Modified Grading System Research Articles

World Allergy Organization Systemic Allergic Reaction Grading System: Is a Modification Needed?

There is no universally accepted grading system to classify the severity of systemic allergic reactions (SARs), including anaphylaxis. Although a consensus definition for anaphylaxis was established in 2005, the signs and symptoms required to define a reaction as anaphylaxis are inconsistently applied in research and clinical practice. As a result, it is difficult to compare and evaluate safety outcomes in surveys, clinical practice and trials, and pharmacovigilance data. In 2010, the World Allergy Organization (WAO) proposed a uniform grading system to classify allergen immunotherapy SARs. The basis of the grading system is the organ system(s) involved and reaction severity. The final grade is determined by the physician/health care professional after the event is over. Although the 2010 WAO grading system was developed to classify allergen immunotherapy SARs, with appropriate modifications, it can be used to classify SARs from any cause. The purpose of this Rostrum is to present a proposed modification of the 2010 WAO SAR grading system that will make it applicable to all SARs due to any cause. The modified grading system allows for classification of less severe SARs, which may be underreported or overreported in clinical trials and surveillance studies, depending on the criteria specified for adverse event reporting. The universal use of the proposed modified SAR grading system will allow for better safety comparisons across different venues and treatment protocols.

Establishment and evaluation of nomogram for predicting biochemical recurrence in patients with locally adverse pathologic features after radical prostatectomy

Objective To construct and evaluate a nomogram for predicting biochemical recurrence (BCR) in patients with locally adverse pathologic features (including seminal vesicle invasion (SVI), extracapsular extension (ECE), or positive surgical margins (PSM)) after radical prostatectomy. Methods This study included prostate cancer patients who were treated with radical prostatectomy (RP) at a single institution between 2003 and 2014, with locally adverse pathological features. The final study comprised of 172 men (median age, 70 years) with a median serum PSA level of 16.1 ng/ml. According to the modified Gleason grade system, the distribution of biopsy Gleason score was as follows: Gleason≤6 (59, 34.3%), Gleason 3+ 4 (51, 29.7%), Gleason 4+ 3 (42, 24.4%), Gleason 8 (18, 10.5%), and Gleason 9-10 (2, 1.2%). Most patients were preoperatively under-staged, with 91.3% of cases had a clinical stage less than T2c. Pathological examination of the species revealed ECE in 108 (62.8%) patients, SVI in 40 (23.3%) patients and PSM in 62 (36.0%) patients. Considering the modified Gleason grading system, the distribution of the patients was as follows: Gleason≤6 (35, 20.3%), Gleason 3+ 4 (54, 31.4%), Gleason 4+ 3 (42, 24.4%), Gleason 8 (23, 13.4%), and Gleason 9-10 (18, 10.5%). Overall, there were 79.1% of patients had early postoperative PSA <0.1 ng/ml. Univariate and multivariate Cox regression analysis the value of factors in predicting the probability of BCR. Variables significantly associated with BCR were included to construct the nomogram. Concordance index and calibration curve were used for the internal validation of nomogram. Results The overall 3-year and 5-year BCR-free survival rate was 60.4% and 43.2% respectively for the entire cohort. In univariate Cox regression analysis, Preoperative PSA(HR=1.474, P<0.05), Early postoperative PSA(HR=3.488, P<0.05), SVI(HR=3.488, P<0.05), PSM(HR=1.795, P<0.05), biopsy Gleason grade(HR=1.795, P<0.05) and specimen Gleason grade(HR=1.898, P<0.05) were significantly associated with BCR. However, in multivariate analysis, only specimen Gleason grade(HR=1.809, P<0.05) and early postoperative PSA(HR=2.490, P<0.05) retained independent significance. The nomogram predicting the risk of BCR showed relative good concordance index (0.766) and good calibration. Conclusions The nomogram to predict the probability of BCR in patients with locally adverse pathologic features after radical prostatectomy showed good clinical applicability. This statistical tool may facilitate discussions at the point of treatment decision making. Key words: Prostatic neoplasms; Radical prostatectomy; Biochemical recurrence; Risk factors; Nomogram

