Classification System Research Articles

Mental Health Diagnoses Risk Among Children and Young Adults With Cerebral Palsy, Chronic Conditions, or Typical Development

Mental health (MH) issues in children with cerebral palsy (CP) are poorly understood compared with other pediatric populations. To examine MH diagnosis code assignment among children and young adults with CP and compare with typically developing (TD) and chronic condition (CC) pediatric populations. This case-control study used International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to create a CP case set and CC and TD control sets using electronic health record data of children and young adults from a large tertiary care children's hospital in the midwestern United States between 2010 and 2022. Case-control matching was performed to control for demographic factors. Data were analyzed from June to December 2023. All MH diagnosis codes were mapped to ICD-10-CM and categorized using Clinical Classifications Software Refined (CCSR). The incidence rates of MH CCSR categories were calculated. Descriptive and comparative statistics were used to evaluate the significance and odds associated with factors. Data from 216 794 individuals (mean [SD] baseline age, 4.3 [5.1] years; 118 562 [55%] male) were analyzed, including 3544 individuals with CP, 142 160 individuals with CC, and 71 080 TD individuals. The CP cohort spread across Gross Motor Function Classification System (GMFCS) levels I (981 individuals [28%]), II (645 individuals [18%]), III (346 individuals [10%]), IV (502 individuals [14%]), and V (618 individuals [17%]). Rates varied significantly for anxiety (824 individuals with CP [23%]; 25 877 individuals with CC [9%]; 6274 individuals with TD [18%]), attention-deficit/hyperactivity disorder (534 individuals with CP [15%]; 22 426 individuals with CC [9%]; 6311 individuals with TD [16%]); conduct or impulse disorder (504 individuals with CP [14%]; 13 209 individuals with CC [5%]; 3715 individuals with TD [9%]), trauma or stress disorders (343 individuals with CP [10%]; 18 229 individuals with CC [8%]; 5329 individuals with TD [13%]), obsessive-compulsive disorder (251 individuals with CP [7%]; 3795 individuals with CC [1%]; 659 individuals with TD [3%]), depression (108 individuals with CP [3%]; 12 224 individuals with CC [5%]; 4007 individuals with TD [9%]), mood disorders (74 individuals with CP [2%]; 4355 individuals with CC [2%]; 1181 individuals with TD [3%]), and suicidal ideation (72 individuals with CP [2%]; 7422 individuals with CC [5%]; 3513 individuals with TD [5%]). There was significant variation in odds of MH diagnoses by GMFCS level (I-II vs III-V: odds ratio [OR], 1.23; 95% CI, 1.09-1.40; P = .001). Among individuals with CP, males were more likely than females to have diagnosis codes for conduct or impulse disorders (OR, 1.41; 95% CI, 1.16-1.73) and attention-deficit/hyperactivity disorder (OR, 1.41 [95% CI, 1.15-1.73]). Black individuals, compared with White individuals, were more likely to have diagnoses for obsessive-compulsive disorder (OR, 1.57 [95% CI, 1.14-2.16]), other mood disorders (OR, 1.85 [95% CI, 1.01-3.38]), and trauma or stress disorders (OR, 1.94 [95% CI, 1.44-2.63]). Odds for trauma or stress disorders were elevated for individuals who identified as other races compared with White individuals (OR, 2.80 [95% CI, 2.03-3.87]). In this case-control study of children and young adults with CP and matched comparisons, anxiety and conduct or impulse diagnoses were higher in individuals with CP. The lower diagnosis rates of depression and suicidal ideation may indicate underdiagnosis among individuals with CP. There is likely a need for assessment tools that are more suitable for children with CP.

The diabetic sausage toe: Prevalence, presentation and outcomes.

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow-up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems.

