3-grade System Research Articles

Enhanced grading methods for lumbar paraspinal fat infiltration and its prognostic value in predicting lumbar disc herniation

BackgroundThe simplified 3-grade system for measuring fat infiltration in the paraspinal muscles is widely utilized. In comparing our proposed 4-grade system to the existing 3-grade system, we evaluated its impact on results and particularly its ability to predict disc herniation, ultimately highlighting deficiencies in the latter. The objective of this investigation was to validate the efficacy of our newly proposed semi-quantitative simplified 4-grade system for assessing fat infiltration, as compared to the existing literature-based simplified 3-grade system, in terms of their predictive value for lumbar disc herniation.MethodsInfiltration of the right and left lumbar multifidus and erector spinae muscles were assessed using a semi-quantitative 3- and 4-grade fat infiltration system on axial magnetic resonance imaging sections at the L3-S1 level in all subjects, with comparison of results between groups. The correlation between these grading systems and lumbar disc herniation was investigated.ResultsThe simplified 3-degree system for measuring fat infiltration was not effective in predicting lumbar disc herniation (p > 0.05), while the 4-degree system proved to be useful in predicting it (p < 0.05). In both grading systems, females were found to have a higher risk of lumbar disc herniation than males (p < 0.05), and the risk increased with age and body mass index (BMI) (p < 0.001).ConclusionsIt was observed that using the 4-grade fat infiltration system to determine the level of fat infiltration in the paraspinal muscles is more effective in predicting lumbar disc herniation compared to the 3-grade system. The 4-grade fat infiltration grading system proves to be an efficient semi-quantitative method that can replace the simplified 3-grade system.

An evaluation of the efficacy of a four-grade fat infiltration classification method, presented for the first time in literature

BackgroundThe deficiency of the commonly used 3-grade fat infiltration system is discussed by comparing it with the 4-grade fat infiltration system, newly presented to the literature. The aim of this study was to evaluate the efficacy of a semi-quantitative simplified 4-grade fat infiltration measurement system, described for the first time in literature, through comparison with the existing simplified 3-grade fat infiltration system in the prediction of lumbar disc herniation.MethodsThe study included 51 patients diagnosed with lumbar disc hernia and 50 healthy individuals as the control group. The patients were evaluated in respect of fat infiltration of the right and left lumbar multifidus and erector spina muscles on axial magnetic resonance imaging slices passing through the centre of the disc at L3-S1 level using the 3 and 4-grade fat infiltration measurement systems.ResultsThe 3-grade fat infiltration system was found to be insufficient in the prediction of lumbar disc herniation (p > 0.05) and the 4-grade fat infiltration system was determined to be effective in the prediction of lumbar disc herniation (p < 0.001).ConclusionThe 4-grade fat infiltration system was seen to be more effective than the 3-grade fat infiltration system in the determination of the level of fat infiltration in the paraspinal muscles and the prediction of lumbar disc herniation. The 4-grade fat infiltration system is a more effective semi-quantitative grading system which can be used instead of the simplified 3-grade system.

Validation of the AASLD recommendations for classification of oesophageal varices in clinical practice.

The American Association for the Study of Liver Diseases recommends the use of a 2-grade classification system (small and large) to describe the size of oesophageal varices (OV). Data on observer agreement (OA) on this system are currently lacking. We aimed to evaluate this classification and compare it to the widely used 3-grade classification (grade 1 'small', grade 2 'medium', grade 3 'large') among operators of variable experience. High-definition video recordings of 100 patients with cirrhosis were prospectively collected using standardised criteria. Nine observers of variable experience performed independent evaluations of the videos in random order. OV were scored using both systems. All assessments were repeated a year later by the same observers to assess intra-observer agreement. Interobserver agreement (all observers) using the 2-grade and the 3-grade system was k=0.71 (95% CI: 0.64-0.78) and k=0.73 (95% CI: 0.66-0.79) respectively. When using the 2-grade system, intra-observer agreement between hepatologists (n=3), luminal gastroenterologists (n=3) and trainee gastroenterologists (n=3) was k=0.89 (95% CI: 0.86-0.91), k=0.72 (95% CI: 0.67-0.77), and k=0.74 (95% CI: 0.67-0.8) respectively. With the 3-grade system; intra-observer agreement between the same three subgroups were k=0.9 (95% CI: 0.87-0.92), k=0.73 (95% CI: 0.68-0.78), k=0.77 (95% CI: 0.71-0.82) respectively. There was no difference in OA between the 2-grade and 3-grade classification systems. Hepatologists had significantly higher levels of consistency in grading OV. This may have implications to create alternative training models for residents and fellows in the recognition and grading of OV.