Metastatic potential to regional lymph nodes with Gleason score ≤7, including tertiary pattern 5, at radical prostatectomy

To determine the risk of pelvic lymph node (LN) metastases at radical prostatectomy (RP) for Gleason score (GS) ≤7: 3 + 3 = 6 (grade group [GG]1); 3 + 4 = 7 (GG2); 3 + 4 = 7 (GG2) with tertiary pattern 5 (T5); 4 + 3 = 7 (GG3); 4 + 3 = 7 (GG3) with T5, using the 2014 modified Gleason grading system and the novel GG system. We searched our RP database to indentify cases of GS ≤7 prostate cancer with simultaneous pelvic LN dissection (PLND) in the period between 2005 and 2014. Since 2005, we have graded all glomeruloid and cribriform cancer as Gleason pattern 4 and have graded mucinous adenocarcinoma based on the underlying architectural pattern, consistent with the 2014 modified Gleason grading system. All RPs were embedded in entirety, including the PLND. A total of 7 442 cases were identified, of which 73 had at least one positive LN (+LN). The incidence rates for regional LN metastases at RP for 3 + 3 = 6 (GG1), 3 + 4 = 7 (GG2), 3 + 4 = 7 (GG2) with T5, 4 + 3 = 7 (GG3) and 4 + 3 = 7 (GG3) with T5 were 0, 0.6, 0.4, 4.3 and 6.3%, respectively. There was a statistically significant difference in risk of +LNs at RP between the grade groups, as defined by the novel GG system. There was no statistically significant difference in risk of +LNs at RP for men with 3 + 4 (GG2) vs 3 + 4 (GG2) with T5 and for men with 4 + 3 (GG3) vs 4 + 3 (GG3) with T5. Non-pelvic LN involvement was identified in 0.2% of all RP cases. Two patients with GS 3 + 4 = 7 with <5% pattern 4 experienced LN metastases. This study supports our previous finding that men with GS 6 (GG1) at RP have no risk of LN metastases. These findings also support the 2014 revisions to the Gleason grading system where 3 + 3 with T4 (2005 modified grading system) is now considered 3 + 4 (GG2), with a comment on percent pattern 4, because <5% pattern 4 increases the risk of LN metastases. It also supports keeping 3 + 4 (GG2) with T5 (<5% pattern 5) and 4 + 3 (GG3) with T5 with their respective grade groups, with a notation of T5 because the <5% higher grade component did not increase the risk of LN metastases within a given GG. Our findings highlight that 3 + 4 (GG2) and 4 + 3 (GG3), even with a 5% higher grade component, are distinct groups with respect to LN metastases and should not be combined under the umbrella designation of GS 7 as is often the case in the literature with the Gleason grading system.

Comparing 2 Whiplash Grading Systems to Predict Clinical Outcomes

ObjectiveTwo whiplash severity grading systems have been developed: Quebec Task Force on Whiplash-Associated Disorders (QTF-WAD) and the Croft grading system. The majority of clinical studies to date have used the modified grading system published by the QTF-WAD in 1995 and have demonstrated some ability to predict outcome. But most studies include only injuries of lower severity (grades 1 and 2), preventing a broader interpretation. The purpose of this study was assess the ability of these grading systems to predict clinical outcome within the context of a broader injury spectrum. MethodsThis study evaluated both grading systems for their ability to predict the bivalent outcome, recovery, within a sample of 118 whiplash patients who were part of a previous case-control designed study. Of these, 36% (controls) had recovered, and 64% (cases) had not recovered. The discrete bivariate distribution between recovery status and whiplash grade was analyzed using the 2-tailed cross-tabulation statistics. ResultsApplying the criteria of the original 1993 Croft grading system, the subset comprised 1 grade 1 injury, 32 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. Applying the criteria of the modified (QTF-WAD) grading system, there were 1 grade 1 injury, 89 grade 2 injuries, and 28 grade 3 injuries. Both whiplash grading systems correlated negatively with recovery; that is, higher severity grades predicted a lower probability of recovery, and statistically significant correlations were observed in both, but the Croft grading system substantially outperformed the QTF-WAD system on this measure. ConclusionsThe Croft grading system for whiplash injury severity showed a better predictive measure for recovery status from whiplash injuries as compared with the QTF-WAD grading system.

