-retest reliability measures of the posture/mobility tests and 56% of the test-retest reliability measures of the locomotion tests. Both of the extracted test-retest reliability measures of the balance test were acceptable.
Weight handling and strength tests were found to have consistently acceptable reliability. Further research is needed to explore the reliability of the other tests as inconsistent findings or a lack of data prevented definitive conclusions.
PMCID: PMC3974446  PMID: 24674029
Functional capacity evaluation; Assessment; Reliability; Systematic review; WorkWell Systems; Isernhagen
8.  The usefulness of toluidine staining as a diagnostic tool for precancerous and cancerous oropharyngeal and oral cavity lesions 
Toluidine blue stain is used as a marker to differentiate lesions at high risk of progression in order to improve early diagnosis of oropharyngeal carcinomas. This study focused on 45 oral mucosal lesions in 32 patients (13 female, 19 male). In 9 cases, multiple biopsies were collected. Of the 45 lesions examined, 26 (57.0%) were defined clinically benign, while 19 (42.3%) were defined as suspected lesions (premalignant or malignant). According to the clinical examination, the sensitivity was 53% (16/30) and for toluidine blue staining 96.2% (26/27) (p = 0.0007). The specificity was 80% (12/15) for clinical examination and 77.7% (14/15) for toluidine blue staining (p = 0.79). In conclusion toluidine blue stain has been shown to be a reliable aid when clinical examination is unable to differentiate lesions at high risk of progression and then it improves early diagnosis for oral cavity and oropharyngeal cancer.
PMCID: PMC2816365  PMID: 20161875
Oral cavity; Oropharynx; Malignant tumours; Precancerous lesions
9.  Risk of bias versus quality assessment of randomised controlled trials: cross sectional study 
Objectives To evaluate the risk of bias tool, introduced by the Cochrane Collaboration for assessing the internal validity of randomised trials, for inter-rater agreement, concurrent validity compared with the Jadad scale and Schulz approach to allocation concealment, and the relation between risk of bias and effect estimates.
Design Cross sectional study.
Study sample 163 trials in children.
Main outcome measures Inter-rater agreement between reviewers assessing trials using the risk of bias tool (weighted κ), time to apply the risk of bias tool compared with other approaches to quality assessment (paired t test), degree of correlation for overall risk compared with overall quality scores (Kendall’s τ statistic), and magnitude of effect estimates for studies classified as being at high, unclear, or low risk of bias (metaregression).
Results Inter-rater agreement on individual domains of the risk of bias tool ranged from slight (κ=0.13) to substantial (κ=0.74). The mean time to complete the risk of bias tool was significantly longer than for the Jadad scale and Schulz approach, individually or combined (8.8 minutes (SD 2.2) per study v 2.0 (SD 0.8), P<0.001). There was low correlation between risk of bias overall compared with the Jadad scores (P=0.395) and Schulz approach (P=0.064). Effect sizes differed between studies assessed as being at high or unclear risk of bias (0.52) compared with those at low risk (0.23).
Conclusions Inter-rater agreement varied across domains of the risk of bias tool. Generally, agreement was poorer for those items that required more judgment. There was low correlation between assessments of overall risk of bias and two common approaches to quality assessment: the Jadad scale and Schulz approach to allocation concealment. Overall risk of bias as assessed by the risk of bias tool differentiated effect estimates, with more conservative estimates for studies at low risk.
PMCID: PMC2764034  PMID: 19841007
10.  Association between oral health and gastric precancerous lesions 
Carcinogenesis  2011;33(2):399-403.
Although recent studies have suggested that tooth loss is positively related to the risk of gastric non-cardia cancer, the underlying oral health conditions potentially responsible for the association remain unknown. We investigated whether clinical and behavioral measures of oral health are associated with the risk of gastric precancerous lesions. We conducted a cross-sectional study of 131 patients undergoing upper gastrointestinal endoscopy. Cases were defined as those with gastric precancerous lesions including intestinal metaplasia or chronic atrophic gastritis on the basis of standard biopsy review. A validated structured questionnaire was administered to obtain information on oral health behaviors. A comprehensive clinical oral health examination was performed on a subset of 91 patients to evaluate for periodontal disease and dental caries experience. A total of 41 (31%) cases of gastric precancerous lesions were identified. Compared with non-cases, cases were significantly more likely to not floss their teeth [odds ratio (OR) = 2.89, 95% confidence interval (CI): 1.09–7.64], adjusting for age, sex, race, body mass index, smoking status, educational attainment and Helicobacter pylori status in serum. Among participants who completed the oral examination, cases (n = 28) were more likely to have a higher percentage of sites with gingival bleeding than non-cases [OR = 2.63, 95% CI: 1.37–5.05 for a standard deviation increase in bleeding sites (equivalent to 19.7%)], independent of potential confounders. Our findings demonstrate that specific oral health conditions and behaviors such as gingival bleeding and tooth flossing are associated with gastric precancerous lesions.
