Validated Classification System Research Articles

Ischaemic stroke etiological classification system: the agreement analysis of CISS, SPARKLE and TOAST

Background and purposeThe ideal stroke classification system needs to have validity, high reliability and applicability among different stroke research settings. The Chinese Ischemic Stroke Subclassification (CISS) and the Subtypes of...

Cancer Pain Assessment and Classification.

More than half of patients affected by cancer experience pain of moderate-to-severe intensity, often in multiple sites, and of different etiologies and underlying mechanisms. The heterogeneity of pain mechanisms is expressed with the fluctuating nature of cancer pain intensity and clinical characteristics. Traditional ways of classifying pain in the cancer population include distinguishing pain etiology, clinical characteristics related to pain and the patient, pathophysiology, and the use of already validated classification systems. Concepts like breakthrough, nociceptive, neuropathic, and mixed pain are very important in the assessment of pain in this population of patients. When dealing with patients affected by cancer pain it is also very important to be familiar to the characteristics of specific pain syndromes that are usually encountered. In this article we review methods presently applied for classifying cancer pain highlighting the importance of an accurate clinical evaluation in providing adequate analgesia to patients.

An analysis of early postoperative complications following biliary reconstruction of major bile duct injuries using the Modified Accordion and Anatomic, Timing Of and Mechanism classifications

BackgroundFew studies have reported patient outcome after surgical repair of bile duct injury using a standardized, validated classification system. This is the first analysis to investigate the correlation between the Anatomic, Timing Of and Mechanism classification of bile duct injury and severity of postoperative complications classified using the Modified Accordion Grading System. MethodsPatients undergoing index hepaticojejunostomy repair of bile duct injury in laparoscopic cholecystectomy at a tertiary referral center from 1993-2018 were included. Patient demographics, geographic distance from referral center, time to referral, Anatomic, Timing Of and Mechanism classification and highest Modified Accordion Grade complication were retrieved from a prospective database. The primary outcome was determined using correlation statistics to assess the relationship between level of injury and severity of postoperative complication. ResultsOne hundred and twenty-eight patients were included. There was no correlation between level of injury and severity of postoperative complication (rs(128) = –0.113, P = .203). Seventy (54.7%) patients had an injury less than 2 cm from the hepatic duct bifurcation and 52% of patients developed a postoperative complication, most mild to moderate in severity. Geographic distance resulted in substantial delays in referral (P < .001) but did not affect complication rate (P = .523). ConclusionIn this prospective analysis the short-term complication rate was higher than previous retrospective reports, but the distribution of the severity of complications and spectrum of injury type were similar. There was no correlation between severity of injury and postoperative complications. Geographic distance from referral center resulted in substantial differences in referral delay but had no statistically significant effect on outcome.

The Functional Communication Classification System: extended reliability and concurrent validity for children with cerebral palsy aged 5 to 18 years.

To examine psychometric properties and clinical utility of the Functional Communication Classification System (FCCS) for classifying observable communication function in children with cerebral palsy (CP) aged 5 to 18 years. Eighty-two children (38 males, 44 females) with CP in six age groups (5y [n=15], 8y [n=14], 10y [n=14], 12y [n=14], 15y [n=11], and 17y [n=14]) were assessed by a speech-language pathologist (SLP) and parent for FCCS ratings. Data were compared with: (1) everyday communication function, assessed using the Clinical Evaluation of Language Fundamentals - Fourth Edition Pragmatics Profile (CELF-4 PP) for familiar and unfamiliar partners; (2) motor speech, gross and fine motor function; and (3) associated impairments, including epilepsy, intelligence, hearing, and vision. Interrater agreement was calculated for FCCS ratings using kappa (κ) statistics. Relationships between FCCS ratings and other measures were examined using Spearman's correlation coefficient. Almost perfect interrater agreement was demonstrated between SLP and parent FCCS ratings (κw =0.96). Correlations were excellent between FCCS ratings with CELF-4 PP ratings, motor speech, and intellect; moderate with gross and fine motor function; and fair with other associated impairments (hearing, visual, and epilepsy). There was no correlation between age and FCCS. The FCCS is a reliable and valid communication classification system for children with CP aged 5 to 18 years, and highly suitable for surveillance, research, and clinical purposes. The Functional Communication Classification System (FCCS) is valid and reliable for communication classification in children with cerebral palsy. Excellent agreement is present between speech language pathologists and parents. The FCCS shows excellent correlation with pragmatics, motor speech, and intelligence. The FCCS is moderately correlated with gross and fine motor function. The FCCS has fair correlation with epilepsy, hearing, and vision.