Reliability of the modified Tufts Lumbar Degenerative Disc Classification between neurosurgeons and neuroradiologists

Cross-specialty inter-rater reliability has not been explicitly reported for imaging characteristics that are thought to be important in lumbar intervertebral disc degeneration. Sufficient cross-specialty reliability is an essential consideration if radiographic stratification of symptomatic patients to specific treatment modalities is to ever be realized. Therefore the purpose of this study was to directly compare the assessment of such characteristics between neurosurgeons and neuroradiologists. Sixty consecutive patients with a diagnosis of lumbago and appropriate imaging were selected for inclusion. Lumbar MRI were evaluated using the Tufts Degenerative Disc Classification by two neurosurgeons and two neuroradiologists. Inter-rater reliability was assessed using Cohen’s κ values both within and between specialties. A sensitivity analysis was performed for a modified grading system, which excluded high intensity zones (HIZ), due to poor cross-specialty inter-rater reliability of HIZ between specialties. The reliability of HIZ between neurosurgeons and neuroradiologists was fair in two of the four cross-specialty comparisons in this study (neurosurgeon 1 versus both radiologists κ=0.364 and κ=0.290). Removing HIZ from the classification improved inter-rater reliability for all comparisons within and between specialties (0.465⩽κ⩽0.576). In addition, intra-rater reliability remained in the moderate to substantial range (0.523⩽κ⩽0.649). Given our findings and corroboration with previous studies, identification of HIZ seems to have a markedly variable reliability. Thus we recommend modification of the original Tufts Degenerative Disc Classification by removing HIZ in order to make the overall grade provided by this classification more reproducible when scored by practitioners of different training backgrounds.

Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation

Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 ± 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 ± 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 ± 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 ± 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) = –6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed.

SOCS3 immunohistochemical expression to support the 2005 International Society of Urological Pathology (ISUP) modified Gleason grading system.

216 Background: In the 2005 International Society of Urological Pathology (ISUP) Consensus Conference, a modified Gleason grading system for prostate cancer was proposed. (Epstein JI et al. Am J Surg Pathol 2005; 29:1228-1242) Afterwards an interobserver study among experts in genitourinary pathology proposed some modifications and refinements to the 2005 ISUP modified grading system concerning the cribriform pattern carcinoma that it should never be diagnosed as Gleason pattern 3, assigning Gleason pattern 4 to cribriform glands (Latour M et al. Am J Surg Pathol 2008; 32: 1532-1539; Epstein J I Journal of Urology 2010: 183:433-440). Methods: The study population consisted of 80 patients undergoing biopsies at the Institute of Urology of our hospital, between February 2012 and January 2013 stratified into 3 different categories on the basis of histologic pattern: 1) 20 patients with classical and modified Gleason score 3+3 = 6; 2) 30 patients with classical Gleason score 3+3 = 6 upgraded to Gleason score 7 according to the ISUP modified grading system; and 3) 30 patients with classical and modified Gleason score 3+4 = 7. We evaluate the immunohistochemical protein expression of the suppressor of cytokine signaling (SOCS) proteins 3 (SOCS3) in these three different group of prostatic cancer biopsies. Results: We found that the SOCS3 pattern staining negative (-) or with SOCS3 negative staining with weak intensity staining in less than 50% of neoplastic glands (+/-) increases progressively in concomitance with the rise of Gleason score and SOCS3 positivity (+), correlates with classical or modified Gleason score 6 (P = 0,0004 Fisher’s exact tests) and with classical Gleason score 3+3 = 6 upgraded to Gleason score 7 (P = 0,0010 Fisher’s exact tests). Conclusions: In conclusion our data seem to support from a molecular point of view the modified criteria by 2005 International Society of Urological Pathology (ISUP) Consensus Conference as well as the hypothesis that the diagnosis of Gleason cribriform pattern 3 virtually does not exist and cribriform glands-regardless of their size-are nearly always considered pattern 4.

