Clinical Decision-making Strategies Research Articles

The Prevalence of Coexisting Lumbar Spondylosis and Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

A systematic review. This study aimed to evaluate the prevalence of coexisting lumbar spondylosis (LS) and knee osteoarthritis (KOA), which has clinical implications on the screening, diagnosis, and management of orthopedic patients. Due to current global health trends, the number of affected patients is expected to increase substantially. However, no prior systematic reviews have discussed this topic. A systematic literature search was conducted in June 2021 in the PubMed, Embase, Scopus, CINAHL, and Cochrane CENTRAL databases. Clinical and epidemiological studies that reported quantitative data on the prevalence of coexisting LS and KOA were included. Studies which reported data on only LS or KOA alone were excluded. Odds ratios (ORs) and 95% confidence intervals (CI) for LS or KOA were retrieved or calculated for meta-analysis. Fixed-effects and random-effects models were used, and statistical significance was considered when p<0.05. Heterogeneity was evaluated using Cochran's Q test and the I2 statistic. Risk of bias was assessed using the MINORs (methodological index for nonrandomized studies) criteria. This review included nine studies (5,758 patients). Four studies (4,164 patients) defined KOA and LS by a Kellgren-Lawrence (KL) grade of ≥2 and were included in the meta-analysis. Two other studies defined KOA and LS by a joint space narrowing grade of ≥2. The remaining three studies reported other outcomes. The combined ORs of having KOA of KL grade ≥2 due to LS was 1.75 (95% CI, 1.22-2.50; p=0.002), while the combined OR of having LS of KL grade ≥2 due to KOA was 1.84 (95% CI, 1.23-2.77; p=0.003). In patients with either KOA or LS, the odds of having a concurrent knee-spine presentation are significantly increased. This may have implications for clinical decision-making and treatment strategies. Further high-level studies with larger patient populations are required to confirm these results in specific populations.

Construction of a Novel LncRNA Signature Related to Genomic Instability to Predict the Prognosis and Immune Activity of Patients With Hepatocellular Carcinoma.

BackgroundGenomic instability (GI) plays a crucial role in the development of various cancers including hepatocellular carcinoma. Hence, it is meaningful for us to use long non-coding RNAs related to genomic instability to construct a prognostic signature for patients with HCC.MethodsCombining the lncRNA expression profiles and somatic mutation profiles in The Cancer Genome Atlas database, we identified GI-related lncRNAs (GILncRNAs) and obtained the prognosis-related GILncRNAs through univariate regression analysis. These lncRNAs obtained risk coefficients through multivariate regression analysis for constructing GI-associated lncRNA signature (GILncSig). ROC curves were used to evaluate signature performance. The International Cancer Genomics Consortium (ICGC) cohort, and in vitro experiments were used for signature external validation. Immunotherapy efficacy, tumor microenvironments, the half-maximal inhibitory concentration (IC50), and immune infiltration were compared between the high- and low-risk groups with TIDE, ESTIMATE, pRRophetic, and ssGSEA program.ResultsFive GILncRNAs were used to construct a GILncSig. It was confirmed that the GILncSig has good prognostic evaluation performance for patients with HCC by drawing a time-dependent ROC curve. Patients were divided into high- and low-risk groups according to the GILncSig risk score. The prognosis of the low-risk group was significantly better than that of the high-risk group. Independent prognostic analysis showed that the GILncSig could independently predict the prognosis of patients with HCC. In addition, the GILncSig was correlated with the mutation rate of the HCC genome, indicating that it has the potential to measure the degree of genome instability. In GILncSig, LUCAT1 with the highest risk factor was further validated as a risk factor for HCC in vitro. The ESTIMATE analysis showed a significant difference in stromal scores and ESTIMATE scores between the two groups. Multiple immune checkpoints had higher expression levels in the high-risk group. The ssGSEA results showed higher levels of tumor-antagonizing immune cells in the low-risk group compared with the high-risk group. Finally, the GILncSig score was associated with chemotherapeutic drug sensitivity and immunotherapy efficacy of patients with HCC.ConclusionOur research indicates that GILncSig can be used for prognostic evaluation of patients with HCC and provide new insights for clinical decision-making and potential therapeutic strategies.

Deriving Effective Decision-Making Strategies of Prosthetists: Using Hidden Markov Modeling and Qualitative Analysis to Compare Experts and Novices.

