Validated Classification System Research Articles

A 5-Year retrospective analysis of adverse events in dentistry at the Dental Hospital, Faculty of Dentistry, Chulalongkorn University

BackgroundPatient safety is a critical concern in dentistry. Adverse events (AEs) can harm patients, increase costs, and decrease satisfaction. Understanding AE types and frequencies is crucial for effective risk management and quality improvement. This study analyzes incident reports to identify preliminary incident patterns as a starting point for developing risk management strategies. However, under-reporting limits the ability to identify true incident patterns, highlighting the need for improved reporting systems and encouragement of incident reporting. Further research is underway to develop such a system and promote reporting to ensure sufficient data quality for effective risk management.MethodsA retrospective analysis of 1,618 incident reports from December 2018 to August 2023 was conducted. A validated classification system, developed from a 5-year retrospective analysis and approved by 14 experts, categorized patient safety incidents, aligning with Thailand’s Hospital Accreditation standards. Descriptive statistics summarized AE frequency and distribution.ResultsOf the reports, 752 were patient safety, 503 personnel safety, and 363 organizational safety incidents. Top patient safety incidents included medical record errors (176), accidental damage (66), post-operative complications (65), medical emergencies (64), and communication errors (53). Personnel safety incidents involved inappropriate working conditions (135) and work-related injuries with contact transmission risk (117). Organizational safety incidents mainly concerned policy and operational processes (131).ConclusionsThis study reveals the preliminary patterns of adverse events (AEs) in dental settings and underscores the limitations due to under-reporting, which affect the ability to fully understand true incident patterns. To effectively manage risks, there is a critical need for improving the existing incident reporting system and encouraging a culture of comprehensive reporting among dental professionals. Future efforts should focus on enhancing reporting systems to ensure high-quality data, enabling better identification of incident trends and supporting targeted risk management strategies to improve patient safety in dentistry.

Defining and Verifying New Local Climate Zones with Three-Dimensional Built Environments and Urban Metabolism

The urban heat island (UHI) effect, where the temperature in an urban area is higher than in the surrounding rural areas, is becoming a major concern. The concept of a Local Climate Zone (LCZ) system was devised to provide an objective framework for UHI research, which allows for a microscale definition of the UHI effect within urban areas by considering ‘urban’ and ‘rural’ as a continuum versus a dichotomy. However, most LCZ types are classified only by surface structure and coverings, which seem irrelevant to climatological and microscale concepts. In addition, microclimate is influenced by urban metabolism related to human activities as well as structural effects, but the LCZ-classification system does not incorporate these functional concepts. Therefore, this study proposes a novel urban-classification system that addresses the limitations of the LCZ concept by quantifying structural and functional elements of the city at the pedestrian level using S-DoT sensors and semantic segmentation techniques. This study holds significance as it suggests a New-LCZ (N-LCZ) system to support the classification framework of highly valid urban types and follow-up studies related to the UHI. Moreover, the N-LCZ offers a regional urban-planning strategy for sustainable development through a more valid classification system.

The bone trauma and soft-tissue injury classification system in total hip arthroplasty (BOSTI Hip).

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed. The BOne trauma and Soft-Tissue Injury classification system in total Hip arthroplasty (BOSTI Hip) grades osseous acetabular trauma and periarticular muscle damage during THA. The classification system has an interclass correlation coefficient of 0.90 (95% CI 0.86 to 0.93) for interobserver agreement and 0.89 (95% CI 0.84 to 0.93) for intraobserver agreement. RO THA was associated with improved BOSTI Hip scores (p = 0.002) and more pristine osseous surfaces in the anterior superior (p = 0.001) and posterior superior (p < 0.001) acetabular quadrants compared with CO THA. There were no differences between the groups in relation to injury to the gluteus medius (p = 0.084), obturator internus (p = 0.241), piriformis (p = 0.081), superior gamellus (p = 0.116), inferior gamellus (p = 0.132), quadratus femoris (p = 0.208), and vastus lateralis (p = 0.135), but overall combined muscle injury was reduced in RO THA compared with CO THA (p = 0.023). The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. RO THA was associated with improved BOSTI Hip scores, more pristine osseous acetabular surfaces, and reduced combined periarticular muscle injury compared with CO THA. Further research is required to understand if these intraoperative findings translate to differences in clinical outcomes between the treatment groups.