The Effect of Gender on Acute Hydrocephalus after Experimental Subarachnoid Hemorrhage.

Acute hydrocephalus is a common complication of subarachnoid hemorrhage (SAH). We investigated the effect of gender on acute hydrocephalus development in a rat SAH model. SAH was induced in adult male and female Sprague-Dawley rats using endovascular perforation. Sham rats underwent the same procedure without perforation. Magnetic resonance imaging (MRI) was performed 24 h after SAH to determine ventricular volume. Hydrocephalus was defined as a ventricular volume that was more than 3 standard deviations from the mean value in sham-operated animals. After MRI, animals were euthanized and the extent of SAH was assessed using a modified grading system. No sham animals died. Mortality rates after SAH induction in male and female animals were 27 and 22 %, respectively. SAH induced significant ventricular enlargement compared with sham-operated rats (p < 0.01). The T2* hypointensity volume in the ventricle (used to assess intraventricular blood) was correlated with ventricular volume after SAH (r = 0.33, p < 0.05). The incidence of acute hydrocephalus 24 h after SAH was greater in female (75 %) than in male animals (47 %, p < 0.05) and the relative changes in ventricular volume were significantly larger in female than in male rats (292 ± 150 % vs 216 ± 127 % of sham-operated animals, respectively, p < 0.05). The increased hydrocephalus occurred even though SAH severity grade and ventricular T2* hypointensity volumes were not significantly different between male and female animals. Our data demonstrate that gender influences acute hydrocephalus development in a rat SAH model. Future studies should determine the role of estrogen in SAH-induced hydrocephalus.

Prognostic impact of pattern-based grading system by the new IASLC/ATS/ERS classification in Asian patients with stage I lung adenocarcinoma.

We examined the prognostic effect of the grading system based on the new IASLC/ATS/ERS classification in an Asian cohort of patients with early-stage lung adenocarcinoma. Patients with a lung adenocarcinoma less than 3cm in diameter that had undergone complete anatomic resection, diagnosed with pT1a-2aN0M0 consecutively from 2004 to 2013, were enrolled. All specimens were reviewed according to the new IASLC/ATS/ERS classification. The growth patterns were divided into three major categories: grade 1 for lepidic growth, grade 2 for acinar and papillary patterns, and grade 3 for solid and micropapillary patterns. Each tumor was then graded according to the modified grading system, the final score being the sum of the two most predominant grades. The correlations of clinical and pathological factors with disease-free survival (DFS) and overall survival (OS) were evaluated. In total, 201 adenocarcinomas were eligible for score grading. Only 37 (18.4%) patients had a pure pathological growth pattern. Higher stage, greater tumor diameter, positive lymphovascular invasion, and a higher score were associated with shorter DFS. In contrast, stage no longer had a significant impact on OS in a multivariable analysis. Acinar/papillary-predominant tumors with a score of 3 or 4 were associated with better survival than those with a score of 5 (5-year DFS rate: 64.68 vs. 44.18%, HR=2.19, 95% CI: 1.24-3.87; 5-year OS rate: 85.61 vs. 68.59%, HR=3.03, 95% CI: 1.25-7.32). The architectural scores may help to stratify survival differences among certain predominant growth subtypes of adenocarcinoma.