PMCID: PMC3384024  PMID: 22139442
11.  Examining intra-rater and inter-rater response agreement: A medical chart abstraction study of a community-based asthma care program 
To assess the intra- and inter-rater agreement of chart abstractors from multiple sites involved in the evaluation of an Asthma Care Program (ACP).
For intra-rater agreement, 110 charts randomly selected from 1,433 patients enrolled in the ACP across eight Ontario communities were re-abstracted by 10 abstractors. For inter-rater agreement, data abstractors reviewed a set of eight fictitious charts. Data abstraction involved information pertaining to six categories: physical assessment, asthma control, spirometry, asthma education, referral visits, and medication side effects. Percentage agreement and the kappa statistic (κ) were used to measure agreement. Sensitivity and specificity estimates were calculated comparing results from all raters against the gold standard.
Intra-rater re-abstraction yielded an overall kappa of 0.81. Kappa values for the chart abstraction categories were: physical assessment (κ 0.84), asthma control (κ 0.83), spirometry (κ 0.84), asthma education (κ 0.72), referral visits (κ 0.59) and medication side effects (κ 0.51). Inter-rater abstraction of the fictitious charts produced an overall kappa of 0.75, sensitivity of 0.91 and specificity of 0.89. Abstractors demonstrated agreement for physical assessment (κ 0.88, sensitivity and specificity 0.95), asthma control (κ 0.68, sensitivity 0.89, specificity 0.85), referral visits (κ 0.77, sensitivity 0.88, specificity 0.95), and asthma education (κ 0.49, sensitivity 0.87, specificity 0.77).
Though collected by multiple abstractors, the results show high sensitivity and specificity and substantial to excellent inter- and intra-rater agreement, assuring confidence in the use of chart abstraction for evaluating the ACP.
PMCID: PMC2396663  PMID: 18471298
12.  Exciting new advances in oral cancer diagnosis: avenues to early detection 
Head & Neck Oncology  2011;3:33.
The prognosis for patients with oral squamous cell carcinoma remains poor in spite of advances in therapy of many other malignancies. Early diagnosis and treatment remains the key to improved patient survival. Because the scalpel biopsy for diagnosis is invasive and has potential morbidity, it is reserved for evaluating highly suspicious lesions and not for the majority of oral lesions which are clinically not suspicious. Furthermore, scalpel biopsy has significant interobserver and intraobserver variability in the histologic diagnosis of dysplasia. There is an urgent need to devise critical diagnostic tools for early detection of oral dysplasia and malignancy that are practical, noninvasive and can be easily performed in an out-patient set-up. Diagnostic tests for early detection include brush biopsy, toluidine blue staining, autofluorescence, salivary proteomics, DNA analysis, biomarkers and spectroscopy. This state of the art review critically examines these tests and assesses their value in identifying oral squamous cell carcinoma and its precursor lesions.
PMCID: PMC3170277  PMID: 21798030
Oral Cancer; Diagnosis; Brush Biopsy; DNA; Saliva; Biomarkers; Spectroscopy
13.  Mast cells distribution and variations in epithelium thickness and basement membrane in oral lichen planus lesion and oral lichenoid reaction 
Dental Research Journal  2012;9(2):180-184.
Oral lichen planus (OLP) is a chronic mucocutaneous lesion with unknown etiology. Oral lichenoid lesions (OLL) comprise a family of lesions with different etiologies. Both lesions have similar clinical and histopathologic characteristics although their management is different. Differential diagnosis between OLP and OLL has always been a major challenge.
Materials and Methods:
In this prospective analytical study, the role of mast cells in pathogenesis of these lesions was investigated by evaluation of 52 patients with clinical and histopathological diagnosis of OLP (26 cases) and OLL (26 cases) based on WHO criteria, and by applying a more accessible staining methods, Hematoxylin and Eosin, toluidine blue (histochemistry) and Periodic Acid Schiff staining. In order to distinguish these two lesions, number of mast cells and thickness of epithelium and basement membrane were measured using light microscopy. Data were analyzed by SPSS software using t-test method (P<0.001).
