Anatomical Classification System Research Articles

Difficulty in bone union after arthrodesis to treat Charcot arthropathy of the foot and ankle

IntroductionA major complication of arthrodesis is non-union in patients with Charcot arthropathy. This study examined the bone union in joints affected arthrodesis for Charcot arthropathy of the foot and ankle. MethodsThe current retrospective study enrolled 15 patients (20 feet) who underwent arthrodesis (performed in 47 joints) for Charcot arthropathy from 2014 to 2020. Post-operative radiographs were classified based on the Brodsky anatomical classification system at 6 months, 1 year, and 2 years post-operatively. The association with pre-operative and intra-operative data was determined. ResultsBone union was achieved in 28 % of patients at 6 months, 57 % at 1 year, and 66 % at 2 years post-operatively. The bone union rates according to the Brodsky anatomic classification at 6 months, 1 year, and 2 years were 50 %, 67 %, and 67 % for type 1; 20 %, 44 %, and 56 % for type 2; and 36 %, 86 %, and 86 % for type 3A, respectively. At 1 year after arthrodesis surgery, the odds ratio for non-union in Brodsky type 2 compared to that in type 3A joints was 8.727 (95 % CI: 1.623–46.935, p = 0.006). ConclusionArthrodesis procedures in joints affected by Charcot arthropathy, especially in Brodsky type 2 joints, should ensure perfect bone-to-bone fitting, good adaptation, sufficient bone grafting, and strong fixation.

Anatomical Evaluation of Proximal Femur Fractures in Trauma Patients Aged 65 or Older Admitted to the Emergency Department

Purpose: This retrospective study aimed to assess the association between classification systems for proximal femur fractures and mid-term mortality in elderly patients, focusing on their clinical and anatomical aspects. Materials and methods: Radiological images of patients aged 65 years and older who underwent surgical procedures for proximal femur fractures were reviewed. Various classification systems were applied, including Anatomical, Pipkin, Garden, Evans-Jensen, Seinsheimer, and AO/OTA classifications. Electronic hospital records provided patient data, and statistical analyses were performed. Results: The study included 298 patients, and the mean age was 81.7±7.3 years, and 63,1% were female. Median length of stay in hospital 7(1-63) days, 19.1% requiring intensive care, and a 13.8% mortality rate within 3 months. Patients were distributed based on anatomical classification, and the distribution of intracapsular and extracapsular fractures according to clinical classifications was detailed. The findings suggest that proximal femur fracture classification systems do not significantly influence mortality rates (p=0.787). Conclusion: Anatomical classification systems may be favored for their simplicity and potential to establish a common language among healthcare professionals. This study provides valuable insights into proximal femur fractures in elderly patients, informing clinical practice.

Commentary on "Bringing Inclusivity to 'Ethnic' Rhinoplasty: A Novel Anatomical Classification System".

Commentary on "Bringing Inclusivity to 'Ethnic' Rhinoplasty: A Novel Anatomical Classification System".

Bringing Inclusivity to "Ethnic" Rhinoplasty: A Novel Anatomical Classification System.

"Ethnic rhinoplasty" is a term that historically has been employed to categorize patterns in nasal anatomy, possible procedures to change appearance, and patient and surgeon expectations for expected outcomes for the multitude of patients with features that belong to non-White groups. Categorizing anatomical structures based on broad definitions of race or ethnicity may not be an accurate representation, nor give an accurate depiction of nasal anatomical features. A shift is needed regarding how race and ethnicity are employed in describing nasal anatomy and rhinoplasty. We present a categorization system based on nasal anatomical patterns that may have more meaningful surgical implications without generalization into ethnic groups. Common anatomical nasal features such as projection, rotation, skin thickness, and anthropometric measurements were grouped into types, which may also help in patient education and remove any ethnic or racial terms.

Anatomical classification of canine congenital extrahepatic portosystemic shunts based on CT angiography: A SVSTS and VIRIES multi-institutional study in 1082 dogs.