Hierarchical-modular framework for habitat mapping through systematic and informed integration of remote sensing data with contextual information

Accurate and up-to-date habitat maps at national or regional levels are critical for informing conservation and restoration actions. Land cover maps generated from Earth Observation (EO) data can, to varying degrees, indicate the extent of some habitat categories but these are often insufficient in terms of the level of detail required. This study introduces a hierarchical-modular framework based on the globally applicable Food and Agriculture Organization (FAO) Land Cover Classification System (LCCS) whereby the land cover classes can be systematically translated to habitat categories and further differentiated by referencing contextual information and expert knowledge. Application is showcased for Wales (United Kingdom) where 10 m spatial resolution land cover maps were first constructed nationally from time-series of Sentinel-1C-band radar and − 2 optical data (2018–2020). The contextual datasets derived from non-EO sources were utilised to associate dominant vegetation types to detailed habitat classes.The accuracy assessment done using field survey data highlights that habitat classes directly derived from EO, including cultivated/managed and forest types, demonstrated higher mapping accuracies (>70% User's and Producer's Accuracies) compared to those that were more heavily dependent on non-EO-derived contextual information. These included neutral grasslands and fen/marsh/swamp that demonstrated lower accuracies (<20%) but also other detailed wetland classes (user's and producer's accuracies ranging from 25 to 60%). These reduced accuracies were largely associated with discrepancies in the contextual datasets used for their differentiation and mapping, and those integrated within field validation datasets. Dependency on contextual datasets diminished as detailed habitat maps were generalized into broader categories. The study proposes that, for enhanced habitat mapping, efforts should focus not only on EO data but also on maximising the accuracy and minimizing inconsistencies in contextual datasets as well as taxonomical systems. The flexible structure of the FAO LCCS hierarchical framework is also highlighted, emphasizing its adaptability for future improvements in habitat mapping by incorporating contextual datasets and more advanced algorithms that can improve EO-derived land cover descriptions.

Human Factors in General Aviation Loss of Control: Survey of Pilot Experiences

Inflight loss of control (LOC-I) is a major cause of general aviation (GA) accidents. Previous studies have identified LOC-I causes from sources such as the National Transportation Safety Board (NTSB) database. NTSB GA accident reports include limited detail on human factors. Getting pilots’ perspectives from other sources, such as surveys, may reveal insights into pilot actions and conditions. This study investigates the role of human factors in LOC-I by analyzing demographics in NTSB accidents and conducting a survey of pilots’ LOC-I experiences based on the Human Factors Analysis and Classification System framework. Note that 80% of the LOC-I events shared by the pilots involved pilot error, most of which were skill-based and decision errors. About one-quarter of pilots mentioned that their instructor had not prepared them well or taught them methods to recover from LOC-I. Several pilots mentioned that, because of their lack of LOC-I recovery training, they could not recover from LOC-I. The study helped in identifying specific pilot errors and issues in training that were not mentioned explicitly in the NTSB reports. Findings from the study may help improve training methods and operating procedures for GA pilots to prevent loss of control in the future.

Oncological Outcomes of Transoral Laser Microsurgery for Early Stage Glottic Cancer with Involvement of the Anterior Commissure.

To assess the value of carbon dioxide transoral laser microsurgery (CO2 TOLMS) for early-stage glottic cancer with special regard to involvement of the anterior commissure (AC). Single-center retrospective cohort study. Grade-A tertiary hospital. A retrospective analysis of patients with early-stage (Tis-T2) glottic cancer who underwent CO2 TOLMS. All patients had at least 2 years of follow-up. The univariate and multivariate survival analyses were used to identify the risk factors for recurrence and the Kaplan-Meier method was used to analyze OS and DSS rates. A total of 102 patients were included in the study. Eleven patients (10.78%) had recurrence. The univariate analysis showed that the recurrence was associated with the AC classification, T staging, tumor size, and tobacco use (P < .05). However, on multivariate analysis, the AC classification was the only independent risk factor for recurrence (P < .001, HR = 3.179). AC classification were distributed as follows: 59 (57.84%) AC0, 29 (28.43%) AC1, 8 (7.84%) AC2, and 6 (5.88%) AC3, 2-year/5-year OS and DSS rates were progressively reduced in the AC0, AC1, AC2, and AC3 groups (P < .001). At the same T staging, the OS rates incrementally decreased as the level of involvement of the AC became higher (P = .004). CO2 TOLMS is an effective treatment for early-stage glottic cancer. AC involvement is an independent risk factors for recurrence and poor prognosis. The AC classification system may be better at grading the prognosis of patients with early-stage glottic cancer and has prognostic value independent of T staging.