No significant difference was observed between the total numbers of mast cells of two groups (P=0.148), but a statistically significant difference was detected between degranulated mast cells in two groups (P<0.001). A significant difference was also observed between the thickness of epithelium in two groups (P<0.001), although no difference was seen between basement membrane thickness in these lesions.
Number of degranulated mast cells in reticular layer of corium in lichenoid lesions was more than that of OLP. This implies that despite the increase in number of these cells, in both groups of diseases, the role of these cells has not been the same in pathogenesis of the diseases. Moreover, the epithelium thickness was lower in lesions of OLP compared to lesions of oral lichenoid, so this parameter may be a useful criterion together with other histopathological and clinical finding to discriminate these lesions. However, discrepancy of basement membrane thickness can not be a reliable criterion. Finally we suggest more accessible staining methods which are reliable for differentiation of these two lesions.
PMCID: PMC3353695  PMID: 22623935
Differential diagnosis; histochemistry; mast cells; oral lichen planus; oral lichenoid lesion
14.  In Vivo Diagnosis of Oral Dysplasia and Malignancy Using Optical Coherence Tomography: Preliminary Studies in 50 Patients 
Lasers in surgery and medicine  2009;41(5):353-357.
In vivo, non-invasive optical coherence tomography (OCT) permits high-resolution imaging of tissue surfaces and subsurfaces, with the potential capability for detection and mapping of epithelial pathologies.
To evaluate the clinical capability of non-invasive in vivo OCT for diagnosing oral dysplasia and malignancy.
Experimental Design
In 50 patients with oral lesions, conventional clinical examination was followed by OCT imaging, then standard biopsy and histopathology. Two blinded, pre-standardized investigators separately diagnosed each lesion based on (1) OCT and (2) histopathology.
Intra- and inter-observer agreement between diagnoses based on histopathology and imaging data was excellent, with λ values between 0.844 and 0.896. Sensitivity and specificity were also very good.
These data demonstrate the excellent capability of in vivo OCT for detecting and diagnosing oral premalignancy and malignancy in human subjects.
PMCID: PMC2862682  PMID: 19533765
imaging; non-invasive diagnosis; oral dysplasia; squamous cell carcinoma
15.  From the Trenches: A Cross-Sectional Study Applying the GRADE Tool in Systematic Reviews of Healthcare Interventions 
PLoS ONE  2012;7(4):e34697.
GRADE was developed to address shortcomings of tools to rate the quality of a body of evidence. While much has been published about GRADE, there are few empirical and systematic evaluations.
To assess GRADE for systematic reviews (SRs) in terms of inter-rater agreement and identify areas of uncertainty.
Cross-sectional, descriptive study.
We applied GRADE to three SRs (n = 48, 66, and 75 studies, respectively) with 29 comparisons and 12 outcomes overall. Two reviewers graded evidence independently for outcomes deemed clinically important a priori. Inter-rater reliability was assessed using kappas for four main domains (risk of bias, consistency, directness, and precision) and overall quality of evidence.
For the first review, reliability was: κ = 0.41 for risk of bias; 0.84 consistency; 0.18 precision; and 0.44 overall quality. Kappa could not be calculated for directness as one rater assessed all items as direct; assessors agreed in 41% of cases. For the second review reliability was: 0.37 consistency and 0.19 precision. Kappa could not be assessed for other items; assessors agreed in 33% of cases for risk of bias; 100% directness; and 58% overall quality. For the third review, reliability was: 0.06 risk of bias; 0.79 consistency; 0.21 precision; and 0.18 overall quality. Assessors agreed in 100% of cases for directness. Precision created the most uncertainty due to difficulties in identifying “optimal” information size and “clinical decision threshold”, as well as making assessments when there was no meta-analysis. The risk of bias domain created uncertainty, particularly for nonrandomized studies.
As researchers with varied levels of training and experience use GRADE, there is risk for variability in interpretation and application. This study shows variable agreement across the GRADE domains, reflecting areas where further guidance is required.
PMCID: PMC3320617  PMID: 22496843
16.  Development and Preliminary Reliability Testing of an Assessment of Patient Independence in Performing a Treatment Program: Standardized Scenarios 
Physical therapists often assess patient independence through observation, however it is not known if therapists make these judgments reliably. We have developed a standardized method to assess a patient’s ability to perform his or her treatment program independently.