This research focuses on studying the clinical decision-making strategies of expert and novice prosthetists for different case complexities. With an increasing global amputee population, there is an urgent need for improved amputee care. However, current prosthetic prescription standards are based on subjective expertise, making the process challenging for novices, specifically during complex patient cases. Hence, there is a need for studying the decision-making strategies of prosthetists. An interactive web-based survey was developed with two case studies of varying complexities. Navigation between survey pages and time spent were recorded for 28 participants including experts (n = 20) and novices (n = 8). Using these data, decision-making strategies, or patterns of decisions, during prosthetic prescription were derived using hidden Markov modeling. A qualitative analysis of participants' rationale regarding decisions was used to add a deep contextualized understanding of decision-making strategies derived from the quantitative analysis. Unique decision-making strategies were observed across expert and novice participants. Experts tended to focus on the personal details, activity level, and state of the residual limb prior to prescription, and this strategy was independent of case complexity. Novices tended to change strategies dependent upon case complexity, fixating on certain factors when case complexity was high. The decision-making strategies of experts stayed the same across the two cases, whereas the novices exhibited mixed strategies. By modeling the decision-making strategies of experts and novices, this study builds a foundation for development of an automated decision-support tool for prosthetic prescription, advancing novice training, and amputee care.

Gestational Diabetes and Risk Assessment of Adverse Perinatal Outcomes and Newborns Early Motoric Development.

Background and Objectives: The aim of this study was to analyze the presence of gestational diabetes mellitus (GDM) on maternal and fetal perinatal parameters, as well to evaluate the influence of GDM on neonatal early motoric development. Materials and Methods: In this prospective study, we evaluated 203 eligible participants that were admitted to obstetrics department for a labor. GDM was assessed by evaluation of maternal parameters, fetal parameters, as well its impact on infants early motoric development (Alberta Infant Motor Scale—AIMS). Results: Presence of GDM was significantly positively associated with: pre-pregnancy weight, obesity degree, weight at delivery, gestational weight gain (GWG), body mass index (BMI) at delivery, GWG and increased pre-pregnancy BMI, glucose levels in mother’s venous blood after the delivery, positive family history for cardiovascular disease, pregnancy-related hypertension, congenital thrombophilia, drug use in pregnancy, large for gestational age (LGA), mode of delivery (Cesarean section and instrumental delivery). Likewise, GDM association was detected for tested ultrasound parameters (biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femoral length (FL)), length at birth, birth weight, newborn’s head circumference, newborn’s chest circumference, AIMS supination and pronation at three months, AIMS supination, pronation, sitting and standing at six months. Only Amniotic Fluid Index and AIMS supination at three months of infant’s age remained significantly associated in multivariate regression model. Conclusions: The presence of significant positive association of numerous tested parameters in our study on perinatal outcomes and early motoric development, points to the necessity of establishing appropriate clinical decision-making strategies for all pregnant woman at risk and emphasize the importance of providing adequate glycaemia control options and further regular follow ups during the pregnancy.

P118 External validation of model predicting early-onset surgery in Crohn’s Disease patients

Abstract Background Screening Crohn’s disease (CD) patients with high risk of early-onset surgery is crucial in launching therapeutic strategies. We have already identified disease behavior, smoking, body mass index, C-reactive protein level at diagnosis, previous perianal or intestinal surgery, maximum bowel wall thickness, use of biologics, and exclusive enteral nutrition as independent significant factors associated with 1-year surgery surgeries risk and further established a prognostic model (Fig.1,World J Gastroenterol. 2020;26(5):524–534). We aimed to validate this model using external cohort. Methods This retrospective study was conducted from Jan, 1, 2017, to Dec, 31, 2019 in three tertiary referral centers including Sixth Affiliated Hospital of Sun Yat-Sen University, Second Affiliated Hospital of Zhejiang University, and Second Affiliated Hospital of Military Medical University. Data of patients with a confirmed diagnosis of CD were collected through hospital electronic system. The published model was validated with calibration using the Hosmer-Lemeshow goodness-of-fit test, and discrimination was assessed using areas under the curve (AUC). Results A total of 756 patients were enrolled in our study with 101 (13.4%) excluded for the sake of incomplete data and loss of follow-up. Of the enrolled patients, 74.8% were male (n = 490) at the mean age of 28.4 ± 11.0 years, with the mean follow-up period of 21.8 ± 8.1 months. An ideal predictive ability of this model was confirmed by receiver operating characteristic curves and AUC as high as 94.5%. Besides, acceptable sensitivity of 69.5% and excellent specificity of 97.0% supported further clinical promotion and application of this model. Conclusion This model owns ideal ability to predict 1-year surgery risk in CD patients, which definitely help clinical decision-making and acid therapeutic strategies launching.