Preoperative gastric volume assessment using ultrasound in cerebral palsy pediatric patients: a prospective observational study

BackgroundAlthough cerebral palsy is a risk factor for aspiration, there is insufficient research on residual gastric volume after preoperative fasting in children with cerebral palsy. We evaluated the incidence of a full stomach by ultrasound assessment of the gastric volume in children with cerebral palsy who underwent orthopedic surgery after preoperative fasting. MethodsThe patients fasted for 8 h for solid foods and 2 h for clear liquids. We obtained the gastric antral cross-sectional area using ultrasound in the semi-recumbent and right lateral decubitus positions. A calculated stomach volume > 1.5 mL.kg−1 was considered as full, which poses a high aspiration risk. The primary outcome was the incidence of full stomach, and the secondary outcomes were the qualitative gastric volume, correlation of disease severity categorized according to the Gross Motor Function Classification System with the residual gastric volume, gastric volume per body weight, and qualitative gastric volume. ResultsThirty-seven pediatric patients with cerebral palsy, scheduled for elective orthopedic surgery, were included for analysis. Full-stomach status was observed in none, and the gastric volume per body weight was 0.5 (0.4–0.7) mL.kg−1. No significant differences were observed in the residual gastric volume (p = 0.114), gastric volume per body weight (p = 0.117), or qualitative grade of gastric volume (p = 0.642) in relation to disease severities. ConclusionChildren with cerebral palsy who fasted preoperatively had empty or nearly empty stomachs. Further studies are required to determine the optimal fasting duration for such children.

Enhancing the solubility of carbamazepine using ionic liquids: An experiment and theoretical calculation

This work investigates the solubility and dissolution mechanism of the insoluble drug, carbamazepine (CBZ), classified as class II drug in the Biopharmaceutical Classification System, in environmentally friendly solvent ionic liquids (ILs). The COSMO-RS model is used to identify suitable ILs for solubilizing CBZ. Experimental data of six ILs confirms the accuracy of the model, validating its usefulness for IL selection. The solubility of CBZ is influenced by both the anionic structure and temperature. Cytotoxicity tests on HUVEC and GES-1 cells show that all ILs are safe for CBZ dissolution. Based on solubility and toxicity data, [EMIM][Ac] is determined to be the optimal IL.The dissolution mechanism of CBZ in ILs is explored using the σ-profile calculated from the COSMO-RS model and quantum chemical (QC) analysis. ILs with anions that have effective hydrogen bond (HB) acceptability ([Ac]-) are found to be the most efficient solvents for CBZ solvation. ILs with longer alkyl chains in the imidazole cations exhibit reduced polarity, increasing their affinity with CBZ. Therefore, [EMIM][Ac] is the superior IL choice due to its moderate polarity in [EMIM]+ and ideal cationic characteristics with long alkyl chains, along with the strong HB acceptability of [Ac]- anions. The findings have significant implications for choosing appropriate solvents, namely ionic liquids, for CBZ, as well as for selecting solvents with comparable structures for other medicines.

Refining Penile Trauma Management: Introduction of the Penile Trauma Score

ObjectivesTo introduce the Penile Trauma Score (PTS), a new statistically driven classification system aimed at enhancing the management of penile trauma by providing clinically relevant treatment protocols. MethodsA retrospective review was conducted of 34 men with penetrating penile injuries at the Elvis Presley Level 1 Trauma Center, Memphis, from January 2014 to December 2016. Variables assessed included injury mechanism, location, depth, and follow-up outcomes related to voiding and erectile function. Odds-ratios were calculated using superficial penile injury as the control group. ResultsBased on physical examination findings and odds ratios calculated, the PTS was developed. Results indicated that higher PTS scores necessitated surgical intervention, while lower scores could be managed nonoperatively. Follow-up showed no missed injuries or reported dysfunctions, validating the PTS's effectiveness. ConclusionsThe Penile Trauma Score (PTS) represents an important modification in the classification and management of penile trauma. By integrating practical, easily identifiable injury characteristics, the PTS facilitates more streamlined surgical decision-making and potentially reduces unnecessary diagnostic procedures. However, further prospective studies with larger sample sizes and longer follow-up are needed to fully validate the PTS’s clinical utility.

