Updated Classification Research Articles

Benign chondrogenic tumors

The fifth edition of the 2020 WHO classification of tumors of soft tissue and bone tumors provides an updated classification scheme and essential diagnostic criteria for bone tumors. We focused on major changes about chondrogenic tumors that represent one of the most common tumors of the bone. The management of these tumors is based on observation, curettage and excision or surgical resection. In rare cases, benign tumors can undergo to malignant transformation. The aim of this paper is to review common chondrogenic tumors, osteochondroma, enchondroma (including enchondromatosis) and chondroblastoma, and to discuss the problems of interpretation of well-differentiated cartilage tumors.

Updated Parkinson's disease motor subtypes classification and correlation to CSF HVA and 5-HIAA levels (P3-11.005)

<h3>Objective:</h3> To update a motor subtypes classification using the MDS-UPDRS and determine if CSF neurotransmitter profiles (HVA and 5-HIAA) are different between MDS-UPDRS subtypes in a cohort from the Parkinson9s Progression Marker Initiative (PPMI). <h3>Background:</h3> Schiess <i>et al</i> designed a UPDRS motor classification of Parkinson9s Disease (PD) that has been widely used, but in the last decade, the field has moved towards the use of the MDS-UPDRS. <h3>Design/Methods:</h3> UPDRS and MDS-UPDRS scores were collected for 20 PD patients. Akinetic-rigid (AR), Tremor-dominant (TD), and Mixed (MX) subtypes were calculated using a UPDRS formula, and a new ratio was developed for MDS-UPDRS. This new formula was subsequently applied to 95 PD patients from the PPMI dataset, and subtyping was correlated to neurotransmitter levels. Data were analyzed using receiver operating characteristic models and ANOVA. <h3>Results:</h3> Compared to previous UPDRS classifications, the new MDS-UPDRS AR/TD ratios produced significantly different areas under the curves (AUC). The optimal sensitivity and specificity cutoff scores were ≥0.82 for TD, ≤0.71 for AR classifications and Mixed &gt;0.71 and &lt;0.82. Analysis of variance showed significant differences in 5-HIAA levels between the HC and AR group. Logistic models utilizing neurotransmitter levels and MDS-UPDRS motor scores showed significant AUCs for MDS-UPDRS classifications. <h3>Conclusions:</h3> This MDS-UPDRS motor subtype classification system provides a method to transition from the original UPDRS to the newer MDS-UPDRS and offers a reliable and quantifiable tool for monitoring disease progression that is supported by neurotransmitter levels. <b>Disclosure:</b> Dr. Suescun has nothing to disclose. Dr. Adams has stock in Medtronic. Dr. Block has nothing to disclose. Dr. Tharp has nothing to disclose. The institution of Prof. Ellmore has received research support from NIMH. Dr. Schiess has nothing to disclose.

Large B-Cell Lymphomas in the 5th Edition of the WHO-Classification of Haematolymphoid Neoplasms—Updated Classification and New Concepts

The family/class of the large B-cell lymphomas (LBCL) in the 5th edition of the World Health Organization (WHO) classification of haematolymphoid tumors (WHO-HAEM5) features only a few major changes as compared to the 4th edition. In most entities, there are only subtle changes, many of them only representing some minor modifications in diagnostic terms. Major changes have been made in the diffuse large B-cell lymphomas (DLBCL)/high-grade B-cell lymphomas (HGBL) associated with MYC and BCL2 and/or BCL6 rearrangements. This category now consists of MYC and BCL2 rearranged cases exclusively, while the MYC/BCL6 double hit lymphomas now constitute genetic subtypes of DLBCL, not otherwise specified (NOS) or of HGBL, NOS. Other major changes are the conceptual merger of lymphomas arising in immune-privileged sites and the description of LBCL arising in the setting of immune dysregulation/deficiency. In addition, novel findings concerning underlying biological mechanisms in the pathogenesis of the different entities are provided.