P523 Survey to identify patient characteristics, treatment preferences and impact of inflammatory bowel disease (IBD) on quality of life across 7 countries in Europe

Abstract Background The treatment paradigm for inflammatory bowel disease (IBD) is becoming increasingly diverse and complex. It is suggested that engaging patients through shared decision-making optimises treatment selection in line with clinical need and patient preference and expectations. This patient survey aimed to explore patients’ preferences towards attributes of currently available advanced therapies for IBD as well as the impact of IBD on patients’ quality of life (QoL) across 7 countries in Europe. The demographic profile of the study cohort and findings on the patient-rated impact of IBD on QoL are reported here. Methods An online, cross-sectional survey (October 2020 to January 2021) enrolling adults aged ≥18 years who self-reported having and being previously/currently treated for Crohn’s disease (CD) or ulcerative colitis (UC) was conducted across Europe (France, the UK, Spain, Italy, Belgium, Switzerland and the Netherlands). Patient perspectives on IBD care and preferences regarding specific attributes of existing treatment options were explored using the Carenity platform and via partnerships with local organisations. This descriptive analysis evaluated the demographic and clinical profile of respondents, treatment management and impact on QoL. Results Overall, 686 patients (CD: 360; UC: 326) across 7 countries completed the survey. Among CD and UC patients, respectively, 71.9% and 57.7% were females; mean age (range) was 48.0 (19.0–77.0) and 50.0 (19.0–82.0) years; and mean disease duration (range) was 13.6 (0.2–49.1) and 11.0 (0.1–68.7) years. Overall, 37.5% of CD patients reported fistulising CD, and 9.4% (CD) and 10.1% (UC) of patients had a stoma or pouch; 76.7% (CD) and 78.5% (UC) of patients were being treated for IBD. Approximately 50.0% of patients with IBD were full-time or part-time employed at the time of survey. Abdominal pain, fatigue, and stool frequency were ranked by 83%, 79%, and 73% patients with CD, respectively, as the symptoms most impacting QoL; 79%, 71%, and 61% patients ranked energy status, general well-being and daily activities, respectively, as the most impacted aspects. Abdominal pain, stool frequency and fatigue were ranked by 73%, 72% and 67% patients with UC, respectively, as the symptoms most impacting QoL; the most impacted aspects were similar to those of patients with CD. Patients in both groups prioritised general well-being, energy status and daily activities as aspects for improvement through treatment. Conclusion This large European survey highlights the most impactful symptoms and QoL aspects from the patient perspective. These findings can support clinical decision-making and treatment strategies to improve treatment outcomes and patient QoL.

Management of Soft Tissue Sarcomas in Extremities: Variation in Treatment Recommendations and Surveillance According to Specialty and Continent

BackgroundThis study aimed to provide an insight into clinical decision-making and surveillance strategy of sarcoma specialists for patients with primary soft tissue sarcoma of the extremities (eSTS). The secondary aim was to quantify the role of patient- and tumor-specific factors in the perioperative management.MethodsMembers of sarcoma societies were sent a Web-based 21-item survey about eSTS management. The survey concerned only primary resectable high-grade eSTS in adults.ResultsThe study enrolled 396 respondents. The majority of the surgical specialists thought the evidence for perioperative chemotherapy (CTX) for high-grade eSTS was insufficient. Radiotherapy (RTX) was less frequently offered in Asia than in North America and Europe. The specialties and continents also differed regarding the importance of patient and tumor characteristics influencing RTX and CTX recommendation. For surveillance after initial treatment outpatient visits, chest computed tomography (CT) scans, and magnetic resonance images of the extremity were the methods primarily used. The specialists in North America preferred chest CT scan over chest x-ray, whereas those in Asia and Europe had no clear preference.DiscussionSpecialty and continent are important factors contributing to the variation in clinical practice, treatment recommendations, and surveillance of patients with primary resectable high-grade eSTS.

Cervical Cancer Prediction by Merging Features of Different Colposcopic Images and Using Ensemble Classifier.