Challenges in Diagnosis of Non-A Non-B Acute Aortic Dissection

ObjectiveNon-A non-B (NANB) aortic dissections are uncommon and frequently unrecognized diseases.However, their proper identification is crucial given the unpredictable behaviour of the dissected aorta with potential mortality and increased morbidity. We investigate the accuracy of radiological computed angio-tomography (CTA) reports in the diagnosis of acute NANB and the risk related to delayed recognition or misdiagnosis. MethodsThe pre-treatment contrast CTA of all consecutive patients admitted with acute aortic dissection (AAD) in a University Hospital in London (UK) between January 2017 and May 2023 were reviewed to retrospectively verify the accuracy of CTA reports in the diagnosis of NANB AAD (B1-2D The risk related to the delayed diagnosis (morbidity, mortality, and hospital re-admissions) were evaluated as secondary outcomes. The study was conducted according to the STROBE guidelines. ResultsOverall, 588 aortic CTAs were reviewed for a total of n=393 (66.8%) type A AADs, n=171 (29%) type B AADs and n=25(4.3%) NANB AADs (n=16, 64% men, mean age 60.56, DS+/- 14.6 years). While no case of misdiagnosis was identified in Type A or B AAD groups, in NANBs only about a third of cases (n=9, 36%) were immediately indicated as “NANB” (n=2, 8%) or “B with retrograde extension into the arch” (n=7, 28%), n=8 cases (32%) were described generically as “arch dissections” (n=6, 24%) or “type A and B” AAD (n=2, 8%). The remaining 32% of patients received a diagnosis that did not include mention of the arch, as n=6(24%) cases were reported to be “type A” and n=2(8%) to be “type B” AADs. Despite the heterogeneity of terms used to describe NANB AAD, no case of cardiac tamponade, new onset malperfusion nor neurological complications were reported, and no sudden death nor home-discharge and readmission while waiting for the proper diagnosis. ConclusionThe heterogeneity of terms used to describe NANB aortic dissection highlights the need for increased awareness, adoption of in guideline based classification systems, and further education to better understand and correctly address this challenging entity, minimizing misdiagnosis in ambiguous or difficult cases.

ANALISA STABILISASI FISIK TANAH PADA PEKERJAAN JALAN GAMPONG ALUE DUA KOTA LANGSA

Soil characteristics depend on soil texture, density, environmental conditions and other factors. The use of selected embankment materials aims to increase the stability of the subgrade in the supporting layer (Capping Layer). The aim of this research is to determine the physical characteristics of the selected embankment soil, determine the soil density value in the laboratory and determine the soil density value in the field. The methods used to determine the physical properties of soil are water content testing, specific weight testing, Atterberg limit testing, sieve analysis testing, soil compaction in the laboratory is carried out using the standard proctor testing method, soil density testing in the field is carried out using the sandcone test method. The results of the soil compaction test in the standard proctor laboratory obtained a max ?d value of 1.397 grams/cm3 and an optimum W of 19.49%. In the Sandcone Test, the values for the degree of field density were obtained, namely STA 0+000 of 115%, STA 0+050 of 106%, STA 0+100 of 103%. The results of testing the physical properties of selected embankment soil include field water content of 16.70%, specific weight (Gs) of 2.66, plasticity index (PI) of 2.13% and sieve analysis that passed number 200 was 10.93%. Based on the AASHTO classification system, it can be concluded that the selected embankment land used in Mulia Indah Hamlet, Alue Dua Village, Langsa Baro District, is included in group A-2-4.