Bone Marrow Reticulin Fibrosis in 579 Patients with Polycythemia Vera and Essential Thrombocythemia: Effect on Clinical Outcome

Background:Prognostic value of bone marrow (BM) fibrosis grading in myeloproliferative neoplasm (MPN) is still debated. Polycythemia Vera (PV) and Essential Thrombocythemia (ET) are long term outcome MPN; however, they could evolve to adverse secondary myelofibrosis-MF or acute leukemia-AL.Aims and Methods:We retrospectively analyzeda cohort of 579 World Health Organization-defined PV (n=180) and ET (n=399) patients, and examined the prevalence and prognostic relevance of BM reticulin fibrosis.All patients were diagnosed between 1990 and 2013 and were recruited in Turin (n= 436) and Bologna (n=143), Italy. BM biopsy sample were reviewed by local pathologist and fiber scoring was performed according to a 3-graded system. Eligibility criteria included the availability of BM samples at diagnosis. Patients with grade 2 or 3-fibrosis were excluded.Overall survival (OS) was evaluated from diagnosis to death using Kaplan Meyer method and Hazard Ratio were estimated with the Cox Model. Cumulative incidence of MF and AL evolution were estimated considering death from any cause as a competing event and compared between groups using the Gray's test.Results:Overall, we observed 115 (63%) grade 0 and 65 (36%) grade 1 fibrosis and 291 (72%) grade 0 and 108 (27%) grade 1 among PV and ET patients, respectively (p= 0.028) We analyzed effect on clinical outcome separately.PVWith a median follow up of 110 months (IQR:70-170), 5 and 10-years OS were 96% and 87%, respectively.Stratifying patients based on fibrosis degree, we observed 15 (13%) and 16 (25%) deaths for grade 0 and 1 fibrosis respectively, with 5 and 10-years OS of 98% vs 90% and 92% vs 82% for grade 0 and grade 1, respectively (p 0.076). Neither clinical findings nor thrombosis were significantly different between fibrosis degree. JAK2 V617F or exon 12 mutation status and allele burden was similar into subgroup. Cumulative incidence of MF evolution at 5 and 10-years was 2,8% and 7,2% vs 3,8% and 18,7% for grade 0 and grade 1 respectively (p 0.123). Cumulative incidence of AL evolution at 10- year was 4,2 % for both grade whereas at 15-years was 4,2% vs 19% for grade 0 and 1, respectively.ETAt a median follow up of 75 months (IQR:39-120), 5 and 10-years OS were 98% and 90%, respectively.We observed 22 (8%) and 16 (55%) deaths for grade 0 and 1 respectively, with 5 and 10-years OS of 98% and 90% for grade 0 vs 97% and 89% for grade 1, respectively (p 0.358).The mutation status was analyzed in 379 patients and showed: 62% JAK2V617F, 19% CALR (type-1/1-like 14% and type2/2-like 5%), 3% MPLW515, 63 patients were triple negative for the above mutations.During follow-up, patients with grade 0 fibrosis showed more thrombotic events, 41 cases (14%; the 71% JAK2V617F-positive) vs 17 (16%). At multivariate analysis MPL mutation showed a higher risk of MF evolution compared to triple negative with an HR of 5,8 (p 0.0014) and to JAK2V617 mutation with an HR of 9,5 (p 0.002).Cumulative incidence of MF evolution was at 5-years 0,5% and 9% and at 10-years 6,2% and 18% for grade 0 and 1, respectively (p 0.0001). Cumulative incidence of AL evolution at 5 and 10-years was 0% for grade 0 and 13% and 7,3% for grade 1, respectively (p 0.096). However grade 0 showed a higher cumulative risk of AL evolution at 15-years (6,9% vs 10% for grade 0 and 1, respectively) (p=0.096).Conclusion:According to data recently published, in ET patients grade 1 BM fibrosis seems to correlate with a higher cumulative risk of MF and AL evolution, whereas in PV patients seems to correlate to a trend of higher mortality, even if not statistically significantly.Data reaffirm the importance of BM examination as part of diagnostic criteria in all MPN. DisclosuresCavo:Janssen-Cilag: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Millennium: Consultancy, Honoraria. Vitolo:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria; Gilead: Honoraria; Celgene: Honoraria; Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Hemodynamic Significance of Internal Carotid or Middle Cerebral Artery Stenosis Detected on Magnetic Resonance Angiography.