Background:Cervical cancer is a significant cause of cancer mortality in women, particularly in low-income countries. In regular cervical screening methods, such as colposcopy, an image is taken from the cervix of a patient. The particular image can be used by computer-aided diagnosis (CAD) systems that are trained using artificial intelligence algorithms to predict the possibility of cervical cancer. Artificial intelligence models had been highlighted in a number of cervical cancer studies. However, there are a limited number of studies that investigate the simultaneous use of three colposcopic screening modalities including Greenlight, Hinselmann, and Schiller.Methods:We propose a cervical cancer predictor model which incorporates the result of different classification algorithms and ensemble classifiers. Our approach merges features of different colposcopic images of a patient. The feature vector of each image includes semantic medical features, subjective judgments, and a consensus. The class label of each sample is calculated using an aggregation function on expert judgments and consensuses.Results:We investigated different aggregation strategies to find the best formula for aggregation function and then we evaluated our method using the quality assessment of digital colposcopies dataset, and our approach performance with 96% of sensitivity and 94% of specificity values yields a significant improvement in the field.Conclusion:Our model can be used as a supportive clinical decision-making strategy by giving more reliable information to the clinical decision makers. Our proposed model also is more applicable in cervical cancer CAD systems compared to the available methods.

An Integrative Approach to Predict Phenotypic Severity in Nonketotic Hyperglycinemia

Background: Nonketotic hyperglycinemia (NKH) is a inherited neurometabolic disorder with variable clinical course and severity, in a spectrum ranging from infantile epileptic encephalopathy to psychiatric disorders. A precise phenotypic characterization and an evaluation of predictive approaches are needed. We report the results of the patient registry of the International Working Group on Neurotransmitter related Disorders (iNTD). Methods: The iNTD patient registry is a multicenter, uncontrolled, non-randomized, open, unblinded observational study (registered on DRKS, DRK7878). Longitudinal clinical and biochemical data of 25 individuals with NKH were studied with in silico analyses, pathogenicity scores and molecular modeling of GLDC and AMT variants. Findings: Age of onset (p=0 · 004) and diagnosis are earlier in life in severe NKH( p=0 · 005). Presenting symptoms affect the age at diagnosis. Psychiatric problems occur predominantly in attenuated NKH. Onset-age ≥3 months (66% specificity, 100% sensitivity, AUC = 0·87) and cerebrospinal fluid (CSF)/plasma glycine ratio ≤0 · 09 (57% specificity, 100% sensitivity, AUC = 0·88) are sensitive indicators for attenuated NKH while CSF glycine concentration ≥116 · 5 µmol/L (100% specificity, 93% sensitivity, AUC = 0·97) and CSF/plasma glycine ratio ≥0 · 15 15 (100% specificity, 64% sensitivity, AUC = 0·88) are specific for severe forms. A ratio threshold of 0 · 128 discriminates the overlapping range. In our study, we present ten new GLDC variants, two mild variants resulting in attenuated phenotype. Two severe variants and a combination of one mild and one severe variant lead to severe phenotype. Interpretation: This study widens the phenotypic spectrum of attenuated NKH and expands the number of pathogenic variants. The multiparametric approach provides a promising tool to predict disease severity, helping to improve clinical management and decision-making strategies. Trial Registration: This study was registered German Clinical Trials Register, https://www.drks.de, DRK7878). Funding: Ministry of Health of the Czech Republic (RVO-VFN 64165 GJIH-0599-00-7-846, ProgresQ26/LF1), FIS P118/00111 and PI19/00348 “Instituto de Salud Carlos III”, “Fondo Europeo de desarrollo regional (FEDER)”, and Dietmar Hopp Foundation. Declaration of Interest: A.G.C. has received teaching honorarium from PTC Therapeutics GT, Inc. G.F.H. receives teaching as well as consultancy honorarium from PTC Therapeutics GT, Inc. O.K.H. has received teaching honorarium from PTC Therapeutics GT, Inc. T.O. receives teaching honorarium and research support from PTC. GFH has received honoraria as a speaker from Takeda and consultancy honoraria from PTC Therapeutics International GT. T.S.P receives consulting honoraria from Teva Pharmaceuticals. The other authors declare no potential conflict of interest. Ethical Approval: iNTD registry study was approved by the Institutional Research Ethics Board (IRB) Heidelberg University Hospital (S-471/2014)

Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study

BackgroundClinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores.MethodsThis multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score’s performance was compared to that of the previous severity scores.ResultsNew scoring system for 28-day mortality was based on six variables (score range, 0–8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%).ConclusionsThe VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.