Canine congenital extrahepatic portosystemic shunt (EHPSS) morphologies have not been fully elucidated. The goal of this retrospective, multi-institutional study was to use CT angiography to create an anatomical-based nomenclature system for canine congenital EHPSS. These shunt morphologies were then evaluated to identify any significant association with patient age, sex, breed, weight, or subjective portal perfusion score. Data collected respectively from the SVSTS and VIRIES list-serves included patient DOB, sex, breed, weight, CT date, and reported diagnosis. A single author (C.W.) viewed all CT scans and classified shunts based on the shunt portal vessel(s) of origin, the shunt systemic vessel(s) of insertion, and any substantial portal vessels contributing to the shunt. Additionally, hepatic portal perfusion was subjectively scored between one (poor/none) and five (good/normal) based on the caliber of the intrahepatic portal veins. A total of 1182 CT scans were submitted from 13 different institutions. Due to exclusion criteria, 100 (8.5%) were removed, leaving 1082 CT scans to be included. Forty-five different EHPSS anatomies were identified with five classifications accounting for 85% of all shunts (left gastric-phrenic [27%], left gastric-azygos [19%], left gastric-caval [15%], aberrant left gastric-caval with right gastric vein [12%], and aberrant left gastric-caval with right gastric vein and short gastric vein [11%]). Shunt origin involved the left gastric vein in 95% of the described classifications. Significant differences were identified among the five most common shunt types with respect to age at the time of the CT scan (P<.001), sex (P=.009), breed (P<.001), weight (P<.001), and subjective portal perfusion score (P<.001). An anatomical classification system for canine EHPSS may enable improved understanding, treatment comparisons, and outcome prediction for these patients.

The impact of angiographic pedal circulation status on wound healing in chronic limb-threatening ischemia after bypass surgery

ObjectiveIn the treatment of chronic limb-threatening ischemia (CLTI), complete wound healing is an important goal. Although foot perfusion status seems to be important for wound healing, the Global Limb Anatomic Staging System (GLASS) of the Global Vascular Guidelines does not include pedal artery status for the staging process due to the lack of sufficient evidence of its importance. This study aimed to clarify the importance of pedal perfusion status after bypass surgery. MethodsAmong the 153 CLTI cases that underwent bypass distal to popliteal arteries from 2014 to 2018, 117 CLTI limbs with wounds and with sufficient pedal angiographic data were enrolled. They were classified into two groups, based on the wound status 6 months postoperatively; early wound healing group (EWG; n = 78), which achieved complete wound healing within 6 months postoperatively, and prolonged healing or unhealed wounds group (PWG; n = 39), which failed to achieve wound healing within 6 months. Various factors associated with wound healing, including the wound, ischemia, and foot infection (WIfI) classification, intraoperative graft flow, and pedal angiographic data, were analyzed. Regarding pedal angiographic data, in addition to the GLASS inframalleolar/pedal disease descriptor (IPD), newly formed classification system of the pedal circulation status in association with the location of wounds was included: pedal circulation status was classified into two groups as visualized arterial perfusion towards wounds (visualized perfusion) and non-visualized arterial perfusion towards wounds (non-visualized perfusion). ResultsUnivariate analysis showed preoperative albumin (Odds ratio [OR], 0.47; 95% confidence interval [CI], 0.24-0.94; P = .027), higher WIfI clinical stage (OR, 3.88; 95% CI, 1.74-10.1; P = .0005), higher IPD (OR, 2.16; 95% CI, 1.16-4.02; P = .012), and non-visualized perfusion to wounds (OR, 5.74: 95% CI, 2.45-14.0; P < .0001) as significant for prolonged wound healing. Multivariate analysis showed higher WIfI stage (OR, 5.04; 95% CI, 1.74-14.6; P = .0029) and non-visualized perfusion to wounds (OR, 4.34; 95% CI, 1.71-11.0; P = .0021) as significant, whereas IPD was not detected as significant. Regarding blood supply to the foot, although graft flow was significantly lower in IPD-P2 than IPD-P0/P1, graft flow was similar regardless of the status of angiographic circulation to wounds, suggesting that distribution of blood supply to the wound would be more important than total amount of blood supply to the foot for wound healing. ConclusionsWIfI clinical stage and pedal circulatory environment were important factors for wound healing after bypass surgery. Pedal anatomical classification system including perfusion status would be important for decision making in CLTI treatment.

Anatomical classification of feline congenital extrahepatic portosystemic shunts based on CT angiography: A SVSTS and VIRIES multi-institutional study in 231 cats.