TP53 Mutations Negatively Impact Survival of Acute Myeloid Leukemia Patients Treated with Standard Doses of Azacitidine

Validated therapies for older pts with AML could rely on intensive or low-intensity strategies. Patient selection for these options remains controversial. There is currently no validated biomarker which can been used to guide therapeutic decision. TP53 mutations which are known to negatively impact AML pts outcome when treated with ICT, have been recently described as a positive prognosis factor for blast clearance with a 10-days regimen of decitabine (Welch, NEJM 2016). To date, it remains unclear whether AML pts with TP53 mutation represent a clinically homogeneous group. Several classification systems of p53 mutant, derived from in vitro or in vivo data, have been validated in solid tumors and aggressive lymphomas as predictors of p53 mutant functional impact or patient outcome. We retrospectively evaluated the impact of TP53 mutational status on the outcome of a real-world cohort of pts, treated frontline with standard doses of azacitidine (AZA). We further hypothesized that functional characterization of TP53 mutations could define a subgroup of pts with specific outcome with AZAFrom Jan 2007 to Dec 2016, we identified 279 AML pts enrolled in the regional cancer network ONCOMIP registry, treated frontline with AZA. Median age was 76 yrs (45-93), karyotype was adverse in 135 pts (49.1%), including 54 pts with -17 or del17p (19.4%). AML was secondary to MDS in 71 pts (25.4%), to MPN in 24 (8.6%) and therapy related in 46 pts (16.5%). Pts received a median of 6 cycles (1-67). Overall, 54 pts obtained CR/CRi (19.4%) and median OS was 10.6 months (95%CI ,9.7-12.1). For 224 pts with an available bone marrow baseline DNA sample, TP53 mutations were screened with next-generation sequencing on an Illumina® MiSeq sequencer. Sequencing results were filtered with the IARC TP53 mutations database and a variant allele frequency (VAF) >10%, strengthening the specificity of the data of this cohort. Of the 224 analyzed cases, 55 cases (24.6%) contained TP53 mutations. Response rates did not significantly differ between TP53mut (21.8% CR/CRi) and TP53wt (17.8% CR/CRi, p=.50) nor between pts with TP53mut and/or -17/del17p (19.1% CR/CRi) and pts without TP53 abnormality (18.6%CR/CRi, p=.93). Median OS was 7.9 months in pts with TP53mut and 12.6 months in TP53wt (p<.0001). With regards to the group of 109 pts with adverse karyotype, response rates did not significantly differ between TP53mut pts (20.8% CR/CRi) and TP53wt (14.3%, p=.37) and median OS was 7.9 months for TP53mut pts versus 9.6 for TP53wt pts (p=.02)Among the 55 pts with TP53mut, 53pts had adverse cytogenetics (96.4%), 16 pts had secondary AML to MDS or MPN (29.1%) and 13 had t-AML (23.6%). This subgroup included 49 cases (89%) with single TP53 mutation (missense n=42, nonsense n= 3, frameshift n=4) and 6 cases (11%) with 2 mutations (2 pts with missense and frameshift mutations and 4 pts with 2 missense mutation). We further characterized TP53mut pts with 3 validated classification systems. Due to dominant negative effect of TP53 mutation, for pts with >1 TP53 mutation, we selected the mutation with the predicted highest impact: •15 pts had disruptive mutations (i.e. missense mutation in L2/L3 helix of the DNA binding domain or truncating mutation) versus 40 pts with non-disruptive mutations (Poeta M, NEJM 2007), which was not associated with clinical response (25% in CR/CRi vs 27.9% in failure; p=1.00) nor with 6mOS (46.7% vs 55%, respectively; p=.79)•Mutant p53 transactivation activity assessed with a 0-100 evolutionary score (Neskey D, Cancer Research 2015), was not associated with response (median score of 79.3[28-90] in CR/CRi vs 73.3 [49-96] in failure, p=1.00) nor with OS (HR 1.01; 95% CI, 0.99-1.03, p=.51).•Relative fitness score (on a log2 scale) which was recently reported as a proxy of p53 mutant in vitro and in vivo cell proliferation advantage (Kotler E, Molecular cell 2018) was not associated with response (median score in CR/CRi of 0.094 [-0.79-0.58] vs 0.094 [-2.52-0.84] in failure, p=.68) nor with OS (HR 0.75; 95% CI, 0.45-1.22, p=.24)Overall, the response rate was not influenced by the TP53mut status, but median OS was negatively impacted by the TP53mut status in the entire cohort and in the sub-group of pts with adverse karyotype. None of the mutant p53 classification systems validated in other neoplasms succeed in identifying a subset of AML pts who specifically benefit from AZA suggesting a rather homogenous functional impact of TP53 mutations in this setting DisclosuresFornecker:Takeda: Honoraria; Servier: Honoraria.