An updated classification of the anatomical variations of the internal iliac venous drainage system: Surgical implications for anterior lumbar spinal approaches

BackgroundAdvanced pelvic surgery is associated with potential vascular risks. The aim of this study was to complete the existing classification of the anatomical variations of the internal iliac veins encountered on a series of preoperative angio CT with a view to performing anterior lumbar spine surgery. Materials and MethodsIn this monocentric retrospective study conducted between 2010 and 2020, all preoperative angio CT performed before an anterior lumbar surgery were systematically analyzed. All the abnormalities of the iliac veins were referenced in an updated classification system. Results910 patients (431 men and 479 women) with a mean age of 49 years [16–88] were included. Apart from the most common variant in the population (type I), 64 anatomical variations (7.0%) in the iliac veins were reported and classified according to our new classification. The percentage of coverage of the L4-L5 intervertebral disc is 52%, including 32% by the inferior vena cava before the confluence of the common iliac veins. At the level of the L5-S1 intervertebral disc, the coverage is 30% (same distribution between left and right). ConclusionsVariations of the iliac veins are frequent, and contrary to what one might think, and even if they can represent an anatomical trap during surgery, certain variations do not limit anterior lumbar spine surgery and are not more associated with vascular complications. Nevertheless, these anatomical variations must be known before any advanced pelvic surgery. Depending on their distribution, level L5-S1 is more suitable for ALIF, level L4-L5 for OLIF approaches.

Lack of Association Between Donor-Derived Cell-Free DNA and Cardiac Allograft Vasculopathy.

Cardiac allograft vasculopathy (CAV) is a leading cause of death after heart transplantation (HT). We evaluated donor-derived cell-free DNA (dd-cfDNA) as a noninvasive biomarker of CAV development after HT. The INSPIRE registry at the Intermountain Medical Center was queried for stored plasma samples from HT patients with and without CAV. At Stanford University, HT patients with CAV (cases) and without CAV (controls) were enrolled prospectively, and blood samples were collected. All the samples were analyzed for dd-cfDNA using the AlloSure assay (CareDx, Inc.). CAV was defined per the ISHLT 2010 standardized classification system. Univariate associations between patient demographics and clinical characteristics and their CAV grade were tested using chi-square and Wilcoxon rank sum tests. Associations between their dd-cfDNA levels and CAV grades were examined using a nonparametric Kruskal-Wallis test. A total of 69 pts were included, and 101 samples were analyzed for dd-cfDNA. The mean age at sample collection was 58.6±13.7 years; 66.7% of the patients were male, and 81% were White. CAV 0, 1, 2, and 3 were present in 37.6%, 22.8%, 22.8%, and 16.8% of included samples, respectively. The median dd-cfDNA level was 0.13% (0.06, 0.33). The median dd-cfDNA level was not significantly different between CAV (-) and CAV (+): 0.09% (0.05%-0.32%) and 0.15% (0.07%-0.33%), respectively, p=0.25 and with similar results across all CAV grades. In our study, dd-cfDNA levels did not correlate with the presence of CAV and did not differ across CAV grades. As such, dd-cfDNA does not appear to be a reliable noninvasive biomarker for CAV surveillance.

Taxonomic and environmental significance of Poaceae and Cyperaceae phytoliths from the Northern Territory, Australia

Phytoliths are a valuable tool for reconstructing past grassy ecosystems. However, they are not commonly utilised as a palaeoecological proxy in Australia due to a lack of modern reference material from plants, particularly grasses. This study analyses phytolith reference material from 49 grass and 4 sedge species from the Northern Territory, Australia. This is used to develop a detailed classification scheme and multivariate morphospace analysis to examine taxonomic and ecological patterns of grass silica short cell phytolith (GSSCP) production within the Poaceae (grass) family. The results of detrended correspondence analysis show that grass subfamilies, tribes, and genera in this region can be differentiated through phytolith assemblages, and that these assemblages reflect the environmental conditions associated with various grass taxa. The developed detailed classification system and examination of co-occurrence patterns reduces redundancy of phytolith morphotypes across subfamilies, improving taxonomic and palaeoecological resolution of phytolith assemblages. Finally, based on the results of this study, a detailed scheme is presented for palaeoecological reconstructions in grassy ecosystems of northern Australia.