To develop a standardized assessment of patient independence in performance of a treatment program and examine the intra- and inter-rater reliability decisions made by two physical therapists.
An assessment of patient independence in performance was developed. Standardized patient scenarios were used to assess the intra- and inter-tester reliability of two physical therapists. Percentage of agreement (%) and kappa’s coefficient (k and kw) indexed rater reliability.
Intra-rater reliability of Therapist 1 was as follows: knowledge: %=95, k=.90; performance: %=95, kw=.82. Intra-rater reliability of Therapist 2 was as follows: knowledge: %=85, k=.68; performance: %=94, kw=.80. Inter-rater reliability for knowledge was %=91 and k=.79 and for performance was %=91 and kw=.72.
Trained therapists displayed substantial to excellent intra-rater reliability and substantial inter-rater reliability in assessing a patient’s independence in a treatment program.
PMCID: PMC3574865  PMID: 20411216
Activities of Daily Living; Exercise Therapy; Directly Observed Therapy; Patient Compliance
17.  Low Inter-rater Reliability of Examiners Performing the Prone Instability Test, a Clinical Test for Lumbar Shear Instability 
To test the inter-rater reliability of examiners performing the prone instability test (PIT), a clinical test proposed to identify lumbar shear instability.
Cross-sectional, test-retest design examining subjects with mechanical low back pain (LBP).
University-based musculoskeletal analysis laboratory.
Thirty subjects with mechanical LBP recruited from community sources in a metropolitan region.
Not applicable.
Main Outcome Measures
Repeated measures of a clinical examination test proposed to identify lumbar shear instability.
Inter-rater reliability of examiners’ judgments of the PIT results were indexed with percent agreement and the kappa statistic. Examiners obtained 63 % agreement and a kappa value of 0.10 (95% CI: −0.27 to 0.47). Adjusted kappa values based on prevalence and bias indices were calculated to evaluate the effect on kappa. The prevalence index associated with examiner judgments of the PIT was 0.43 and the bias index was 0.03. The prevalence-adjusted-bias-adjusted kappa value was slightly higher than the unadjusted kappa value (k=0.27; 95% CI: −0.08 to 0.61).
The results of our study are not consistent with those of previous studies examining reliability of therapists performing the PIT. We conclude that examiners do not attain acceptable inter-rater reliability when performing the procedures for the PIT based on the information that is currently provided in the literature. Based on our experience we suggest further exploration, standardization, and clarification of procedural details to improve therapists’ ability to conduct the PIT on people with LBP.
PMCID: PMC3104326  PMID: 21621668
Diagnosis; Low back pain; Rehabilitation; Reliability
18.  The Application of Vizilite in Oral Cancer 
This article depicts the various applications of Vizilite plus in oral cancer. The oral cavity demonstrates a variety of red and white, pigmented and vesiculo- bullous lesions. Oral cancer still happens to carry the highest mortality worldwide, especially in India. In India, the prime focus is on the downstreaming of oral cancer from an advanced stage to an early diseased state. The techniques that are promoted to facilitate an earlier detection and diagnosis of an oral malignancy include Toluidine blue, ViziLite Plus with TBlue, ViziLite, Microlux DL, Orascoptic DK, VEL scope, Oral CDx and brush biopsy.
PMCID: PMC3576785  PMID: 23450083
Oral cancer; Toluidine blue; VELscope; OralCDx; Brush biopsy; Vizilite
19.  Diagnostic Concordance Characteristics of Oral Cavity Lesions 
The Scientific World Journal  2013;2013:785929.
Purpose. The objective of this study was to evaluate the diagnostic concordance characteristics of oral cavity lesions by comparing the clinical diagnosis of the lesions with the histopathologic diagnosis. Material and Method. A retrospective analysis was conducted on the patients, who were admitted with oral cavity pathology and underwent biopsy procedure between 2007 and 2011. The oral cavity lesions were classified into 6 different groups as odontogenic cysts, nonodontogenic cysts, odontogenic tumors, nonodontogenic tumors, malignant tumors, and precancerous lesions in accordance with the 2005 WHO classification. The diagnoses were also recategorized into 3 groups expressing prognostic implications as benign, precancerous, and malignant. The initial clinical diagnoses were compared with the histopathologic diagnoses. Data were analyzed statistically. Results. A total of 2718 cases were included. Histopathologic diagnosis did not match the clinical diagnosis in 6.7% of the cases. Nonodontogenic tumors and malignant tumors had the highest misdiagnosis rates (11.5% and 9%, resp.), followed by odontogenic tumors (7.7%), precancerous lesions (6.9%), and odontogenic cysts (4.4%). Clinicians were excelled in diagnosis of benign and precancerous lesions in clinical setting. Conclusion. The detailed discordance characteristics for each specific lesion should be considered during oral pathology practice to provide early detection without delay.