Histological Features of IgA Nephropathy in Pediatrics and the Magnitude of the Disease in Saudi Children.

This review addresses the microscopic features of immunoglobulin A nephropathy (IgA nephropathy), its prognostic variables in children, and measures to which extent these features and variables differ from adults. Furthermore, it describes the extent of this disease process among children in Saudi Arabia and the rest of the Arab countries and compares it with the data from the West and the Far East. All the original work described the histological features of pediatric IgA nephropathy, and studies involved in developing the prognostic classification of IgA nephropathy, Oxford Classification, were reviewed. Moreover, the studies describing the crescent prevalence and outcome in pediatric IgA nephropathy in addition to thrombotic microangiopathy association were studied. National studies describing the prevalence of pediatric IgA nephropathy and pediatric crescentic glomerulonephritis were tracked with an overview of the regional data from the rest of the Arab world. IgA nephropathy in children showed more glomerular proliferative changes and less glomerular vascular and tubule-interstitial chronic injury compared to adults. The reference study that described the association between thrombotic microangiopathy and IgA nephropathy did not include the pediatric age group. Moreover, it was found that the data from the Middle East was not encountered in developing the original and updated IgA nephropathy Oxford Classification. Furthermore, the prevalence of IgA nephropathy in children is described in the regional literature, but its histological features were not well detailed. Finally, the percentage of crescentic glomerulonephritis (GN) due to IgA nephropathy is less in our country compared to the West and concords with the Far East findings. A well-designed regional study addressing IgA nephropathy in Middle East children with a focus on histological features, association with crescent, and thrombotic microangiopathy and challenging the validity of the updated IgA nephropathy Oxford Classification is recommended.

RadioGraphics Update: Pictorial Guide to CAD-RADS 2.0

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

What is a digital nomad? Definition and taxonomy in the era of mainstream remote work

ABSTRACT Digital nomadism gradually expanded during the 2010s. Since the COVID-19 pandemic, remote work (a prerequisite to digital nomadism), suddenly became mainstream. In this new context the term digital nomadism is increasingly used in ways that are broader or different to its original conception. This paper reviews scientific literature and draws on the author’s ethnographic fieldwork to create an updated classification of contemporary digital nomadism that acknowledges the broad spectrum of individuals, groups, communities, identities, and imaginaries labelled with the term digital nomad. The paper updates the definition of digital nomadism and provides a new taxonomy which subdivides the digital nomad model into five distinct types: freelance digital nomads; digital nomad business owners; salaried digital nomads; experimental digital nomads and armchair digital nomads. It also proposes that six key variable themes should be applied to these classifications. These are: autonomy over mobility; homebase practices; domestic vs. transnational travel; legal legitimacy; work-life balance and coworking space usage. The taxonomy and the variable themes are proposed as a roadmap for future research and as a tool so researchers and policymakers can more accurately evaluate real-world examples of digital nomad context, motivation, practice, and impact.