Virtual chromoendoscopy by using optical enhancement improves the detection of Barrett’s esophagus–associated neoplasia

The Seattle protocol for endoscopic Barrett's esophagus (BE) surveillance samples a small portion of the mucosal surface area, risking a potentially high miss rate of early neoplastic lesions. We assessed whether the new iScan Optical Enhancement system (OE) improves the detection of early BE-associated neoplasia compared with high-definition white-light endoscopy (HD-WLE) in both expert and trainee endoscopists to target sampling of suspicious areas. Such a system may both improve early neoplasia detection and reduce the need for random biopsies. A total of 41 patients undergoing endoscopic BE surveillance from January 2016 to November 2017 were recruited from 3 international referral centers. Matched still images in both HD-WLE (n= 130) and iScan OE (n= 132) were obtained from endoscopic examinations. Two experts, unblinded to the videos and histology, delineated known neoplasia, forming a consensus criterion standard. Seven expert and 7 trainee endoscopists marked 1 position per image where they would expect a target biopsy to identify dysplastic tissue. The same expert panel then reviewed magnification images and, using a previously validated classification system, attempted to classify mucosa as dysplastic or nondysplastic, based on the mucosal and vascular (MV) patterns observed on magnification endoscopy. Diagnostic accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. Improvements in dysplasia detection in HD-WLE versus OE and interobserver agreement were assessed by multilevel logistic regression analysis and Krippendorff alpha, respectively. Improvements in diagnostic performance were expressed as an odds ratio between the odds of improvement in OE compared with the odds of improvement in HD-WLE. Accuracy of neoplasia detection was significantly higher in all trainees who used OE versus HD-WLE (76% vs 63%) and in 6 experts (84% vs 77%). OE improved sensitivity of dysplasia detection compared with HD-WLE in 6 trainees (81% vs 71%) and 5 experts (77% vs 67%). Specificity improved in 6 trainees who used OE versus HD-WLE (70% vs 55%) and in 5 experts (92% vs 86%). PPV improved in both an expert and trainee cohort, but NPV improved significantly only in trainees. By using the MV classification and OE magnification endoscopy compared with HD-WLE, we demonstrated improvements in accuracy (79.9% vs 66.7%), sensitivity (86.3% vs 83.4%), and specificity (71.2% vs 53.6%) of dysplasia detection. PPV improved (62%-76.6%), as did NPV (67.7%-78.5%). Interobserver agreement also improved by using OE from 0.30 to 0.55. iScan OE may improve dysplasia detection on endoscopic imaging of BE as well as the accuracy of histology prediction compared with HD-WLE, when OE magnification endoscopy is used in conjunction with a simple classification system by both expert and non-expert endoscopists.

Classifications in Brief: The Nerot-Sirveaux Classification for Scapular Notching.