PMCID: PMC3886281  PMID: 24453906
20.  Rapid Detection of Malaria Parasite by Toluidine Blue Method: A New Staining Method 
Malaria is a commonest mosquito-borne infectious disease worldwide. Early identification and management of malaria prevents complications and mortality. Identification of the malaria mainly relies on detection of the parasite on blood smears. The present study was conducted to compare Toluidine blue method with Leishman method for detection of malaria parasite and also to study the efficacy and advantages of using Toluidine blue method.
Materials and Methods:
In 540 consecutive patients with clinical suspicion of malaria, peripheral smears were prepared. Smears were processed for both conventional Leishman method and Toluidine blue method simultaneously. The significance of Toluidine blue method over Leishman method was analyzed using Chi-square (χ2) test.
Out of 540 smears, 28.3% (153/540) were positive for malaria parasite on conventional Leishman method, while the smear positivity was more by Toluidine blue method to 33.3% (180/540) [P value < 0.01]. The remaining 66.67% (360/540) were negative by both Toluidine blue method and conventional Leishman method.
The Toluidine blue method is simple, rapid, inexpensive, and easily available. The implementation of Toluidine blue method clearly improves microscopic detection of malaria parasite and can be a useful contribution to routine hematology even at rural health sectors.
PMCID: PMC3958985  PMID: 24672177
Leishman method; Malaria; Peripheral smear; Toluidine blue method
21.  Mast cells density in fibrotic capsule of enchondroma and well-differentiated chondrosarcoma: a method for histopathologic differentiation 
An enchondroma is a benign and a well-differentiated chondrosarcoma is an invasive chondroid tumor with high recurrence potential. In spite of biologic differences, these two tumors have very similar histopathologic appearance. It has been shown that the biologic nature of the connective tissue around benign and malignant tumors varies in the number of mast cells. The aim of this study was to study the histopathologic distinction of enchondroma and well-differentiated chondrosarcoma using the density of the mast cells in fibrotic capsule.
Twelve enchondroma and 15 well-differentiated chondrosarcoma were collected from Pathology department of Cancer Institute and Central Pathology department of Imam Khomeini Hospital in Tehran. 3 micron paraffin embedded tissue sections were stained by toluidine blue for mast cells counting. Mast cells were counted in fibrous capsule of all cases. Mast cells counts were accomplished in 10 high power fields. The average number of mast cells in 10HPF was determined as an index for each lesion. Mann-Whitney U test was used for statistical analysis.
Mean index in enchondroma and well-differentiated chondrosarcoma groups were 0.1±0.12 and 0.31±0.33 respectively, showing a significant difference between number of mast cells in the fibrotic capsule in these two lesions (p = 0.028). Comparison of the corresponding points in ROC curve, showed a cut-off point = 0.15, with positive predictive value of 61%, negative predictive value 71%, specificity of 33.3% and sensitivity of 66.7%, (p = 0.025).
Average density of the mast cells in the surrounding fibrotic capsules of enchondroma and well-differentiated chondrosarcoma along with other criterions, could be a beneficial factor for histologically differentiation between these two lesions.
PMCID: PMC3587891  PMID: 23482895
Enchondroma; Well-differentiated Chondrosarcoma; Mast cell; Toluidine blue staining
22.  Precancerous conditions and epithelial dysplasia in the stomach. 
Journal of Clinical Pathology  1980;33(8):711-721.
A distinction can be made between a precancerous condition and a precancerous lesion. The former is a clinical state associated with a significantly increased risk of cancer, whereas a precancerous lesion is a histopathological abnormality in which cancer is more likely to occur than in its apparently normal counterpart. Up to the present time atrophic gastritis, gastric ulcer, pernicious anaemia, gastric stumps, gastric polyps, and Ménétrier's disease have all been considered as precancerous conditions and lesions of the stomach. Of these, only atrophic gastritis, pernicious anaemia, gastric stumps, and certain types of gastric polyp can now be regarded as having any really significant malignant potential. The precancerous lesion common to these is epithelial dysplasia which can occur in ordinary (foveolar) gastric epithelium as well as in intestinal metaplasia. The criteria for grading dysplasia in gastric epithelium into mild, moderate, and severe grades are given, and attention is drawn to the problems of differentiating inflammatory or regenerative change from mild dysplasia and intramucosal carcinoma from severe dysplasia. The clinical and epidemiological implications of gastric dysplasia are discussed with suggestions for further research.