The prevalence of anatomical-based subtypes of feline congenital extrahepatic portosystemic shunts (EHPSS) has not been completely elucidated. The goal of this study was to use CT angiography to create an anatomical-based nomenclature system for feline congenital EHPSS. Additionally, subjective portal perfusion scores were generated to determine if intrinsic portal vein development was associated with different shunt conformations or patient age at the time of CT. The SVSTS and VIRIES list services were used to recruit cases. Data collected included patient DOB, gender, breed, weight, CT date, and reported diagnosis. Shunts were classified based upon (1) the shunt portal vessel(s) of origin, (2) the shunt systemic vessel(s) of insertion, and (3) any substantial portal vessels contributing to the shunt. Additionally, hepatic portal perfusion was subjectively scored between 1 (poor/none) and 5 (good/normal) based on the caliber of the intrahepatic PVs. A total of 264 CT scans were submitted from 29 institutions. Due to exclusion criteria, 33 (13%) were removed, leaving 231 CT scans to be included. Twenty-five different EHPSS anatomies were identified with five classifications accounting for 78% of all shunts (LGP [53%], LGC-post [11%], LCG [7%], LGC-pre [4%], and PC [4%]). Shunt origin involved the left gastric vein in 75% of the described classifications. Significant differences were identified among the five most common shunt types with respect to age at the time of CT scan (P=.002), breed (P<.001), and subjective portal perfusion score (P<.001). This refined anatomical classification system for feline EHPSS may enable improved understanding, treatment comparisons, and outcome prediction for cats with these anomalies.

Renal anatomical classification systems cannot predict the occurrence of vascular complications after partial nephrectomy.

To determine the relationship between renal tumor complexity and vascular complications after partial nephrectomy using PADUA, RENAL, and ZS scores. Between January 2007 and December 2018, a total of 1917 patients with available cross-sectional imaging were enrolled in the study. Logistic regressions were used to identify independent predictors of vascular complications. Of 1917 patients, 31 (1.6%) developed vascular complications, including 10 females and 21 males. The high-complexity category was significantly associated with a decreased risk of vascular complication in PADUA (OR = 0.256; 95%CI = 0.086-0.762; P = 0.014) and ZS score (OR = 0.279; 95%CI = 0.083-0.946; P = 0.040). Laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were independent risk factors for vascular complications. Meanwhile, the incidence was significantly reduced in the recent 4years in the high score tumor group alone in PADUA (0.2% [1/474] vs. 2.2% [3/139], P = 0.038) and ZS score (0.2% [1/469] vs. 2.7% [3/112], P = 0.024). In the first 8years, laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were the only two independent risk factors for vascular complications. In the recent 4years, only the high-complexity category was significantly associated with a decreased risk of vascular complication in the PADUA score (OR = 0.110; 95%CI = 0.013-0.938; P = 0.044). The renal anatomic classification system cannot predict the occurrence of vascular complications after partial nephrectomy.

CtDNA predicts clinical T1a to pathological T3a upstaging after partial nephrectomy.

Most patients diagnosed with clear cell renal cell carcinoma (ccRCC) are also detected with small and organ-confined tumors, and the majority of these are classified as clinical tumor stage 1a (cT1a). A considerable proportion of patients with cT1 RCC shows tumor upstaging to pathological stage 3a (pT3a), and these patients have worse oncological outcomes. The role of circulating tumor DNA (ctDNA) in RCC has been limited to monitoring treatment response and resistance. Therefore, the present study aimed to evaluate the potential of ctDNA in predicting pT3a upstaging in cT1a ccRCC. We sequenced plasma samples preoperatively collected from 48 patients who had undergone partial nephrectomy for cT1a ccRCC using data from a prospective cohort RCC. The ctDNA were profiled and compared with clinicopathological ccRCC features to predict pT3a upstaging. Associations between ctDNA, tumor complexity, and pT3a upstaging were evaluated. Tumor complexity was assessed using the anatomical classification system. Univariate analysis used chi-squared and Student's t-tests; multivariate analysis considered significant factors from univariate analyses. Of the 48 patients with cT1a ccRCC, 12 (25%) were upstaged to pT3a, with ctDNA detected in 10 (20.8%), predominantly in patients with renal sinus fat invasion (SFI; n = 8). Among the pT3a group, ctDNA was detected in 75%, contrasting with only 2.8% in patients with pT1a (1/36). Detection of ctDNA was the only significant preoperative predictor of pT3a upstaging, especially in SFI. This study is the first to suggest ctDNA as a preoperative predictor of pT3a RCC upstaging from cT1a based on preoperative radiological images.