Multimodality Imaging of Pulmonary Hypertension

Pulmonary hypertension (PH) is a complex, progressive abnormal physiologic and hemodynamic state seen in many conditions. The purpose of this review is to discuss the updated clinical and hemodynamic classification systems and diagnostic criteria of PH, discuss the role of noninvasive imaging for diagnosing PH, and outline a diagnostic pathway to facilitate targeted therapies. PH is defined as a mean pulmonary arterial pressure (mPAP) > 20 mmHg since the sixth World Symposium on Pulmonary Hypertension (WSPH) in 2018, a lower threshold than the longstanding definition of mPAP > 25 mmHg. Additionally, in 2018, Truong et al. established a four-tier classification for the diagnosis of PH based upon the degree of main pulmonary artery enlargement on computed tomography, whereby the likelihood of PH increases with increasing tier severity. Other noninvasive modalities, particularly echocardiography and cardiac magnetic resonance imaging (CMR), aid in prognostication of PH and drive clinical decision-making and treatment strategies. Multimodality imaging is paramount in the screening, diagnosis, and management of PH by providing anatomical, physiologic, functional, and prognostic information. Cumulative findings on echocardiography, ventilation/perfusion scintigraphy, computed tomography, and CMR imaging can often identify the etiology of PH and provide insight into pathophysiology and disease stage.

Prognostic value of pretreatment neutrophil-to-lymphocyte ratio in renal cell carcinoma: a systematic review and meta-analysis

BackgroundNumerous studies show that the pretreatment neutrophil-to-lymphocyte ratio (NLR) is associated with the prognosis of patients with RCC. However, their findings are inconsistent, urging us to explore the prognostic value of NLR in RCC patients.MethodsThis study was pre-registered in PROSPERO (CRD42020167131). Two reviewers independently performed a systematical search of PubMed, Web of Science, EMBASE, and Cochrane Library databases for prospective or retrospective cohort studies investigating the prognostic value of pretreatment NLR. Hazard ratios with 95% confidence intervals for overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), cancer-specific survival (CSS), and other useful clinicopathological features were extracted and analyzed with fixed or random-effect models by using Review Manager 5.3 and Stata 12.0 software. Heterogeneity was estimated on the basis of Cochran’s Q test and I2 value. Sensitivity analyses and subgroup analyses were also performed to explore the potential sources of heterogeneity. Publication bias was assessed with funnel plots and precisely assessed by Egger’s tests. The quality of the evidence was evaluated in accordance with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).ResultsOverall, 6461 RCC patients from 24 retrospective studies and 1 prospective study were included. In overall population, elevated pretreatment NLR was associated with poorer OS (pooled HR = 1.90, 95% CI = 1.56–2.30, p < 0.001; I2 = 87%), DFS/PFS (pooled HR = 2.09, 95% CI: 1.49–2.94, p < 0.001; I2 = 99%), and CSS (pooled HR = 2.31, 95% CI: 1.61–3.33, p < 0.001; I2 = 14%). Furthermore, this negative association was further confirmed in patients with nonmetastatic and metastatic RCC patients, respectively. We also investigated the predictive role of NLR in metastatic RCC patients treated with immune checkpoint inhibitors (ICIs). The results indicated that the level of NLR was significantly associated with OS (pooled HR = 3.92, 95% CI: 2.00–7.69, p < 0.001; I2 = 0%) and PFS (pooled HR = 2.20, 95% CI: 95% CI: 1.61–3.01, p < 0.001; I2 = 20%).ConclusionsThis study demonstrated that elevated pretreatment NLR was significantly associated with poor prognosis of RCC patients. NLR could be helpful as a potential prognostic biomarker to guide clinical decision-making and select individualized treatment strategies for RCC patients.

Subtotal Cholecystectomy: Results of a Single-Centre, Registry-Based Retrospective Cohort Study of 180 Adults in 2011–2018