Validation of International Society of Urological Pathology (ISUP) grading for prostatic adenocarcinoma in thin core biopsies using TROG 03.04 ‘RADAR’ trial clinical data

In 2014 a consensus conference convened by the International Society of Urological Pathology (ISUP) adopted amendments to the criteria for Gleason grading and scoring (GS) for prostatic adenocarcinoma. The meeting defined a modified grading system based on 5 grading categories (grade 1, GS 3+3; grade 2, GS 3+4; grade 3, GS 4+3; grade 4, GS 8; grade 5, GS 9-10). In this study we have evaluated the prognostic significance of ISUP grading in 496 patients enrolled in the TROG 03.04 RADAR Trial. There were 19 grade 1, 118 grade 2, 193 grade 3, 88 grade 4 and 79 grade 5 tumours in the series, with follow-up for a minimum of 6.5 years. On follow-up 76 patients experienced distant progression of disease, 171 prostate specific antigen (PSA) progression and 39 prostate cancer deaths. In contrast to the 2005 modified Gleason system (MGS), the hazards of the distant and PSA progression endpoints, relative to grade 2, were significantly greater for grades 3, 4 and 5 of the 2014 ISUP grading scheme. Comparison of predictive ability utilising Harrell's concordance index, showed 2014 ISUP grading to significantly out-perform 2005 MGS grading for each of the three clinical endpoints.

Delayed Gastric Emptying After Pancreaticoduodenectomy: an Analysis of Risk Factors and Cost

IntroductionDelayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), yet it remains incompletely understood. The International Study Group of Pancreatic Surgery (ISGPS) in 2007 defined a three-tiered grading system to standardize studies of DGE. MethodsIn this study, 721 patients undergoing PD between 2006 and 2012 were retrospectively categorized by the ISGPS DGE criteria, as well as a modified grading system (termed primary DGE) if, on retrospective review, DGE was not believed to be a sequela of a separate complication. Predictive factors and associated outcomes were determined. ResultsISGPS-defined DGE occurred in 140 (19.4 %) patients. In a multivariate analysis, predictors of ISGPS-defined DGE included abdominal infection (odds ratio (OR) 5.5, p < 0.001), male gender (OR 1.92, p = 0.007), smoking history (OR 1.75 p = 0.033), and periampullary adenocarcinoma (OR 1.66, p = 0.041). Primary DGE occurred in 12.2 % of patients. Predictors included abdominal infection (OR 3.15, p < 0.001) and smoking history (OR 2.04, p = 0.008). Median hospital charges increased over $10,000 with each severity grade of DGE (p < 0.001). ConclusionDGE is common after PD and contributes substantially to cost. DGE is frequently a secondary complication of abdominal infection, and interventions that limit such complications may be the most effective strategy toward preventing DGE.

Predictors of Outcome in Patients Presenting with Acute Ischemic Stroke and Mild Stroke Scale Scores

Although National Institutes of Health Stroke Scale (NIHSS) is a known predictor of outcome in acute ischemic stroke, there are other factors like age, ambulatory status, and ability to swallow that may be predictors of outcome but are not assessed by the traditional NIHSS. The aim of this retrospective review was to identify predictors of outcome in mild ischemic stroke. Discharge outcomes from patients who presented to our large academic stroke center with acute ischemic stroke from 2005 to 2013 were retrospectively reviewed. Of 7189 patients reviewed, 2597 had initial NIHSS less than 5. Outcome measures were modified Rankin Scale (MRS) score 0-1 and discharge to home. In all, 65% of patients with NIHSS 0-4 were discharged directly home independent of treatment. Of those patients discharged to home, 74% were able to ambulate independently and 98% passed their dysphagia screen. Of patients not discharged directly home, 66% were unable to ambulate independently and 21% did not pass their dysphagia screen. Multivariate logistic regression analysis revealed a significant effect of dysphagia screen (P = .001), ability to ambulate independently (P = .002), age (P = .016), and NIHSS (P = .005) on discharge to home but not MRS of 0-1 (P = .564). In patients with mild stroke scale scores defined as NIHSS 0-4, several factors including age, NIHSS, ambulatory status, and ability to swallow may be independent predictors of functional outcome and discharge home. These data support the development of a modified grading system for assessing functional outcome in mild stroke that considers these factors.

Bleeding following coblation tonsillectomy: a 10-year, single-surgeon audit and modified grading system.