Classifications in Brief: The Nerot-Sirveaux Classification for Scapular Notching.

Reproducibility of data-driven Parkinson's disease subtypes for clinical research

IntroductionPD subtype classification systems attempt to address heterogeneity in PD, a widely recognized feature of the disease with implications in prognosis and therapeutic development. There is no consensus on a valid PD subtype classification system, and its use in clinical research is sparse. Reproducibility has not been systematically assessed as a step for the validation of a PD subtype classification system. We aimed at assessing reproducibility of previously published data-driven PD subtype classification systems in a well-characterized cohort created for clinical research purposes, the Longitudinal and Biomarker Study in Parkinson's Disease (LABS-PD). MethodsWe identified all published studies of data-driven PD subtype classification systems and included those with variables that conceptually matched the variables available in LABS-PD. We reproduced the cluster analyses of the included studies in LABS-PD. Reproducibility was determined by a panel of experts using a modified Delphi consensus process. ResultsWe included eight studies of data-driven PD subtype classification systems and completed the replication in LABS-PD of the analyses conducted in each original study. After two iterations of the modified Delphi consensus process, no study was reproducible in LABS-PD. ConclusionsCurrently published data-driven PD subtype classification systems lack reproducibility in a well-characterized cohort of patients initially recruited for a clinical trial of a disease-modifying intervention. The results raise concerns about the utility of the widely-discussed concept of data-driven PD subtypes. This gap is a barrier for a meaningful use of PD subtypes and calls for the establishment of standards for the validation and use of these subtype classification systems.

Association of Daily Intellectual Activities With Lower Risk of Incident Dementia Among Older Chinese Adults

ImportanceAssociations between late-life participation in intellectual activities and decreased odds of developing dementia have been reported. However, reverse causality and confounding effects due to other health behaviors or problems have not been adequately addressed.ObjectiveTo examine whether late-life participation in intellectual activities is associated with a lower risk of incident dementia years later, independent of other lifestyle and health-related factors.Design, Setting, and ParticipantsA longitudinal observational study was conducted at all Elderly Health Centres of the Department of Health of the Government of Hong Kong among 15 582 community-living Chinese individuals age 65 years or older at baseline who were free of dementia, with baseline evaluations performed January 1 to June 30, 2005, and follow-up assessments performed from January 1, 2006, to December 31, 2012. Statistical analysis was performed from January 1, 2015, to December 31, 2016.Main Outcomes and MeasuresThe main outcome was incident dementia as diagnosed by geriatric psychiatrists in accordance with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, or a Clinical Dementia Rating of 1 to 3. At baseline and follow-up interviews, self-reported information on participation in intellectual activities within 1 month before assessment was collected. Examples of intellectual activities, which were described by a local validated classification system, were reading books, newspapers, or magazines; playing board games, Mahjong, or card games; and betting on horse racing. Other important variables including demographics (age, sex, and educational level), physical and psychiatric comorbidities (cardiovascular risks, depression, visual and hearing impairments, and poor mobility), and lifestyle factors (physical exercise, adequate fruit and vegetable intake, smoking, and recreational and social activities) were also assessed.ResultsOf the 15 582 individuals in the study, 9950 (63.9%) were women, and the median age at baseline was 74 years (interquartile range, 71-77 years). A total of 1349 individuals (8.7%) developed dementia during a median follow-up period of 5.0 years. Multivariable logistic regression analysis showed that the estimated odds ratio for incident dementia was 0.71 (95% CI, 0.60-0.84; P < .001) for those with intellectual activities at baseline, after excluding those who developed dementia within 3 years after baseline and adjusting for health behaviors, physical and psychiatric comorbidities, and sociodemographic factors.Conclusions and RelevanceActive participation in intellectual activities, even in late life, might help delay or prevent dementia in older adults.

Modern treatment of meniscal tears.

The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body.The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue.It is the orthopaedic surgeon’s responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion.Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus.Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, “If it is torn, take it out!” to the currently accepted slogan, “Save the meniscus!” which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future.Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170067.