Background: Data on subtotal cholecystectomy (STC) as an alternative to conventional cholecystectomy in difficult surgical situations are limited. This multi-aspectual report aims to reduce the STC-specific knowledge gap and inform clinical decision-making strategies. Methods: All 180 patients who underwent STC at a single centre between 2011 and 2017 were assessed in this retrospective cohort study. Their outcomes were followed up until March 23, 2018. Six subgroups stratified by surgical setting (elective/non-elective), surgical approach used (open/laparoscopic), and type of procedure (reconstituting/fenestrating) were compared. Findings: The ratio of conventional to STC procedures during the study period was 13:1. Of the 180 patients, 150 (83%) had a history of hospitalisation for acute biliary disease. The proportion of all cholecystectomies that were STC ranged from 1% to 71% between individual surgeons; similarly, laparoscopic STC comprised 0%–97% of all STCs. STC was associated with high intraoperative and short-term postoperative complication rates (10·6% and 88·0%, respectively). There were three intraoperative complications, comprising one case each of bile duct injury (3·9%), significant bleeding from hepatic vessels (3·3%), and intestinal injury requiring repair (2·2%). The most common postoperative surgical site complications were external bile leak (21%), wound infection (17%), and biloma (10%). Strong associations between fenestrating STC and the rates of postoperative bile leak and retained gallstones, mainly in the main bile duct, were observed. A total of 532 targeted non-invasive and invasive investigations (304 computed tomography scans, 153 endoscopic retrograde cholangiopancreatography scans, 50 magnetic resonance cholangiopancreatography scans, and 25 endoscopic ultrasound scans) were performed. Interpretation: STC is associated with significant intraoperative and postoperative complication rates and a high investigation burden. Injury can be avoided when conversion to STC is timely and its technical variant is correctly selected. The STC rate could be introduced as a quality indicator for gallbladder surgery. Funding: Neither author received specific funding for this work. Declaration of Interests: The authors declare no competing financial interests. Ethics Approval Statement: The institutional clinical audit management board reviewed, approved, and registered the project as a no-risk observational cohort study. Hence, acquisition of informed consent from patients was not required for this study, as it does not include personal information about individual patients.

A subject-specific method to measure dynamic spinal alignment in adult spinal deformity

BACKGROUND CONTEXTTwo-dimensional static radiography currently forms the golden standard in spinal alignment measurement in adult spinal deformity (ASD). However, these static measurements offer no information on dynamic spinal behavior. To fully understand the functionality and compensation strategies of ASD patients, tools to assess dynamic spinal alignment are needed. PURPOSETherefore, the aim of this study was to introduce, validate and assess the reliability of a new kinematic model to measure dynamic spinal parameters in ASD based on a polynomial function, taking into account the subject-specific anatomy. STUDY DESIGNValidation and reliability study OUTCOME MEASURESRadiographic parameters, spinal kinematics and range of motion (ROM), Scoliosis Research Society Outcome Questionnaire (SRS-22), Core Outcome Measures Index (COMI). METHODSSpinal alignment of 23 ASD patients and 18 controls was measured using both x-rays and motion capture. Marker positions were corrected to the underlying anatomy and a polynomial function was fitted through these corrected marker positions. By comparing the polynomial method to x-ray measurements concurrent validity was assessed. Test-retest, inter- and intrarater reliability during standing and sit-to-stand (STS) were assessed on a subsample of eight ASD patients and eight controls. RESULTSThe results showed good to excellent correlations (r>0.75) between almost all x-ray and anatomy-corrected polynomial parameters. Anatomy correction consistently led to better correlations than no correction. Intraclass correlation coefficients for the polynomial method were good to excellent (>0.75) between sessions and between and within raters and comparable or even better than radiographic measurements. Also, during STS reliability was excellent. Fair to moderate correlations were found between spinal ROM during STS and quality of life, measured with SRS-22 and COMI. CONCLUSIONSThe results of this study indicate the polynomial method, with subject-specific anatomy correction, can measure spinal alignment in a valid and reliable way using motion capture in both healthy and deformed spines. This method makes it possible to extend evaluation in ASD from mainly static, by means of x-ray measurements, to dynamic and functional assessments. CLINICAL SIGNIFICANCEEventually, this newly obtained dynamic spinal alignment information might lead to new insights in clinical decision-making and new treatment strategies, based and oriented on dynamic parameters and functionality.

Factors Affecting Clinical Decision-Making and Treatment Planning Strategies for Tooth Retention or Extraction: An Exploratory Review.

Dentists are often confronted with challenges concerning the determination of the treatment type for questionable teeth (retention or extraction) in their routine dental practice. The objective of this review was to explore the available literature pertaining to the factors influencing clinical decision-making and treatment strategies of dentists regarding tooth retention or extraction. Explorative analysis of the literature was conducted based on its relevance to the subjected study area and scope. Primarily, the papers were extracted from sources such as ERIC, PubMed, Scopus, and Medline. The keywords used for searching articles include Clinical Decision-Making, Treatment Strategies, Tooth Extraction, and Tooth Retention. Papers published up to 2018 were extracted and evaluated. The analyzed studies highlighted that a successful treatment plan is based on the practitioner's knowledge, abilities, and skills as well as patients' preference, which is also a determinant of treatment success in restorative dentistry. Multidisciplinary dental treatment is generally adopted for decision making in dental clinics. Overall, the treatment plan should be based on the extensive learning and keen observation of the disease and the associated factors which enable long-term success of the treatment.