PREVALENCE OF ATROPHIC GASTRITIS IN SYMPTOMATIC PATIENTS UNDERGOING GASTRIC BIOPSY IN A TERTIARY CARE CENTER OF NEPAL

Background: Atrophic gastritis and intestinal metaplasia are precancerous conditions associated with Helicobacter pylori infection. The prevalence of these conditions varies among countries and even among different regions in same country. There is limited data from central Nepal regarding these entities. The primary aim of this study was to assess the prevalence of atrophic gastritis in gastric biopsy of symptomatic patients. Methods: A prospective study which included all consecutive patients undergoing endoscopic gastric biopsy. Biopsies from body and antrum obtained as per Sydney protocol. Histopathological examination was done by a team of histopathologists and reported according to updated Sydney classification. Statistical software SPSS (version 26, SPSS Inc. Chicago, IL) and STATA 14 were used for statistical analysis. Results: Of 113 consecutive patients, 103 were included for final analysis (female: 59.2% and mean age: 46.29 ± 16.54 years). Dyspepsia [EPS: 69 (66.9%) and PDS:19 (18.4%)] followed by GERD in 21 (20.3%) were the commonest presentations. On histology, atrophic gastritis was present in 101 (98.05%) patients with mild-, moderate-, and severe AG seen in 12 (11.8%), 87 (86.1%), and 2 (1.9%) respectively. Prevalence of AG was not different in patients with or without H. pylori infection (p=0.10). Intestinal metaplasia was present in 13 (12.62%). Helicobacter pylori were present in 58 (56.3%) with prevalence in antrum and body being 57 (55.3%) vs. 41 (39.8%), p=0.02. Conclusions: Atrophic gastritis, IM, and H. pylori infection is highly prevalent in symptomatic patients and the prevalence in younger population is equally high compared to older population.

Newly Recognized CNS Tumors in the 2021 World Health Organization Classification: Imaging Overview with Histopathologic and Genetic Correlation.

In 2021, the World Health Organization released an updated classification of CNS tumors. This update reflects the growing understanding of the importance of genetic alterations related to tumor pathogenesis, prognosis, and potential targeted treatments and introduces 22 newly recognized tumor types. Herein, we review these 22 newly recognized entities and emphasize their imaging appearance with correlation to histologic and genetic features.

Top-Down Genomic Surveillance Approach To Investigate the Genomic Epidemiology and Antibiotic Resistance Patterns of Enterococcus faecium Detected in Cancer Patients in Arkansas.

Control of hospital-associated Enterococcus faecium infection is a strenuous task due to the difficulty of identifying transmission routes and the persistence of this nosocomial pathogen despite the implementation of infection control measures that have been successful with other important nosocomial pathogens. This study provides a comprehensive analysis of over 100 E. faecium isolates collected from 66 cancer patients at the University of Arkansas for Medical Sciences (UAMS) between June 2018 and May 2019. In the top-down approach used in this study, we employed, in addition to the 106 E. faecium UAMS isolates, a filtered set of 2,167 E. faecium strains from the GenBank database to assess the current population structure of E. faecium species and, consequently, to identify the lineages associated with our clinical isolates. We then evaluated the antibiotic resistance and virulence profiles of hospital-associated strains from the species pool, focusing on antibiotics of last resort, to establish an updated classification of high-risk and multidrug-resistant nosocomial clones. Further investigation of the clinical isolates collected from UAMS patients using whole-genome sequencing analytical methodologies (core genome multilocus sequence typing [cgMLST], core single nucleotide polymorphism [coreSNP] analysis, and phylogenomics), with the addition of patient epidemiological data, revealed a polyclonal outbreak of three sequence types occurring simultaneously in different patient wards. The integration of genomic and epidemiological data collected from the patients increased our understanding of the relationships and transmission dynamics of the E. faecium isolates. Our study provides new insights into genomic surveillance of E. faecium to assist in monitoring and further limiting the spread of multidrug-resistant E. faecium. IMPORTANCE Enterococcus faecium is a member of the gastrointestinal microbiota. Although its virulence is low in healthy, immunocompetent individuals, E. faecium has become the third leading cause of health care-associated infections in the United States. This study provides a comprehensive analysis of over 100 E. faecium isolates collected from cancer patients at the University of Arkansas for Medical Sciences (UAMS). We employed a top-down analytical approach (from population genomics to molecular biology) to classify our clinical isolates into their genetic lineages and thoroughly evaluate their antibiotic resistance and virulence profiles. The addition of patient epidemiological data to the whole-genome sequencing analytical methodologies performed in the study allowed us to increase our understanding of the relationships and transmission dynamics of the E. faecium isolates. This study provides new insights into genomic surveillance of E. faecium to help monitor and further limit the spread of multidrug-resistant E. faecium.

Episodic Ataxias: Primary and Secondary Etiologies, Treatment, and Classification Approaches.