Coblation tonsillectomy can be controversial. This study assessed post-tonsillectomy haemorrhage outcomes for patients operated on by a single experienced coblation-trained ENT surgeon. A retrospective audit of coblation tonsillectomies was performed using the Flinders modification of Stammberger criteria for post-tonsillectomy haemorrhage. Case note review, interview and database interrogation were utilised to obtain the dataset. Haemorrhage results were compared to reports in the current literature. Of those who underwent coblation tonsillectomy, 3.4 per cent were readmitted to hospital with haemorrhage and 1.3 per cent returned to the operating theatre (0.4 per cent primary haemorrhage and 0.9 per cent secondary haemorrhage). Younger children had a lower risk of returning to the operating theatre than older children or adults (0.3 per cent under the age of 12 years vs 2.0 per cent aged 12 years or older). Coblation can be a safe method for tonsillectomy with low complication rates when performed by an experienced ENT surgeon. The Flinders modification of the Stammberger criteria for post-tonsillectomy haemorrhage provides a simple system for data comparison.

The role of surfactant and non-invasive mechanical ventilation in early management of respiratory distress syndrome in premature infants.

Surfactant replacement therapy has been used for few decades for the treatment of respiratory distress syndrome (RDS) and has significantly improved morbidity and mortality in premature infants. Non-invasive respiratory support has recently emerged as a strategy in the early management of RDS. In this review, we discuss the different strategies of early management of RDS. A literature search of PubMed database was conducted to review the subject. The quality of evidence of key clinical studies was graded according to a modified grading system of the international GRADE group. Continuous positive airway pressure (CPAP) with selective surfactant is a safe alternative to routine intubation, surfactant and mechanical ventilation in preterm infants with spontaneous breathing, and such an approach has been associated with decreased risk of death and bronchopulmonary dysplasia. There is a risk of pneumothorax when using a high pressure of CPAP (≥8 cm of H2O), a high partial pressure of carbon dioxide (PCO2 >75 mm of Hg), and a high fraction of inspired oxygen (FiO2 >0.6) as a threshold for intubation while on CPAP. Not all preterm infants need surfactant treatment, and non-invasive respiratory support is a safe and effective approach.

Abstract T P290: Predictors of Outcome in Patients Presenting with Acute Ischemic Stroke and Mild Stroke Scale Scores

Objective: Although NIHSS is a known predictor of outcome in acute ischemic stroke, there are other factors like age, ambulatory status and ability to swallow that may be predictors of outcome, but are not assessed by the traditional NIHSS. The aim of this retrospective review was to identify predictors of outcome in mild ischemic stroke. METHODS: Discharge outcomes from patients who presented to our large academic stroke center with acute ischemic stroke from 2005-2013 were retrospectively reviewed. Of 7189 patients reviewed, 2597 had initial NIHSS &lt;5. At the time of abstract submission data was available for 971 patients. Outcome measures were modified rankin score (MRS) and discharge to home. RESULTS: In this retrospective review, 64% of patients with NIHSS 0-4 were discharged directly home independent of treatment. The mean age of patients discharged to home was 62 and of those not being discharged to home was 70. Of those patients discharged to home, 99% were able to ambulate independently and 98% passed their dysphagia screen. Of patients unable to be discharged directly to home, 6% were not ambulating independently and 17% did not pass their dysphagia screen. Univariate analysis of variance revealed a significant effect of dysphagia screen (p &lt; 0.001), ability to ambulate independently (p &lt; 0.001), and age (p &lt; 0.001) on both discharge to home and MRS 0-1. Multivariate analysis of variance revealed no significant interaction between ability to ambulate, dysphagia and age on discharge to home or MRS 0-1 (p &gt; 0.05). CONCLUSIONS: In patients with mild stroke scale scores defined as NIHSS 0-4, several factors including age, ambulatory status, and ability to swallow may be independent predictors of functional outcome. These data support the development of a modified grading system for assessing functional outcome in mild stroke that considers these factors.

