Evidence map›Paper›PMID 33473044›Full record

ArticleEndoscopic ultrasound

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers.

Seifeldin Hakim, Emmanuel Coronel, Graciela M Nogueras González, Philip S Ge, Suresh T Chari, Nirav Thosani, Srinivas Ramireddy, Ricardo Badillo, Tomas DaVee, Marc F Catalano and 14 more

Open access · greenAbstract read
PubMed Full text at PMC Publisher
In one paragraph

Article in Endoscopic ultrasound. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 4 papers.

0numbers the graph read from it
0cells of the map it votes in
4citing papers in PubMed
0.4field-weighted citation impact, top 36% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

4 citing papers in PubMed, 6 citations in OpenAlex.

  1. Review
  2. Diagnostic and Predictive Features of Pancreatic Cysts Using Endoscopic Ultrasound: A Retrospective Analysis from a Single Centre.The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology · 2025
    Article
  3. Article
  4. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

24 authors at 13 institutions in 7 countries.

Seifeldin HakimDepartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Emmanuel CoronelDepartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Graciela M Nogueras GonzálezDepartment of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Philip S GeDepartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Suresh T ChariDepartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Nirav ThosaniDepartment of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Srinivas RamireddyDepartment of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Ricardo BadilloDepartment of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Tomas DaVeeDepartment of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Marc F CatalanoDepartment of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA.
Robert J SealockDepartment of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.
Sreeram ParupudiDivision of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX, USA.
Lyndon V HernandezDepartment of Gastroenterology, Ascension Hospital, Racine, Wisconsin, USA.
Virendra JoshiDepartment of Medicine, LSU Health Sciences Center, New Orleans, LA, USA.
Atsushi IrisawaDepartment of Gastroenterology, Dokkyo Medical University, Mibu, Japan.
Surinder RanaDepartment of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Sundeep LakhtakiaDepartment of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyberabad, Telangana, India.
Peter VilmannDivision of Endoscopy, Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark.
Adrian SaftoiuResearch Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy, Craiova; Department of Gastroenterology, Ponderas Academic Hospital Bucharest, Romania.
Siyu SunDepartment of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China.
Marc GiovanniniDepartment of Endoscopy, Institute Paoli-Calmettes, Marseille, France.
Matthew H KatzDepartment of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Michael P KimDepartment of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Manoop S BhutaniDepartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
The University of Texas MD Anderson Cancer Center · USThe University of Texas Health Science Center at Houston · USAscension Providence Hospital · USAsian Institute of Gastroenterology · INBaylor College of Medicine · USChina Medical University · CNClinical Emergency Hospital Bucharest · RODokkyo Medical University · JPGentofte Hospital · DKInstitut Paoli-Calmettes · FRLouisiana State University Health Sciences Center New Orleans · USPost Graduate Institute of Medical Education and Research · INThe University of Texas Medical Branch at Galveston · US

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

BACKGROUND AND

objectivesNo single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the "string sign" test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied.

methodsAn experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: "Is the string sign positive?" and "If the string sign is positive, what is the length of the formed string?" Also asked "What is the cutoff length for string sign to be considered positive?" Interobserver variability was assessed using the kappa statistic (κ).

resultsA total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive.

conclusionString sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.

Indexed as

mucinous pancreatic cystmucouspancreatic cyststring signsurface tensionviscosity

Identifiers

PMID33473044
PMCPMC7980687
OpenAlexW3124141235

What OpenQuestion holds

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LicenceCC BY-NC-SA
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.