Episodic ataxia (EA), characterized by recurrent attacks of cerebellar dysfunction, is the manifestation of a group of rare autosomal dominant inherited disorders. EA1 and EA2 are most frequently encountered, caused by mutations in KCNA1 and CACNA1A. EA3-8 are reported in rare families. Advances in genetic testing have broadened the KCNA1 and CACNA1A phenotypes, and detected EA as an unusual presentation of several other genetic disorders. Additionally, there are various secondary causes of EA and mimicking disorders. Together, these can pose diagnostic challenges for neurologists. A systematic literature review was performed in October 2022 for 'episodic ataxia' and 'paroxysmal ataxia', restricted to publications in the last 10 years to focus on recent clinical advances. Clinical, genetic, and treatment characteristics were summarized. EA1 and EA2 phenotypes have further broadened. In particular, EA2 may be accompanied by other paroxysmal disorders of childhood with chronic neuropsychiatric features. New treatments for EA2 include dalfampridine and fampridine, in addition to 4-aminopyridine and acetazolamide. There are recent proposals for EA9-10. EA may also be caused by gene mutations associated with chronic ataxias (SCA-14, SCA-27, SCA-42, AOA2, CAPOS), epilepsy syndromes (KCNA2, SCN2A, PRRT2), GLUT-1, mitochondrial disorders (PDHA1, PDHX, ACO2), metabolic disorders (Maple syrup urine disease, Hartnup disease, type I citrullinemia, thiamine and biotin metabolism defects), and others. Secondary causes of EA are more commonly encountered than primary EA (vascular, inflammatory, toxic-metabolic). EA can be misdiagnosed as migraine, peripheral vestibular disorders, anxiety, and functional symptoms. Primary and secondary EA are frequently treatable which should prompt a search for the cause. EA may be overlooked or misdiagnosed for a variety of reasons, including phenotype-genotype variability and clinical overlap between primary and secondary causes. EA is highly treatable, so it is important to consider in the differential diagnosis of paroxysmal disorders. Classical EA1 and EA2 phenotypes prompt single gene test and treatment pathways. For atypical phenotypes, next generation genetic testing can aid diagnosis and guide treatment. Updated classification systems for EA are discussed which may assist diagnosis and management.

Impact of microscopic extrathyroidal extension on differentiated thyroid cancer post-surgical risk of recurrence: a retrospective analysis

PurposeIn the last edition of the American Joint Committee on Cancer (AJCC) staging system, differentiated thyroid cancers (DTC) showing microscopic extrathyroidal extension (mETE) are considered comparable to intrathyroidal cancers for their clinical behavior and prognosis. The aim of the study is to evaluate the impact of this updated assessment of T, when applied to the postoperative recurrence risk stratification, according to the American Thyroid Association Guidelines (ATA-RR).MethodsOne-hundred DTC patients who underwent total thyroidectomy were retrospectively evaluated. The downstaging of mETE was introduced in the definition of T, and the updated classification defined as modified ATA-RR (ATAm-RR). For each patient, post-surgical basal and stimulated thyroglobulin (Tg) levels, neck ultrasound (US) and post-ablative 131-I whole body scan (WBS) reports were considered. The predictive performance (PP) of disease recurrence was calculated both for each single parameter, as well as for all of them.ResultsAccording to ATAm-RR classification, 19/100 patients (19%) were downstaged. ATA-RR proved a significant PP for disease recurrence (DR) (sensitivity 75.0%, specificity 63.0%, p = 0.023). However, ATAm-RR performed slightly better due to an increased specificity (sensitivity 75.0%, specificity 83.7%, p < 0.001). For both classifications, the PP was optimal when all the above-mentioned predictive parameters were considered.ConclusionOur results suggest that the new assessment of T considering mETE resulted in a downgrading of ATA-RR class in a significant number of patients. This provides a better PP for disease recurrence, and the best PP was obtained when considering the whole predictive variables together.