Inter- and Intra-rater Reliability of the Hart-ISSG Proximal Junctional Failure Severity Scale.

Reliability/external validation study. Investigate inter- and intrarater reliability of the Hart-International Spine Study Group (ISSG) Proximal Junctional Failure Severity Scale (PJFSS) and its correlation with operative revision in patients with proximal junctional failure (PJF). The Hart-ISSG PJFSS is a validated classification system for PJF. Reliability of the PJFSS has not been assessed. Sixteen detailed clinical scenarios were assessed using the ISSG PJFSS classification in six categories: neurologic status, axial pain, instrumentation issue, proximal kyphotic angle, level of upper instrumented vertebrae (UIV), and severity of UIV/UIV+1 fracture. Eleven spine surgeons evaluated each case in all six categories during two different assessments, and provided recommendations regarding operative revision or observation for each case. Inter- and intrarater reliability were calculated based on intraclass correlation coefficients. All intraclass correlation coefficients demonstrated "almost perfect"' (0.817-0.988) inter-rater agreement for both assessments, except UIV/UIV+1 fracture severity during the second assessment, which demonstrated "substantial" agreement' (0.692). Five of six categories had "almost perfect" mean intrarater reliability (0.805-0.981), while "instrumentation issue" demonstrated "substantial" mean agreement (0.757). Inter-rater reliability for recommendation of surgical intervention was "almost perfect" during both assessments (0.911 and 0.922, respectively). Mean PJFSS scores between the two assessments were significantly higher for cases recommended for operative revision (8.43 ± 0.90) versus cases recommended for observation (P < 0.0001). The ISSG PJFSS is a reliable and repeatable classification system for assessing patients with PJF. Higher PJFSS scales correlate with recommendation for operative revision, extending prior external validation of the PJFSS. 3.

Screening for caregivers at risk: Extended validation of the short version of the Burden Scale for Family Caregivers (BSFC-s) with a valid classification system for caregivers caring for an older person at home

BackgroundInformal caregivers’ (CGs’) subjective burden is an important aspect of the care situation because it is linked to various outcomes such as health, mortality risk, institutionalization, and caregiving style. The aims of this study were a) to examine the convergent and discriminant validity of the 10-item short version of the Burden Scale for Family Caregivers (BSFC-s) and b) to develop a valid classification system for interpreting BSFC-s scores.MethodsIn this cross-sectional study, we analyzed data obtained from 386 informal CGs who applied for an initial grade or upgrade of the care level for the care recipient at the Medical Service of Compulsory Health Insurance Funds of Bavaria (Germany). To validate the BSFC-s, we analyzed the reliability and the convergent/discriminant validity. We calculated correlations with the short form of the Giessen Symptom Complaints List (GBB-24), the Caregiver Strain Index (CSI), the personal further development sub-scale of the Berlin Inventory of Caregivers’ Burden with Dementia Patients (BIZA-D), and other scales for establishing informal CGs’ situations. To develop the classification system, we compared the percentile ranks of the GBB-24 with the respective BSFC-s sum scores and their distributions and derived three classification categories.ResultsResults confirmed the convergent and discriminant validity of the BSFC-s (GBB-24: r = 0.68; CSI: r = 0.70; BIZA-D: r = 0.16; p < 0.001). For informal CGs with low subjective burden, the risk of physical psychosomatic complaints was elevated to a less than average level (BSFC-s scores of 0-4). In those with a moderate subjective burden (BSFC-s scores of 5-14), the risk was elevated. In those with a high burden (BSFC-s scores of 15-30), the risk was substantially elevated.ConclusionsThe BSFC-s is a valid scale for measuring subjective burden in informal CGs. The risk of physical psychosomatic complaints, which is a consequence of subjective CG burden, can be determined by using the valid classification system to deduce the necessity for action and to give concrete recommendations for interventions. The BSFC-s should therefore be employed as a screening instrument in medical contexts and in counseling services for informal CGs.

Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System

BackgroundThe objective of this study was to compare macroscopic bone and soft tissue injury between robotic-arm assisted total knee arthroplasty (RA-TKA) and conventional jig-based total knee arthroplasty (CJ-TKA) and create a validated classification system for reporting iatrogenic bone and periarticular soft tissue injury after TKA. MethodsThis study included 30 consecutive CJ-TKAs followed by 30 consecutive RA-TKAs performed by a single surgeon. Intraoperative photographs of the femur, tibia, and periarticular soft tissues were taken before implantation of prostheses. Using these outcomes, the macroscopic soft tissue injury (MASTI) classification system was developed to grade iatrogenic bone and soft tissue injuries. Interobserver and Intraobserver validity of the proposed classification system was assessed. ResultsPatients undergoing RA-TKA had reduced medial soft tissue injury in both passively correctible (P < .05) and noncorrectible varus deformities (P < .05); more pristine femoral (P < .05) and tibial (P < .05) bone resection cuts; and improved MASTI scores compared to CJ-TKA (P < .05). There was high interobserver (intraclass correlation coefficient 0.92 [95% confidence interval: 0.88-0.96], P < .05) and intraobserver agreement (intraclass correlation coefficient 0.94 [95% confidence interval: 0.92-0.97], P < .05) of the proposed MASTI classification system. ConclusionThere is reduced bone and periarticular soft tissue injury in patients undergoing RA-TKA compared to CJ-TKA. The proposed MASTI classification system is a reproducible grading scheme for describing iatrogenic bone and soft tissue injury in TKA. Clinical RelevanceRA-TKA is associated with reduced bone and soft tissue injury compared with conventional jig-based TKA. The proposed MASTI classification may facilitate further research correlating macroscopic soft tissue injury during TKA to long-term clinical and functional outcomes.

Association Between Pseudotumor Formation and Patient Factors in Metal-on-Metal Total Hip Arthroplasty Population

BackgroundPseudotumor formation from metal-on-metal (MoM) hip implants is associated with implant revision. The relationship between pseudotumor type and patient outcomes is unknown. MethodsWe retrospectively reviewed patients with a MoM total hip arthroplasty and metal artifact reduction sequence magnetic resonance imaging. Pseudotumors were graded using a validated classification system by a fellowship-trained radiologist. Patient demographics, metal ion levels, and implant survival were analyzed. ResultsPseudotumors were present in 49 hips (53%). Thirty-two (65%) pseudotumors were cystic thin walled, 8 (16%) were cystic thick walled, and 9 (18%) were solid masses. Patients with pseudotumors had high offset stems (P = .030) but not higher metal ion levels. Patients with thick-walled cystic or solid masses were more likely to be symptomatic (P = .025) and were at increased risk for revision (P = .004) compared to patients with cystic lesions. ConclusionPseudotumor formation is present in 53% of patients with a MoM total hip arthroplasty, of which 40% were asymptomatic. Patients with thick-walled cystic and solid lesions were more likely to be symptomatic and undergo revision.

Generalist versus Subspecialist Characteristics of the U.S. Radiologist Workforce.

Purpose To assess subspecialty practice characteristics of the U.S. radiologist workforce. Materials and Methods This study used the Medicare Physician and Other Supplier Public Use File and did not constitute human subject research. The authors identified 33 090 radiologists who billed for professional services between 2012 and 2014 and used a validated classification system to map services to seven subspecialties and quantify subspecialty-focused effort on the basis of work relative value units (RVUs). Radiologists with more than half of their billed work RVUs in a single subspecialty were designated subspecialists; the remainder were classified as generalists. Matching radiologists with various characteristics extracted from other publicly available data sets, associations were explored through use of analysis of variance and multivariable logistic regression. Results More than half (55.3%) of U.S. radiologists practice predominantly as generalists but dedicate on average 36.0% effort to one subspecialty. Among radiologists practicing as majority subspecialists, neuroradiologists (10.1% of all radiologists) and breast imagers (8.4%) are most common. Subspecialization is more common (P < .001) among radiologists who are female, are earlier in their career, work in larger practices, have academic affiliations, and practice in the Northeast. By subspecialty, female representation varies from 8.6% (interventional radiology) to 63.1% (breast imaging); cardiothoracic imagers were more commonly early career radiologists, and nuclear medicine physicians were later career radiologists. Subspecialization is considerably more common in larger (≥100 members) practices (63.1%). An academic affiliation is the strongest independent predictor of subspecialization (odds ratio, 3.56; 95% confidence interval: 3.30, 3.84). Conclusion Despite an increased focus on radiology subspecialization, most U.S. radiologists are majority general radiologists on the basis of their work RVUs. Subspecialization is by far more prevalent in larger and academic practices. © RSNA, 2017 Online supplemental material is available for this article.