Trend analysis of proton pump inhibitor consumption and expenditure: The real-world evidence.

Proton pump inhibitors (PPIs) constitute a widely utilized pharmaceutical class, frequently associated with notable instances of therapeutic inappropriateness. Such patterns of misuse not only contribute to elevated healthcare expenditure, but may also exacerbate clinical conditions in certain patients. A comprehensive analysis was conducted between 2019 and 2023 to assess all prescriptions dispensed using the Anatomical, Therapeutic and Chemical (ATC) classification system, which allowed trends among primary PPIs to be visualized. This was achieved by calculating the defined daily dose (DDD) and then defining the total expenditure incurred on these drugs. With regard to the prescription of PPIs, an upward trend in consumption was observed with a decreasing expenditure, due to the phenomena of drug generics and increased competition between pharmaceutical companies, ranging from €9,512,481.22 in the first six months of 2019 to €8,509,820.80 in the first sixmonths of 2023. From 2019 to 2023, consumption increased by approximately 3 million DDDs for a total ranging from 18,483,167.59 DDDs to 21,480,871.00 DDDs. Pantoprazole and esomeprazole, the most expensive drugs compared to omeprazole, rabeprazole and lansoprazole, accounted for 61.4% of therapies in the first sixmonths of 2023, up from 2019, where these two drugs were prescribed 54.9%. Within this analysis, we provide an illustrative representation of the prescribing trends for PPIs within a European context. Omeprazole, rabeprazole and lansoprazole appear to be the cheapest drugs compared to pantoprazole and esomeprazole. However, the results show that the most widely used PPIs, despite their therapeutic equivalence, are precisely the high-cost ones, thus generating higher expenditure for central governments.

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.

Predicting cardiac and pregnancy outcomes in women with adult congenital heart disease using the Anatomic and Physiological (AP) Classification System: How much does physiology matter?

BackgroundPregnancy in women with congenital heart disease (CHD) is associated with an increased risk of adverse maternal and fetal events. Despite the physiological impact of CHD on pregnancy, current risk stratification scores primarily consider anatomical lesions. We assessed the performance of the novel American Heart Association Anatomic and Physiological (AP) classification system in predicting adverse maternal cardiac, obstetric and fetal events, and compared it with established risk models. MethodsThis retrospective cohort study enrolled pregnant women with CHD managed by the Westmead Hospital high-risk pregnancy team. Preconception risk stratification scores (AP classification, mWHO classification, CARPREG II and ZAHARA scores) were retrospectively assigned to each pregnancy by an adult CHD cardiologist and compared with the primary outcome measures, which were maternal cardiac, obstetric and fetal complications. ResultsWe analysed 176 pregnancies in 120 women with CHD. Maternal cardiac risk significantly increased between AP class 2 and 3 (p = 0.001). Within class 3, higher physiological status correlated with maternal cardiac events (p < 0.001). Increasing AP severity correlated with lower fetal birthweight percentiles (p = 0.003). The AP classification was similar to mWHO at predicting maternal cardiac outcomes (AUC 0.787 vs 0.777, p < 0.001), but the CARPREG II (AUC 0.852, p < 0.001) and ZAHARA scores (AUC 0.864, p < 0.001) had higher discriminatory ability within our cohort. ConclusionThe AP classification system shows non-inferior preconception maternal cardiac risk prediction compared to current validated scores. Consideration of physiological status has additive predictive value in the most complex patients (Stage III). Prospective, multicenter studies are required for further validation for preconception risk estimation.

Angiographic evaluation of the distance from the top of the jugular bulb to the inferior petrosal sinus-internal jugular vein junction: simple classification and identification method for the orifice of the non-visualized inferior petrosal sinus during neuroendovascular surgery.