Inhibition of epidural fibrosis after microendoscopic discectomy with topical application of mitomycin C: a randomized, controlled, double-blind trial

The authors conducted a study to evaluate the effects and the safety of locally applied mitomycin C (MMC) on epidural fibrosis after microendoscopic discectomy (MED). Seventy-five patients undergoing single-level unilateral MED for lumbar disc herniation were randomly assigned to receive cotton wool impregnated with either 0.5 mg/ml MMC or saline applied at the site of discectomy for 5 minutes. Outcome measures included degrees of pain severity, functional disability, physical symptoms, and quantitative evaluation of postoperative epidural fibrosis shown on follow-up lumbar contrast-enhanced MRI. Sixty-two patients completed the follow-up. Neither serious drug adverse effects nor clinically significant laboratory adverse effects were observed. Patients in both groups showed similar clinical recoveries postoperatively. A statistically significant difference (p < 0.05) between the 2 treatments was shown in a quantitative evaluation of postoperative MRI-documented epidural fibrosis in the MMC group and the saline group using a modified grading system. The mean cross-sectional areas of epidural fibrosis were 7.32-70.06 mm(2) in the MMC group and 22.94-90.48 mm(2) in the saline group. The epidural fibrosis index ranged from 0.0296 to 0.3267 in the MMC group and from 0.1191 to 0.3483 in the saline group. A significant difference was also observed using the Ross grading system to evaluate postoperative MR images. Although no benefit was observed clinically, the authors observed a notable reduction of epidural fibrosis after MED radiologically, with 0.5 mg/ml MMC locally applied and no clinical side effects.

Grading system modification and management of blunt aortic injury.

The traditional approach to blunt aortic injury (BAI) has been emergent intervention. This study aimed to utilize a modified imaging grading system that may allow us to categorize these injuries as needing emergent, urgent, or non-operative management. From January 2003 to December 2011, 28 patients with BAI were managed at our institution. Imaging and medical records were reviewed retrospectively. BAI was classified into 4 grades based on imaging studies. Grade Ia: intimal tear, Grade Ib: intramural hematoma; Grade II: intimal injury with periaotic hematoma; Grade IIIa: aortic transection with pseudoaneurysm, Grade IIIb: multiple aortic injuries; and Grade IV: free rupture. Progression and clinical outcomes of ABI were analyzed. Of the 28 patients, 22 were males and 6 were females with mean age of 38 (range, 7 - 69) years. Twenty-five (89.3%) had descending thoracic aortic injury, two (7.1%) had abdominal aortic injury and one (3.6%) presented with multiple aortic injuries. Three patients (10.7%) with Grade I, 1 (3.6%) Grade II, 22 (78.6%) Grade III, and 2 (7.1%) Grade IV injuries. Twenty-five patients underwent thoracic endovascular aortic repair and 3 were managed medically. Median time between injury and surgical intervention was (2 ± 1) days. One (3.6%) patient developed paraplegia after thoracic endovascular aortic repair (TEVAR). One Type 2 endoleak spontaneously sealed within 1 month, and another patient died from ruptured Type 1 endoleak 3 years later. Median follow-up time was 16 (range, 1 - 96) months. Perioperative 30-day mortality rate was 3.6%. This study based on our modified BAI grading system indicated that Grade I BAI can be managed conservatively. Grade II injury requires close observation and repeated computerized tomography angiogram (CTA) within 48 - 72 hours. If injury appears worse on follow up imaging, surgery should be performed. Delayed repair of Grade III BAI is acceptable if associated life threatening traumatic injuries need to be addressed first.

Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis

The aim of this systematic review was to compare intracorporeal (IA) versus extracorporeal anastomosis (EA) after laparoscopic right hemicolectomy for cancer. The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Studies published from 2009 to 2012 that compare IA and EA after laparoscopic right hemicolectomy were identified. The included non-randomized studies were assessed for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network. Intraoperative, early postoperative, and postoperative recovery outcomes were compared using weighted mean differences and odds ratios. Five non-randomized controlled trials published between 2009 and 2011, comprising 425 patients, were included in this analysis. IA was associated with significant faster bowel movement, faster first flatus, shorter time to solid diet, decreased use of analgesics, and shorter duration of the hospital stay. No differences were observed for nasogastric tube reintroduction rate, operative time, incision length, number of nodes harvested, intraoperative complications, mortality, non-surgical site complications, surgical site complications (anastomotic leakage, anastomotic bleeding, wound infection, ileus), reintervention, and readmission rate. Even when the limitations are taken into account due to the observational nature of the included studies, the results suggest that the IA after laparoscopic right hemicolectomy for cancer results in better postoperative recovery outcomes, such as shorter hospital stay, faster bowel movement recovery, faster first flatus, faster time to solid diet, and lesser analgesic usage.

Minimum 3-Year Outcomes in Patients with Lumbar Spinal Stenosis after Bilateral Microdecompression by Unilateral or Bilateral Laminotomy

ObjectiveLumbar spine stenosis (LSS) can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Minimally invasive surgery has come to be more commonly used for the treatment of LSS. The current study describes outcomes of bilateral microdecompression by unilateral or bilateral laminotomy (BML) for degenerative LSS after a minimum follow-up period of 3 years and investigates factors that result in a poor outcome.MethodsTwenty-one patients who were followed-up for at least 3 years were included in this study. For clinical evaluation, the Japanese Orthopedic Association (JOA) scoring system for low back pain was used. The modified grading system of Finneson and Cooper was used for outcome assessment. Radiographic evaluation was also performed for spondylolisthesis, sagittal rotation angle, and disc height.ResultsTwenty-one patients (10 men, 11 women) aged 53-82 years (64.1±8.9 years) were followed-up for a minimum of 3 years (36-69 months). During follow-up, two patients underwent reoperation. Average preoperative JOA score and clinical symptoms, except persistent low back pain, improved significantly at the latest follow-up. There were no significant differences in radiological findings preoperatively and postoperatively. Thirteen patients (61.9%) had excellent to fair outcomes.ConclusionBML resulted in a favorable and persistent outcome for patients with degenerative LSS without radiological instability over a mid-term follow-up period. Persistent low back pain unrelated to postoperative instability adversely affects mid-term outcomes.

Long-term neurologic outcome of hemilaminectomy and disk fenestration for treatment of dogs with thoracolumbar intervertebral disk herniation: 831 cases (2000–2007)

To determine the proportion of dogs with thoracolumbar intervertebral disk herniation (IVDH) that successfully recovered following hemilaminectomy and fenestration, the time to ambulation (TTA) in affected dogs after surgery, and the frequency of urinary and fecal incontinence in recovered dogs and to document long-term complications. Retrospective case series. 831 dogs with thoracolumbar IVDH treated by hemilaminectomy and concomitant disk fenestration by the same surgeon. For all dogs, neurologic deficits before surgery had been assessed with a modified grading system. Dogs were reexamined after surgery over a period of 3 to 6 months, and follow-up evaluation was performed at > 12 months. The proportion of dogs that neurologically improved after surgery, TTA, and incidence of fecal or urinary incontinence in recovered dogs were compared among dogs with various grades of neurologic dysfunction before surgery. Of 831 dogs, 122 had unsuccessful outcomes and 709 had successful outcomes. Of 620 dogs with intact deep nociception before surgery, 606 (97.7%) were ambulatory after surgery. Despite maintaining the ability to walk, 7 dogs were judged to have an unsuccessful outcome because the severity of ataxia did not improve. Of 211 paraplegic dogs with loss of deep nociception, 110 (52.1%) dogs became ambulatory after surgery. Long-term complications included incontinence, permanent neurologic deterioration, and self-mutilation. Dogs with paraplegia before surgery had a higher frequency of urinary or fecal incontinence, compared with dogs that were ambulatory. Prognosis for dogs with thoracolumbar IVDH that retain deep nociception in at least 1 of the pelvic limbs or tail before surgery was good.