Skin Tears: Finally Recognized

Skin Tears: Finally Recognized

Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis.

To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postoperative wound infections : Diagnosis, classification and treatment

Surgical site infections are afrequent complication of surgery and asevere burden for the patient as well as for the healthcare system. Sound knowledge of the disease pattern is an essential prerequisite for effective therapy. This article presents an overview of the diagnosis, classification and treatment options for surgical site infections. Based on the existing experience, the currently available evidence and pathophysiological considerations, an overview of the diagnostic possibilities, the existing classification systems and the treatment options is presented. The diagnosis of surgical site infections is based on the clinical symptoms and can particularly be supported by the microbiological analysis of wound samples. There is no validated classification system but the definition of the Centers for Disease Control and Prevention is most commonly used. After initial bedside processing, debridement and wound cleansing are the basis for the further treatment, which is supplemented by the rational use of antiseptics and antibiotics. The use of modern dressings with the aim of maintaining aphysiological moist wound environment promotes wound healing. The negative pressure wound therapy is an available treatment option. Rare diseases need to be considered. The low level of evidence and critical consideration of the treatment options have been discussed in many guidelines, consensus documents and systematic reviews on the basis of which this article was written. Strengthening the evidence situation through intensive, targeted research should be the goal.

Developing a Patient Classification System for a Neonatal ICU.

The purpose of this study was to develop a valid and reliable patient classification system (PCS) for a neonatal ICU (NICU). PCSs have been widely used to determine required care hours, budgeting, and staffing. There is a lack of and a vital need for a valid and reliable pediatric PCS because of differences in needs and treatment from adults. Data were collected in a NICU using work sampling, chart reviews, and expert opinion. The resulting PCS was assessed for validity and reliability, ease of use, effectiveness, and satisfaction. The PCS showed significantly high reliability and validity. Survey scores revealed nurses perceived the tool to be easy to use and effective. Using subjective and objective methods, a NICU PCS was shown to be a valid and reliable measure to determine the hours per patient day required to provide care.

Advanced endoscopic imaging: European Society of Gastrointestinal Endoscopy (ESGE) Technology Review.

Background and aim: This technical review is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the utilization of advanced endoscopic imaging in gastrointestinal (GI) endoscopy. Methods: This technical review is based on a systematic literature search to evaluate the evidence supporting the use of advanced endoscopic imaging throughout the GI tract. Technologies considered include narrowed-spectrum endoscopy (narrow band imaging [NBI]; flexible spectral imaging color enhancement [FICE]; i-Scan digital contrast [I-SCAN]), autofluorescence imaging (AFI), and confocal laser endomicroscopy (CLE). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. Main recommendations:1. We suggest advanced endoscopic imaging technologies improve mucosal visualization and enhance fine structural and microvascular detail. Expert endoscopic diagnosis may be improved by advanced imaging, but as yet in community-based practice no technology has been shown consistently to be diagnostically superior to current practice with high definition white light. (Low quality evidence.) 2. We recommend the use of validated classification systems to support the use of optical diagnosis with advanced endoscopic imaging in the upper and lower GI tracts (strong recommendation, moderate quality evidence). 3. We suggest that training improves performance in the use of advanced endoscopic imaging techniques and that it is a prerequisite for use in clinical practice. A learning curve exists and training alone does not guarantee sustained high performances in clinical practice. (Weak recommendation, low quality evidence.) Conclusion: Advanced endoscopic imaging can improve mucosal visualization and endoscopic diagnosis; however it requires training and the use of validated classification systems.