PurposeWe evaluated hemodynamic significance of stenosis on magnetic resonance angiography (MRA) using acetazolamide perfusion single photon emission computed tomography (SPECT).Materials and MethodsOf 171 patients, stenosis in internal carotid artery (ICA) and middle cerebral artery (MCA) (ICA-MCA) on MRA and cerebrovascular reserve (CVR) of MCA territory on SPECT was measured using quantification and a 3-grade system. Stenosis and CVR grades were compared with each other, and their prognostic value for subsequent stroke was evaluated.ResultsOf 342 ICA-MCA, 151 (44%) presented stenosis on MRA; grade 1 in 69 (20%) and grade 2 in 82 (24%) cases. Decreased CVR was observed in 9% of grade 0 stenosis, 25% of grade 1, and 35% of grade 2. The average CVR of grade 0 was significantly different from grade 1 (p<0.001) and grade 2 stenosis (p=0.007). In quantitative analysis, average CVR index was -0.56±7.91 in grade 0, -1.81±6.66 in grade 1 and -1.18±5.88 in grade 2 stenosis. Agreement between stenosis and CVR grades was fair in patients with lateralizing and non-lateralizing symptoms (κ=0.230 and 0.346). Of the factors tested, both MRA and CVR were not significant prognostic factors (p=0.104 and 0.988, respectively), whereas hypertension and renal disease were significant factors (p<0.05, respectively).ConclusionA considerable proportion of ICA-MCA stenosis detected on MRA does not cause CVR impairment despite a fair correlation between them. Thus, hemodynamic state needs to be assessed for evaluating significance of stenosis, particularly in asymptomatic patients.

Effectiveness of Mastoid Process Percussion for Identification of the Vertebral Artery Ostium on Doppler Studies

The pretransverse or first segment of the vertebral artery may be confused with adjacent branches of the proximal subclavian artery during Doppler assessment. This study investigated the effectiveness of mastoid process percussion, the "mastoid tap" maneuver, for identification of the vertebral artery ostium. Fifty patients presenting consecutively for carotid sonography were recruited. Doppler waveforms were collected at the vertebral artery ostia, thyrocervical trunks, and proximal subclavian arteries while the mastoid tap maneuver was performed. The outcome indicator was serrate distortion of the Doppler waveform. Two raters graded the waveforms according to a 3-grade system: grade 0, no distortion; grade 1, mild distortion; and grade 3, marked distortion. The difference between the proportions of the vertebral artery ostia and thyrocervical trunks showing waveform distortion was evaluated with the χ(2) test. The differences in the extents of waveform distortion in the ipsilateral vertebral artery ostia, thyrocervical trunks, and subclavian arteries were evaluated with Friedman and Wilcoxon signed rank tests. Ninety-five vertebral artery ostia in 50 patients were successfully assessed. There was a significant difference between the proportions of vertebral artery ostia (95 of 95 [100%]) and thyrocervical trunks (9 of 95 [9.5%]) that showed waveform distortion (P < .001). There were significant differences in the extents of distortion between the ipsilateral vertebral artery ostia and thyrocervical trunks and between the ipsilateral vertebral artery ostia and subclavian arteries, with the vertebral artery ostia showing a higher degree of distortion in both cases (P < .001). The mastoid tap maneuver is useful for distinguishing between the vertebral arteries and thyrocervical trunks on Doppler studies.

Review of Terminology of Precursors of Vulvar Squamous Cell Carcinoma

The popular term for vulvar squamous cell carcinoma in situ/dysplasia is vulvar intraepithelial neoplasia (VIN). VIN is a histological diagnosis based on loss of squamous epithelial maturation associated with enlarged, hyperchromatic, pleomorphic nuclei and increased, usually atypical mitoses. There are two types of VIN: the usual (not otherwise specified) type, also known as warty-basaloid, and the differentiated type. There are 3 grading systems for warty-basaloid VIN: the traditional 3-grade system of VIN 1-3, a low-grade/high grade Bethesda-like system and the International Society for the Study of Vulvovaginal Disease's proposal for only 1 grade. The ISSVD system eliminates VIN 1 and combines VIN 2 and 3 on the grounds that VIN 1 has not been shown to be a reproducible diagnosis and VIN 2 and 3 are not reliably separated. The evidence supports the ISSVD proposal. Warty basaloid VIN may be sub-typed into warty and basaloid VIN. Sub-typing has clinical relevance but its reproducibility is not proven. Warty-basaloid VIN may regress. Differentiated VIN has been typically diagnosed co-incident with squamous cell carcinoma. With increased frequency of performance of biopsy of hyperplastic lesions, differentiated VIN should be diagnosed more commonly before squamous carcinoma occurs.