Osteoporotic vertebral compression fracture (OVCF) detection using artificial neural networks model based on the AO spine-DGOU osteoporotic fracture classification system

BackgroundOsteoporotic Vertebral Compression Fracture (OVCF) substantially reduces a person's health-related quality of life. Computer Tomography (CT) scan is currently the standard for diagnosis of OVCF. The aim of this paper was to evaluate the OVCF detection potential of artificial neural networks (ANN). MethodsModels of artificial intelligence based on deep learning hold promise for quickly and automatically identifying and visualizing OVCF. This study investigated the detection, classification, and grading of OVCF using deep artificial neural networks (ANN). Techniques: Annotation techniques were used to segregate the sagittal images of 1,050 OVCF CT pictures with symptomatic low back pain into 934 CT images for a training dataset (89%) and 116 CT images for a test dataset (11%). A radiologist tagged, cleaned, and annotated the training dataset. Disc deterioration was assessed in all lumbar discs using the AO Spine-DGOU Osteoporotic Fracture Classification System. The detection and grading of OVCF were trained using the deep learning ANN model. By putting an automatic model to the test for dataset grading, the outcomes of the ANN model training were confirmed. ResultsThe sagittal lumbar CT training dataset included 5,010 OVCF from OF1, 1942 from OF2, 522 from OF3, 336 from OF4, and none from OF5. With overall 96.04% accuracy, the deep ANN model was able to identify and categorize lumbar OVCF. ConclusionsThe ANN model offers a rapid and effective way to classify lumbar OVCF by automatically and consistently evaluating routine CT scans using AO Spine-DGOU osteoporotic fracture classification system.

Study of Weathering and Rock Mass Quality using the Geological Strength Index (GSI) method on the Tuntun mine road Banggai Regency Central Sulawesi Province

Abstract The mining road in the Tuntun area of Banggai Regency, Central Sulawesi Province has experienced a landslide. The mining road mitigation engineering is a concern for the sustainability of road use. The study area is composed of peridotite rocks which are included in the Ophiolite (Ku) rock formation, where these rocks undergo a very strong deformation process by showing the fractured rock conditions. The Study of Weathering and Rock Mass Quality Using the Geological Strength Index (GSI) Method on this mine road is the focus of this research. The Geological Strength Index (GSI) is a rock mass classification system developed to assist the inaccurate Rock Mass Rating System (RMR) in determining the quality of rock masses that have very poor conditions or have undergone very strong rock deformation. using the GSI value by using two quantitative parameters, namely the condition of the discontinuity plane and the density of the discontinuity plane. The value of the Geological Strength Index (GSI) at location points 1, 2, 3, 4 and 5 is 32,17,12,2, 33.4 and 23. The rock mass value indicates that the rock mass quality in the study area has poor rock mass quality. to very bad. The results of this investigation become a reference in the method of handling slopes on mining roads.

The CHD Severity Classification System: Development of a Tool to Assist With Disease Stratification for CHD Research

The CHD Severity Classification System: Development of a Tool to Assist With Disease Stratification for CHD Research

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation.