Paediatric Pulmonary hypertension

Pulmonary hypertension (PH) is a rare disease in newborns, infants, and children that is associated with significant morbidity and mortality. In the majority of pediatric patients, PH is idiopathic or associated with congenital heart disease and rarely is associated with other conditions such as connective tissue or thromboembolic disease. Incidence data from the Netherlands has revealed an annual incidence and point prevalence of 0.7 and 4.4 for idiopathic pulmonary arterial hypertension and 2.2 and 15.6 for pulmonary arterial hypertension, respectively, associated with congenital heart disease (CHD) cases per million children. The updated Nice classification for PH has been enhanced to include a greater depth of CHD and emphasizes persistent PH of the newborn and developmental lung diseases, such as bronchopulmonary dysplasia and congenital diaphragmatic hernia. The management of pediatric PH remains challenging because treatment decisions continue to depend largely on results from evidence based adult studies and the clinical experience of pediatric experts. (J Am Coll Cardiol 2013;62:D117-26) ©2013 by the American College of Cardiology Foundation.

The Updated World Health Organization Classification Better Predicts Survival in Patients With Endocervical Adenocarcinoma (KROG 20-07)

The 2020 World Health Organization classification divided endocervical adenocarcinoma (ADC) into human papillomavirus-associated (HPVA) and human papillomavirus-independent (HPVI) ADCs. This multi-institutional study aimed to investigate the clinical features and prognosis of patients with endocervical ADC based on the updated World Health Organization classification. We retrospectively reviewed the 365 patients with endocervical ADC who underwent radical hysterectomy from 7 institutions. Tumor characteristics, patterns of failure, and survival outcomes were compared between HPVA and HPVI ADCs. Two hundred seventy-five (75.3%) and 90 (24.7%) patients had HPVA and HPVI ADC diagnoses, respectively. In all cases, the 5-year disease-free survival (DFS) and overall survival (OS) rates were 58.2% and 71.3%, respectively. HPVI ADC showed higher rates of local recurrence (25.6% vs 10.9%) and distant metastasis (33.3% vs 17.5%) than HPVA ADC. Multivariate survival analysis revealed that HPVI ADC showed significantly worse DFS (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.324-2.781; P < .001), distant metastasis-free survival (HR, 2.100; 95% CI, 1.397-3.156; P < .001), and OS (HR, 2.481; 95% CI, 1.586-3.881; P < .001) than HPVA ADC. Patients with gastric- and serous-type HPVI ADC had significantly worse OS than those with other HPVI ADCs (P=.020). Similarly, invasive stratified mucin-producing-type HPVA ADC showed significantly worse OS than other HPVA ADCs (P < .001). We demonstrated that HPVI ADC exhibited inferior DFS and OS and higher rates of local and distant recurrence compared with HPVA ADC. Gastric- and serous-type HPVI ADCs and invasive stratified mucin-producing-type HPVA ADC showed worse OS than other types of HPVI and HPVA ADCs, respectively. Our observation of significant differences in prognoses according to the histologic types needs to be validated in larger cohorts of patients with endocervical ADC.

Clinical updates on gliomas and implications of the 5th edition of the WHO classification of central nervous system tumors.