The inferior petrosal sinus (IPS) is the transvenous access route for neurointerventional surgery that is occasionally undetectable on digital subtraction angiography (DSA) because of blockage by a clot or collapse. This study was aimed at analyzing the distance from the jugular bulb (JB) to the IPS-internal jugular vein (IJV) junction and proposing a new anatomical classification system for the IPS-IJV junction to identify the non-visualized IPS orifice. DSA of 708 IPSs of 375 consecutive patients were retrospectively investigated to calculate the distance from the top of the JB to the IPS-IJV junction, and a simple classification system based on this distance was proposed. The median distance from the top of the JB to the IPS-IJV junction was 20.8 ± 14.7mm. Based on the lower (10.9mm) and upper (31.1mm) quartiles, IPS-IJV junction variants were: type I, 0-10mm (22.3%); type II, 11-30mm (45.8%); type III, > 31mm (23.9%); and type IV, no connection to the IJV (8.0%). Bilateral distances showed a positive interrelationship, with a correlation coefficient of 0.86. The bilateral symmetry type (visualized IPSs bilaterally) according to our classification occurred in 267 of 300 (89.0%) patients. In this study, the IPS-IJV junction was located far from the JB (types II and III), with a higher probability (69.6%). This distance and the four-type classification demonstrated high degrees of homology with the contralateral side. These results would be useful for identifying the non-visualized IPS orifice.

Anatomical variants of the retroaortic left renal vein

BackgroundAnatomical variants of the left renal vein (LRV), such as the retroaortic (RLRV) and circumaortic (CLRV) course, are of surgical importance. Different morphological and topographical possibilities of the RLRV could occur. It was aimed at documenting the anatomical variables of the RLRV. MethodA retrospective study on 375 computed tomography angiograms was performed. Five different anatomical types of LRV were documented: preaortic types 1 and 2 and retroaortic types 3–5. ResultsIn 344/375 cases, preaortic LRVs were found. In 31/375 cases, different types of RLRV were found: type 3a – single RLRV, 41.94%; type 3b – single RLRV with bifid caval end, 9.68%; type 3c – single RLRV with trifid caval end, 3.23%; type 4a – CLRV with extrahilar origin, 29.03%; type 4b – CLRV with renal sinus origin, 12.9%; type 5 – triple LRV (one preaortic LRV and two RLRVs), 3.23%. Reference vertebral levels were recorded for the prevertebral segment of the RLVR. The vertebral level of type 3a varied from the L1/L2 disc to the upper third of the L4 vertebra. Type 3b was found in 3/31 RLRV cases; in one of these, the hemiazygos vein was inserted by two roots into the LRV and its upper caval end trunk. There was a significant statistical association between type 3b and the vertebral level, all cases being centered on the middle third of the L4 vertebra. ConclusionsNew morphological possibilities of the LRV were distinguished, and a new anatomical classification system of the RLRV results. The RLRV variant should be documented case-by-case as it has its anatomical variables.

P11.04.B ASSESSMENT OF TUMOR ELOQUENCE IN GLIOMA RESECTIONS: A SYSTEMATIC REVIEW

Abstract BACKGROUND Tumor location and eloquence are two crucial factors when deciding on the optimal surgical strategy in glioma management. Consensus is currently lacking on the assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas used in current clinical practice. MATERIAL AND METHODS A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study’s Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use. RESULTS This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS. CONCLUSION None of the definitions or techniques to define eloquence described in the articles are entirely satisfactory as an objective, quantifiable, preoperative factor in glioma treatment and surgical decision-making. Therefore, we propose the development of a new, easily applicable and interpretable anatomical preoperative grading system to assess tumor eloquence. This may aid neurosurgeons in their perioperative decision-making to improve surgical outcomes on an individual patient level and to facilitate the execution and interpretation of multicenter studies.

Bilateral Lumbar Artery Perforator Flaps for Breast Reconstruction: A Perforator Classification System.