There is no consensus on optimal management of pilonidal disease. Surgical practice is varied, and existing literature is mainly single-centre cohort studies of varied disease severity, interventions and outcome assessments. A prospective cohort study to determine: • disease severity and intervention relationship • most valued outcomes and treatment preference by patients • recommendations for policy and future research. Observational cohort study with nested mixed-methods case study. Discrete choice experiment. Clinician survey. Three-stage Delphi survey for patients and clinicians. Inter-rater reliability of classification system. Thirty-one National Health Service trusts. Patients aged > 16 years referred for elective surgical treatment of pilonidal disease. Surgery. Pain postoperative days 1 and 7, time to healing and return to normal activities, complications, recurrence. Outcomes compared between major and minor procedures using regression modelling, propensity score-based approaches and augmented inverse probability weighting to account for measured potential confounding features. Clinician survey: There was significant heterogeneity in surgeon practice preference. Limited training opportunities may impede efforts to improve practice. Cohort study: Over half of patients (60%; N = 667) had a major procedure. For these procedures, pain was greater on day 1 and day 7 (mean difference day 1 pain 1.58 points, 95% confidence interval 1.14 to 2.01 points, n = 536; mean difference day 7 pain 1.53 points, 95% confidence interval 1.12 to 1.95 points, n = 512). There were higher complication rates (adjusted risk difference 17.5%, 95% confidence interval 9.1 to 25.9%, n = 579), lower recurrence (adjusted risk difference -10.1%, 95% confidence interval -18.1 to -2.1%, n = 575), and longer time to healing (>34 days estimated difference) and time to return to normal activities (difference 25.9 days, 95% confidence interval 18.4 to 33.4 days). Mixed-methods analysis: Patient decision-making was influenced by prior experience of disease and anticipated recovery time. The burden involved in wound care and the gap between expected and actual time for recovery were the principal reasons given for decision regret. Discrete choice experiment: The strongest predictors of patient treatment choice were risk of infection/persistence (attribute importance 70%), and shorter recovery time (attribute importance 30%). Patients were willing to trade off these attributes. Those aged over 30 years had a higher risk tolerance (22.35-34.67%) for treatment failure if they could experience rapid recovery. There was no strong evidence that younger patients were willing to accept higher risk of treatment failure in exchange for a faster recovery. Patients were uniform in rejecting excision-and-leave-open because of the protracted nursing care it entailed. Wysocki classification analysis: There was acceptable inter-rater agreement (κ = 0.52, 95% confidence interval 0.42 to 0.61). Consensus exercise: Five research and practice priorities were identified. The top research priority was that a comparative trial should broadly group interventions. The top practice priority was that any interventions should be less disruptive than the disease itself. Incomplete recruitment and follow-up data were an issue, particularly given the multiple interventions. Assumptions were made regarding risk adjustment. Results suggest the burden of pilonidal surgery is greater than reported previously. This can be mitigated with better selection of intervention according to disease type and patient desired goals. Results indicate a framework for future higher-quality trials that stratify disease and utilise broad groupings of common interventions with development of a patient-centred core outcome set. This trial is registered as ISRCTN95551898. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/17/02) and is published in full in Health Technology Assessment; Vol. 28, No. 33. See the NIHR Funding and Awards website for further award information.

Inter-rater and intrarater reliability of superior labrum anterior to posterior lesion classification using MRa

BackgroundThe glenoid labrum is a fibrocartilaginous ring that affixes the joint capsule and ligaments of the glenohumeral joint2. Superior labrum anterior to posterior (SLAP) lesions are a subset of injuries that affect the superior glenoid labrum, most common in laborers and overhead-throwing athletes11. In 1990, Snyder et al classified SLAP lesions into one of four types10. Later, Maffet et al expanded this scale to include three additional subclassifications8. At present, arthroscopy is considered the gold standard for SLAP tear diagnosis5. Classification under arthroscopy has demonstrated low to moderate inter-rater reliability3. MRa is an alternate, less invasive test for diagnosing SLAP lesions. The reliability of MRa for diagnosing slap tears is uncertain. MethodsMR arthrograms were identified using the Picture Archiving and Communication System (PACS). In total, 273 shoulder arthrograms were reviewed, and 20 were selected with the desired pathology. Three orthopedic surgeons and three musculoskeletal radiologists were asked to classify the SLAP lesions into one of seven categories (Snyder & Maffet classification systems). Data was collected on two separate occasions at an interval of at least two months. Inter- and intra-rater reliability were calculated using Fleiss Kappa and Cohen's Kappa, respectively. ResultsBetween all raters, there was poor inter-rater reliability for each round of data collection (κ = .177, κ = .124 for rounds 1 and 2, respectively). Between orthopedic surgeons, there were poor levels of agreement (κ = -.056, κ = .114), whereas, between radiologists, there was fair to moderate agreement (κ = 0.479, κ = 0.340). Within orthopedic raters, κ values ranged from -0.059 to 0.125, indicating, at best, poor intra-rater reliability. Within radiologists, κ values ranged from 0.545 to 0.553, indicating moderate agreement within raters. The analysis determined that none of the orthopedic values for inter or intra-rater reliability could be deemed statistically different from zero. ConclusionOverall, classification using MRa resulted in significant disagreement between and within raters. Trained radiologists demonstrated higher overall levels of agreement than orthopedic surgeons. In summary, when using MRa to assess SLAP lesions, Snyder and Maffet classification demonstrates poor reliability by orthopedic surgeons and moderate reliability when used by musculoskeletal radiologists.