The 5th edition of the World Health Organization (WHO) classification of central nervous system tumors incorporated specific molecular alterations into the categorization of gliomas. The major revision of the classification scheme effectuates significant changes in the diagnosis and management of glioma. This study aimed to depict the clinical, molecular, and prognostic characteristics of glioma and its subtypes according to the current WHO classification. Patients who underwent surgery for glioma at Peking Union Medical College Hospital during 11 years were re-examined for tumor genetic alterations using next-generation sequencing, polymerase chain reaction-based assay, and fluorescence in situ hybridization methods and enrolled in the analysis. The enrolled 452 gliomas were reclassified into adult-type diffuse glioma (ntotal=373; astrocytoma, n=78; oligodendroglioma, n=104; glioblastoma, n=191), pediatric-type diffuse glioma (ntotal=23; low-grade, n=8; high-grade, n=15), circumscribed astrocytic glioma (n=20), and glioneuronal and neuronal tumor (n=36). The composition, definition, and incidence of adult- and pediatric-type gliomas changed significantly between the 4th and the 5th editions of the classification. The clinical, radiological, molecular, and survival characteristics of each subtype of glioma were identified. Alterations in CDK4/6, CIC, FGFR2/3/4, FUBP1, KIT, MET, NF1, PEG3, RB1, and NTRK2 were additional factors correlated with the survival of different subtypes of gliomas. The updated WHO classification based on histology and molecular alterations has updated our understanding of the clinical, radiological, molecular, survival, and prognostic characteristics of varied subtypes of gliomas and provided accurate guidance for diagnosis and potential prognosis for patients.

RadioGraphics Update: New Follow-up and Management Recommendations for Polypoid Lesions of the Gallbladder

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new informaion such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

Investigator-Determined Categories for Fever of Unknown Origin (FUO) Compared With International Classification of Diseases-10 Classification of Illness: A Systematic Review and Meta-analysis With a Proposal for Revised FUO Classification.

Classifying fever of unknown origin (FUO) into categorical etiologies (ie, infections, noninfectious inflammatory, oncologic, miscellaneous, and undiagnosed disorders) remains unstandardized and subject to discrepancies. As some disease classifications change, a systematic review of studies would help physicians anticipate the frequency of illness types they may encounter that could influence care. We systematically reviewed prospective FUO studies published across the Medline (PubMed), Embase, Scopus, and Web of Science databases from January 1, 1997, to July 31, 2022. We performed a meta-analysis to estimate associated pooled proportions between the investigator-determined choice of disease category and those determined by the International Classification of Diseases, 10th edition (ICD-10), methodology. The proportion of patients with a difference between the investigator and ICD-10-adjusted noninfectious inflammatory disorder category was 1.2% (95% CI, 0.005-0.021; P < .001), and the proportion was similar for the miscellaneous category at 1.5% (95% CI, 0.007-0.025; P < .001). The miscellaneous and noninfectious inflammatory disorders categories demonstrated significant across-study heterogeneity in the proportions of patients changing categories, with 52.7% (P = .007) and 51.0% (P = .010) I2 , respectively. Adjusting FUO-associated diagnoses by ICD-10 methodology was associated with a statistically significant risk of over- or underestimation of disease category frequency approximation when using a 5 FUO category system. An FUO diagnostic classification system that better reflects mechanistic understanding would assist future research and enhance comparability across heterogenous populations and different geographic regions. We propose an updated FUO classification scheme that streamlines categorizations, aligns with the current understanding of disease mechanisms, and should facilitate empirical decisions, if necessary.

Fine-tuning characterization of patients with interstitial pneumonia and an underlying autoimmune disease in real-world practice: We get closer with Nailfold videocapillaroscopy.

To assess performance of interstitial pneumonia (IP) with autoimmune features (IPAF) criteria in clinical practice and describe the utility of additional workup in identifying patients with underlying connective tissue diseases (CTD). We set a retrospective study of our patients with autoimmune IP, who were allocated to CTD-IP, IPAF or undifferentiated autoimmune IP (uAIP) subgroups according to the updated classification criteria. Presence of the process-related variables comprising IPAF defining domains was scrutinized in all patients, and, when available, the results of nailfold videocapillaroscopy (NVC) were recorded. Thirty nine out of 118 patients, accounting for 71% of former undifferentiated cases, fulfilled IPAF criteria. Arthritis and Raynaud's phenomenon were prevalent in this subgroup. While systemic sclerosis-specific autoantibodies were restricted to CTD-IP patients, anti-tRNA synthetase antibodies were also present in IPAF. In contrast, rheumatoid factor, anti-Ro antibodies and ANA nucleolar patterns could be found in all subgroups. Usual interstitial pneumonia (UIP) / possible UIP were the most frequently observed radiographic patterns Therefore, the presence of thoracic multicompartimental findings as also performance of open lung biopsies were useful in characterizing as IPAF those UIP cases lacking a clinical domain. Interestingly, we could observe NVC abnormalities in 54% of IPAF and 36% of uAIP tested patients, even though many of them did not report Raynaud's phenomenon. Besides application of IPAF criteria, distribution of IPAF defining variables along with NVC exams help identify more homogeneous phenotypic subgroups of autoimmune IP of potential relevance beyond clinical diagnosis.