Autologous breast reconstruction is continually evolving, with focus on the ideal donor site. This study presents 108 consecutive simultaneous lumbar artery perforator (LAP) flaps and a perforator classification system. A retrospective review of all LAP flaps was completed, and appropriate data were recorded. All simultaneous bilateral LAP flaps were included, and perforator patterns were assessed using CT angiography (CTA). Fifty-four patients (108 flaps) were included in the final review. The mean patient age was 50.7 years, and the mean body mass index was 26.6. Mean ischemia times for all flaps and grafts were 130 ± 64.5 and 300.6 ± 97.3 minutes, respectively. The average pedicle length was 4.6 ± 1.5 cm, and the average composite graft length was 6.2 ± 1.7 cm. Donor-site complications consisted of seromas (10 patients [19%]), hematomas (6 patients [11%]), procedural wounds (4 patients [8%]), and infections (2 patients [4%]). The total flap loss rate was 2.8%. Perforators were classified into categories based on pedicle pattern, lumbar spine level, and clusters, all in relation to posterior iliac bone as seen per CTA. Vascular pedicle patterns were categorized as type 1 (43.9%), 2 (45.6%), 3 (8.8%), or 4 (1.8%). Perforators were dissected at lumbar spine level L3 in 51.8% of patients, L4 in 46.5%, and L5 in 1.8%. The authors present a CTA-directed anatomic perforator classification system to assist in preoperative planning, dissection, and choice of the composite graft best suited for particular perforator patterns or calibers. Simultaneous LAP flaps can be performed successfully with excellent outcomes in cases unsuitable for other flaps. Therapeutic, IV.

INCLUSION OF OPEN INJURIES IN AN UPDATED SCHENCK CLASSIFICATION OF KNEE DISLOCATIONS BASED ON A GLOBAL DELPHI CONSENSUS STUDY

AbstractIntroductionKnee dislocations (KDs) are complex injuries which are often associated with damage to surrounding soft tissues or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system.MethodsA global panel of orthopaedic knee surgery specialists participated in a Delphi process. A list of factors to be included in a KD classification system was formulated by 91 orthopaedic surgeons, which was subsequently prioritised by 27 experts from 6 countries. The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system.ResultsThe four factors that reached consensus agreement and thus deemed critical for inclusion in a classification system were vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%).ConclusionThe wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. The Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injuries. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier.

New classification system for radical rectal cancer surgery based on membrane anatomy.

Total mesorectal excision along the "holy plane" is the only radical surgery for rectal cancer, regardless of tumor size, localization or even tumor stage. However, according to the concept of membrane anatomy, multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection. To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery. A three-dimensional template of the member anatomy of the pelvis was established, and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation. Then, we suggested a new and simple classification system for rectal cancer surgery. For simplification, the classification was based only on the lateral extent of resection. The fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces (medial, middle and lateral), and blood vessels and nerves are precisely positioned in the fascia or space. Three types of radical surgery for rectal cancer are described, as are a few subtypes that consider nerve preservation. The surgical planes of the proposed radical surgeries (types A, B and C) correspond exactly to the medial, middle, and lateral spaces, respectively. Three types of radical surgery can be precisely defined based on membrane anatomy, including nerve-sparing procedures. Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

Identification of Prescribing Patterns in Hemodialysis Outpatients Taking Multiple Medications

We investigated the relationship between multidrug administration and the characteristics, pathophysiology, and drug class in outpatients with hemodialysis. A retrospective cross-sectional study was conducted at Saitama Medical University Hospital in October 2018. Multidrug administration was defined as receiving either more than six drugs or more than the median number of drugs. The drugs used were represented by their anatomical classification codes in the Anatomical Therapeutic Chemistry Classification System (ATC classification). A latent class analysis (LCA) was used to identify clusters at risk of receiving multiple medications. A stepwise logistic regression analysis was performed to select ATC classifications prone to being involved in multidrug administration. As of October 2018, 98 outpatients with hemodialysis were enrolled in the study. In the LCA, when diabetes was the main primary disease, oral hypoglycemic agents available to dialysis patients were limited, but the number of drugs administered was large. Old age, poor nourishment, a long history of dialysis, and chronic nephritis were associated with multidrug administration among nondiabetic patients. In the second level of the ATC classification, the drugs frequently used were coded A02 (drugs for acid-related disorders), A07 (antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents), B01 (antithrombotic agents), and N05 (psycholeptics). The prescribing patterns for either diabetic patients or nondiabetic elderly patients were identified in outpatients with hemodialysis taking multiple medications, and drugs for acid-related disorders, antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents, antithrombotic agents, and psycholeptics are frequently used in those patients.

Incidence and multimodal imaging characteristics of macular neovascularisation subtypes in Chinese neovascular age-related macular degeneration patients

AimsTo investigate the incidence of macular neovascularisation (MNV) subtypes of neovascular age-related macular degeneration (nAMD) and summarise these subtypes’ clinical features in the Chinese population using multimodal imaging.MethodsWe retrospectively analysed...