Restorative Emergence Profile for Single-Tooth Implants in Healthy Periodontal Patients: Clinical Guidelines and Decision-Making Strategies.

The peri-implant soft tissue seal consists of a connective tissue cuff and a junctional epithelium that is different from the arrangement of periodontium around a natural tooth. However, the peri-implant soft tissue complex lacks Sharpey's fibers, thus offering less resistance to clinical probing and biofilm penetration compared to the natural dentition. Therefore, the proper restorative emergence profile design is essential to facilitate favorable esthetic outcomes and maintain peri-implant health. The aim of this article is to review the currently available evidence related to the design of subgingival (critical and subcritical) and supragingival contours of the implant restorative emergence profile (IREP) as well as provide a flowchart for decision-making in clinical practice. Theoretically, the subgingival contours of the crown/abutment complex should mimic the morphology of the root and the cervical third of the anatomic crown as much and as often as possible. However, this is highly dependent upon the three-dimensional spatial position of the implant relative to the hard and soft tissue complex, in addition to the location of the definitive restoration. Frequently, a convex critical contour is required on the facial aspect of a palatally or incisally positioned implant to support an adequate gingival-margin architecture. Conversely, if the implant is placed too far facially, then a flat or concave contour is recommended. In instances where soft tissue support is not needed, the subcritical area may be undercontoured to increase the thickness, height, and stability of the soft tissue cuff.

Association of Thyroid Function Test Abnormalities and Thyroid Autoimmunity With Preterm Birth

Maternal hypothyroidism and hyperthyroidism are risk factors for preterm birth. Milder thyroid function test abnormalities and thyroid autoimmunity are more prevalent, but it remains controversial if these are associated with preterm birth. To study if maternal thyroid function test abnormalities and thyroid autoimmunity are risk factors for preterm birth. Studies were identified through a search of the Ovid MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and Google Scholar databases from inception to March 18, 2018, and by publishing open invitations in relevant journals. Data sets from published and unpublished prospective cohort studies with data on thyroid function tests (thyrotropin [often referred to as thyroid-stimulating hormone or TSH] and free thyroxine [FT4] concentrations) or thyroid peroxidase (TPO) antibody measurements and gestational age at birth were screened for eligibility by 2 independent reviewers. Studies in which participants received treatment based on abnormal thyroid function tests were excluded. The primary authors provided individual participant data that were analyzed using mixed-effects models. The primary outcome was preterm birth (<37 weeks' gestational age). From 2526 published reports, 35 cohorts were invited to participate. After the addition of 5 unpublished data sets, a total of 19 cohorts were included. The study population included 47 045 pregnant women (mean age, 29 years; median gestational age at blood sampling, 12.9 weeks), of whom 1234 (3.1%) had subclinical hypothyroidism (increased thyrotropin concentration with normal FT4 concentration), 904 (2.2%) had isolated hypothyroxinemia (decreased FT4 concentration with normal thyrotropin concentration), and 3043 (7.5%) were TPO antibody positive; 2357 (5.0%) had a preterm birth. The risk of preterm birth was higher for women with subclinical hypothyroidism than euthyroid women (6.1% vs 5.0%, respectively; absolute risk difference, 1.4% [95% CI, 0%-3.2%]; odds ratio [OR], 1.29 [95% CI, 1.01-1.64]). Among women with isolated hypothyroxinemia, the risk of preterm birth was 7.1% vs 5.0% in euthyroid women (absolute risk difference, 2.3% [95% CI, 0.6%-4.5%]; OR, 1.46 [95% CI, 1.12-1.90]). In continuous analyses, each 1-SD higher maternal thyrotropin concentration was associated with a higher risk of preterm birth (absolute risk difference, 0.2% [95% CI, 0%-0.4%] per 1 SD; OR, 1.04 [95% CI, 1.00-1.09] per 1 SD). Thyroid peroxidase antibody-positive women had a higher risk of preterm birth vs TPO antibody-negative women (6.6% vs 4.9%, respectively; absolute risk difference, 1.6% [95% CI, 0.7%-2.8%]; OR, 1.33 [95% CI, 1.15-1.56]). Among pregnant women without overt thyroid disease, subclinical hypothyroidism, isolated hypothyroxinemia, and TPO antibody positivity were significantly associated with higher risk of preterm birth. These results provide insights toward optimizing clinical decision-making strategies that should consider the potential harms and benefits of screening programs and levothyroxine treatment during pregnancy.