The History of Classification Systems for Periprosthetic Femoral Fractures: A Literature Review.

Periprosthetic femoral fractures (PPFFs) following total hip arthroplasty (THA) present a significant clinical challenge due to their increasing incidence with an aging population and evolving surgical practices. Historically, classifications were primarily based on anatomical fracture location, the stability of the implant, and bone quality surrounding the implant. We critically analyzed 25 classification systems, highlighting the emergence and adaptations of key systems such as the Vancouver classification system (VCS) and the Unified classification system (UCS), which are lauded for their simplicity and effectiveness yet require further refinement. VCS, developed in 1995, categorizes fractures based on the site, implant stability, and bone quality, and remains widely used due to its robust applicability across different clinical settings. Introduced in 2014, UCS expands the VCS to encompass all periprosthetic fractures with additional fracture types, aiming for a universal application. Despite their widespread adoption, these systems exhibit shortcomings, including the incomplete inclusion of all PPFF types and the imprecise assessment of implant stability and surrounding bone loss. These gaps can result in misclassification and suboptimal treatment outcomes. This paper suggests the necessity for ongoing improvements in classification systems to include emerging fracture types and refined diagnostic criteria, ensuring that they remain relevant to contemporary orthopedic practices and continue to facilitate the precise tailoring of treatment to patient-specific circumstances. This comprehensive historical review serves as a foundation for future innovations in classification systems, ultimately aiming to standardize PPFF treatment and improve patient prognosis.

The Role of Spinal Cord Compression in Predicting Intraoperative Neurophysiological Monitoring Events in Patients With Kyphotic Deformity: A Magnetic Resonance Imaging-Based Study

Objective: To establish a novel classification system for predicting the risk of intraoperative neurophysiological monitoring (IONM) events in surgically-treated patients with kyphotic deformity.Methods: Patients with kyphotic deformity who underwent surgical correction of cervicothoracic, thoracic, or thoracolumbar kyphosis in our center from July 2005 to December 2020 were recruited. We proposed a classification system to describe the morphology of the spinal cord on T2-weighted sagittal magnetic resonance imaging: type A, circular/symmetric cord with visible cerebrospinal fluid (CSF) between the cord and vertebral body; type B, circular/oval/symmetric cord with no visible CSF between the cord and vertebral body; type C, spinal cord that is fattened/deformed by the vertebral body, with no visible CSF between the cord and vertebral body. Furthermore, based on type C, the spinal cord compression ratio (CR) &lt; 50% was defined as the subtype C-, while the spinal cord CR ≥ 50% was defined as the subtype C+. IONM event was documented, and a comparative analysis was made to evaluate the prevalence of IONM events among patients with diverse spinal cord types.Results: A total of 294 patients were reviewed, including 73 in type A; 153 in type B; 53 in subtype C- and 15 in subtype C+. Lower extremity transcranial motor-evoked potentials and/or somatosensory evoked potentials were lost intraoperatively in 41 cases (13.9%), among which 4 patients with type C showed no return of spinal cord monitoring data. The 14 subtype C+ patients (93.3%) had IONM events. Univariate logistic regression analysis showed that patients with a type C spinal cord (subtype C-: odds ratio [OR], 10.390; 95% confidence interval [CI], 2.215–48.735; p = 0.003; subtype C+, OR, 497.000; 95% CI, 42.126– 5,863.611; p &lt; 0.001) are at significantly higher risk of a positive IONM event during deformity correction compared to those with a type A. In further multiple logistic regression analysis, the spinal cord classification (OR, 5.371; 95% CI, 2.966–9.727; p &lt; 0.001) was confirmed as an independent risk factor for IONM events.Conclusion: We presented a new spinal cord classification system based on the relative position of the spinal cord and vertebrae to predict the risk of IONM events in patients with kyphotic deformity. In patients with type C spinal cord, especially those in C+ cases, it is essential to be aware of potential IONM events, and adopt standard operating procedures to facilitate neurological recovery.