An updated classification of meditation methods using principles of taxonomy and systematics.

This paper revisits the proposal for the classification of meditation methods which we introduced in our initial 2013 publication, "Toward a Universal Taxonomy and Definition of Meditation". At that time, we advanced the thesis that meditation methods could be effectively segregated into three orthogonal categories by integrating the taxonomic principle of functional essentialism and the paradigm of Affect and Cognition; and we presented relevant research findings which supported that assertion. This iteration expands upon those theoretical and methodological elements by articulating a more comprehensive Three Tier Classification System which accounts for the full range of meditation methods; and demonstrates how recent neuroscience research continues to validate and support our thesis. This paper also introduces a novel criterion-based protocol for formulating classification systems of meditation methods, and demonstrates how this model can be used to compare and evaluate various other taxonomy proposals that have been published over the past 15 years.

Abstract TMP49: Accuracy Of Toast Subtype Classification In Clinical Practice: Implications For The Get With The Guidelines National Stroke Registry

Background: TOAST is the most commonly used ischemic stroke subtype classification system worldwide and a required field in the US National GWTG-Stroke registry. However, stroke diagnostics have advanced substantially since TOAST was designed 30 years ago, potentially making it difficult to now apply reliably. Methods: We analyzed consecutive ischemic stroke patients admitted to a CSC between July-Oct 2021. Clinical practice TOAST diagnoses rendered by the stroke team in the EMR at discharge were retrieved from GWTG-Stroke registry and compared to a reference (“gold”) standard diagnosis derived from agreement between 2 expert raters after review of the EMR and patient imaging. Results: Among 49 patients, age was 72.3y (±12.1), 53% female, and presenting NIHSS median 3 (IQR 1-11). Work-up included: brain imaging in 100%; cardiac rhythm assessment in 100%; cervical/cerebral vessel imaging in 98%; TTE±TEE in 92%; and TCD emboli eval in 51%. Reference standard diagnoses were: LAA-6%, SVD-14%, CE-41%, OTH-8%, UND-more than one cause-18%, and UND-cryptogenic-12%. The Figure shows a bubble plot of congruence between EMR/GWTG-Stroke and reference standard diagnoses. GWTG-Stroke TOAST diagnoses agreed with reference standard diagnoses in 29/49 (59%). Among the 6 subtype diagnoses singly, specificity was generally high (83%-100%), but sensitivity suboptimal for LAA (33%), OTH (75%), UND-MT1 (0%), and UND-CRYPT (17%). Positive predictive value was suboptimal for all: LAA (13%), SVD (58%), CE (77%), OTH (75%), SVD OTH (75%), UND-MT1 (0%), and UND-CRYPT (33%). Conclusion: Clinical practice subtype diagnoses using TOAST and entered into GWTG-Stroke were accurate in only 59% of patients, hampering the ability of the national registry to provide dependable insights into subtype-related aspects of care. Development of an updated ischemic stroke subtype classification system, with algorithmic logic directly embedded in electronic medical records, is desirable.

Giving form to the formless: An updated classification of cyanobacterial taxonomy.

Giving form to the formless: An updated classification of cyanobacterial taxonomy.