Pathological Tumor Regression Grade Classifications in Gastrointestinal Cancers: Role on Patients' Prognosis.

Preoperative chemotherapy or combined radiotherapy and chemotherapy (CRT), followed by surgery, represents the standard approach for locally advanced esophageal, gastric, and rectal carcinomas. To adequately evaluate the effects of neoadjuvant CRT in the resection specimens, several histopathologic tumor regression grade (TRG) scoring systems have been introduced into clinical practice. The primary goal of these TRG systems relies on a correct prognostic stratification of patients in the attempt to help clinical decision-making and influence surgical strategies, postoperative adjuvant therapies, and surveillance intensity. However, most TRG systems suffer from poor reproducibility and low interobserver concordance rates. Many efforts have been made in the identification of alternative, robust, simple, and universally accepted TRG scoring systems, which would help in the comparison of different treatment strategies and in the standardization of multimodal therapies. The aim of this review is to analyze the most commonly used TRG systems in gastrointestinal cancers highlighting their pitfalls and usefulness, depending on the tumor type.

Osteopathic clinical reasoning: An ethnographic study of perceptual diagnostic judgments, and metacognition

BackgroundClinical reasoning has been widely researched in the health sciences; however, in osteopathy it is still in its relative infancy. ObjectiveTo explore the moment by moment clinical reasoning processes of an osteopath whilst with patients, to understand the role of perceptual diagnostic judgments, and metacognitive processes. MethodA qualitative interpretive study with a novel narrative method as an organising structure: the moment by moment thought processes of a single osteopath were recorded and transformed into descriptions of the interactions with patients. The descriptive texts were expanded into narratives using autoethnography and reflective practice. Narratives were then analysed using methods originating from grounded theory. ResultsOur interpretations indicate that osteopaths establish a multisensory construct during clinical reasoning which enables both analytic and intuitive decision-making strategies. Clinical reasoning was monitored by a variety of metacognitive processes, including intuitive discernments such as feeling that a decision is correct, and the judgment that there is sufficient information to make that decision. ConclusionsThis is the first study to explore the subjective moment by moment clinical reasoning and decision-making strategies of an osteopath whilst with patients. It suggests that perceptual diagnostic judgments are multisensory and include mental and visual imagery, and embodied senses. These enable analytic and intuitive diagnostic strategies that are accompanied by persistent metacognitive processes during the consultation, which guide the practitioner's decision strategies.

Characterization and Predictive Value of Segmental Curve Flexibility in Adolescent Idiopathic Scoliosis Patients.

A prospective radiographic analysis of adolescent idiopathic scoliosis (AIS) patients managed with alternate-level pedicle screw fixation was performed. The objective of this study was to characterize segmental curve flexibility and to determine its predictive value in curve correction in AIS patients. Little is known regarding the distinct segmental curve characteristics and their ability to predict curve correction in patients with AIS. The segmental Cobb angle was measured on posteroanterior standing radiographs and on fulcrum bending radiographs. Radiographs were analyzed preoperatively and at 2 years postoperatively and the curve was divided into upper, mid, and lower segments based on predefined criteria. The segmental flexibility and the segmental fulcrum bending correction index (FBCI) were calculated. Eighty patients were included with mean age of 15 years. Preoperative mean segmental Cobb angles were 18, 31, and 17 degrees in the upper, mid, and lower segments, respectively. Segmental bending Cobb angles were 6, 13, and 4 degrees, respectively, corresponding to segmental flexibilities of 50%, 47%, and 83% in the upper, mid, and lower segments, respectively (P < 0.001). At 2-year follow up, the mean segmental FBCI were 155%, 131%, and 100% in the upper, mid, and lower segments, respectively (P < 0.001), which suggested that the lower segment of the curve was more flexible than the other segments and that higher correction was noted in the upper segments. A significant, positive correlation was noted between the segmental bending Cobb angle and the segmental FBCI (P < 0.05), whereby the strength of the correlation varied based on the curve segment. This is the first study to demonstrate the segmental variations in curve flexibility using the fulcrum bending radiograph in AIS patients. Curve flexibility is not uniform throughout the curve and different segments exhibit greater flexibility/correctibility than others. Segmental flexibility should be considered in assessing AIS patients and in the clinical decision-making strategy to optimize curve correction outcomes. 03.