PMCID: PMC1146204  PMID: 7430384
23.  Toluidine blue: A review of its chemistry and clinical utility 
Toluidine blue is a basic thiazine metachromatic dye with high affinity for acidic tissue components, thereby staining tissues rich in DNA and RNA. It has found wide applications both as vital staining in living tissues and as a special stain owing to its metachromatic property. Toluidine blue has been used in vivo to identify dysplasia and carcinoma of the oral cavity. Use of toluidine blue in tissue sections is done with the aim to highlight components, such as mast cells granules, mucins, and cartilage. This article provides an overview on chemistry, technique, and the various applications of toluidine blue.
PMCID: PMC3424943  PMID: 22923899
Metachromasia; toluidine blue; vital staining
24.  Tumour thickness in oral cancer using an intra-oral ultrasound probe 
European Radiology  2010;21(1):98-106.
To investigate tumour-thickness measurement with an intra-operative ultrasound (US) probe.
A retrospective data analysis was undertaken for a total of 65 patients with a T1-2 oral cavity cancer, who were seen at a tertiary referral centre between 2004 and 2010. The correspondence between tumour thickness measured by ultrasonography and histopathology was assessed by Pearson’s correlation coefficient, and also between tumour thickness and the development of neck metastasis.
In 11 cases, intra-oral measurement was not optimal due to limited mouth opening (n = 2) or impossibility to depict the lesion (n = 9). Tumour thickness measured by US correlated well with histopathology (n = 23, R = 0.93). Tumour thickness of ≤7 mm carries a risk of lymph node metastasis of 12%, whereas in tumours exceeding 7 mm this risk is 57% (p = 0.001). Twenty-five percent developed neck metastasis and 19% had local recurrence.
Tumour thickness is an important predictive marker for lymph node metastases. As such, it can help in decision-making with regard to management of the primary tumour and neck. Based upon our findings, a wait-and-see policy is only warranted for superficial lesions with tumour thickness of less than 7 mm, but only if regular follow-up using US-guided aspiration of the neck is ensured.
PMCID: PMC2995869  PMID: 20680291
Intra-oral ultrasonography; Tumour thickness; Head and neck; Cervical metastasis; MR imaging
25.  Screening of the spine in adolescents: inter- and intra-rater reliability and measurement error of commonly used clinical tests 
Evidence on the reliability of clinical tests used for the spinal screening of children and adolescents is currently lacking. The aim of this study was to determine the inter- and intra-rater reliability and measurement error of clinical tests commonly used when screening young spines.
Two experienced chiropractors independently assessed 111 adolescents aged 12–14 years who were recruited from a primary school in Denmark. A standardised examination protocol was used to test inter-rater reliability including tests for scoliosis, hypermobility, general mobility, inter-segmental mobility and end range pain in the spine. Seventy-five of the 111 subjects were re-examined after one to four hours to test intra-rater reliability. Percentage agreement and Cohen’s Kappa were calculated for binary variables, and interclass correlation (ICC) and Bland-Altman plots with Limits of Agreement (LoA) were calculated for continuous measures.
Inter-rater percentage agreement for binary data ranged from 59.5% to 100%. Kappa ranged from 0.06-1.00. Kappa ≥ 0.40 was seen for elbow, thumb, fifth finger and trunk/hip flexion hypermobility, pain response in inter-segmental mobility and end range pain in lumbar flexion and extension. For continuous data, ICCs ranged from 0.40-0.95. Only forward flexion as measured by finger-to-floor distance reached an acceptable ICC(≥ 0.75). Overall, results for intra-rater reliability were better than for inter-rater reliability but for both components, the LoA were quite wide compared with the range of assessments.
Some clinical tests showed good, and some tests poor, reliability when applied in a spinal screening of adolescents. The results could probably be improved by additional training and further test standardization. This is the first step in evaluating the value of these tests for the spinal screening of adolescents. Future research should determine the association between these tests and current and/or future neck and back pain.
PMCID: PMC3922274  PMID: 24512306
Reliability; Measurement error; Scoliosis; Hypermobility; Intersegmental mobility; Spine; Adolescents; Mobility

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