Podcast on How to Classify Foot Ulcers in People with Diabetes (2023 Update of the IWGDF Guidelines on Classification).

In this podcast, we present the result of the 2023 scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. These guidelines were based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. We first assessed the value of each system independently and, in the second stage, chose the best one or two to be used in each clinical scenario. We recommend (1)for communication among healthcare professionals to use the Site, Ischaemia, Neuropathy, Bacterial infection, Area, Depth (SINBAD) classification (first option) or consider using Wound, Ischaemia, foot Infection (WIfI) system (alternative option, when the required equipment and level of expertise are available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (2) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (3) for characterising a person with an infected ulcer: the use of the IDSA (Infection Diseases Society of America)/IWGDF (first option) classification or consider using the WIfI system (alternative option, when the required equipment and level of expertise are available and it is considered as feasible); (4) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (5) for the audit of outcome(s) of populations: the use of the SINBAD score. Although there is no classification that fits all purposes, it is crucial that healthcare professionals standardize the way they characterise diabetes-related foot ulcers and guide their decision-making process by using validated classification systems.

(215) Penuma® Penile Implant Adverse Events in the Manufacturer and User Facility Device Experience (MAUDE) Database

Abstract Introduction Penuma® is an FDA-approved penile implant intended to increase flaccid penile length and girth for improved cosmesis. It is the only FDA-approved product of its kind, with reportedly thousands of implants since 2004. There is a paucity of data on the adverse events related to this procedure. Objective To describe and characterize adverse events related to Penuma® using a national database. Methods The Manufacturer and User Facility Device Experience (MAUDE) database, a voluntary-reported database of medical device complications with data since 1991, was queried. The MAUDE adverse event classification system, a validated classification system, was used as a standardized tool to classify adverse events based on severity. All adverse events related to Penuma® were identified and quantified. Results 42 reports of adverse events related to Penuma® were identified (Figure 1). Of these, 35 patients were reported to undergo device removal most commonly due to infection (n=8) or protrusion (n=8). (Table 1). The most commonly reported adverse event was deformity/disfigurement (n=27), of which 18 cases reported loss of penile length. Other adverse events included: pain (n=16), infection (n=12), decreased sensitivity (n=10), scar tissue (n=9), erectile dysfunction (n=8), seroma (n=7), and erosion (n=6). Conclusions To our knowledge, this is the first study to systematically characterize publicly reported adverse events occurring with Penuma® implantation, using the MAUDE database. Further research is warranted to delineate the incidence of adverse events related to Penuma®. Disclosure No.

A Modified and Refined Classification System for Secondary Cleft Nasolabial Deformities.

Secondary cleft lip (CL) deformities are commonly encountered in cleft management. Various attempts have been made to create a classification system that can comprehensively encapsulate residual CL deformities after primary repair. The aim of this study is to reinforce valid classification systems and to introduce a new classification subtype (Type V Revision). A longitudinal retrospective analysis was done in 35 outreach programs in 4 countries (Ecuador, Lebanon, Peru, and El Salvador) between 2015 and 2023. Two hundred sixty-nine patients, between the ages of 9 months and 45 years, with residual CL deformities after primary lip repair, were classified into one of the 5 classification types. Patients with syndromes were excluded from the study. Patients received one of 5 revision types depending on their initial preoperative evaluation and intraoperative analysis of anatomic involvement. The mean age at surgery was 12.86 years. Twenty-five patients received type I revision, 29 patients received type II revision, 81 patients received type III revision, 106 patients received type IV revision, and 28 patients received type V revision. As the surgical complexity advanced from type I to V, there was a gradual increase in the average surgical time. The Congruence between preoperative and postoperative revision types was substantial. Residual CL defects cause a significant burden on both the patient and cleft care provider. This classification system, with the newly introduced type V revision, enhances and eases the categorization and management of secondary CL deformities.

Surgeons’ perspectives for a future obstetric fistula classification system: exploring the key parameters

Background There is currently no unified classification scheme for accurately describing vesico-vaginal fistulas, thereby limiting communication between surgeons and the ability to compare research. Many factors related to surgical failure or success have not been explored, and surgeons currently do not universally use the same classifications. The objective of this study is to determine which factors are the most important to include in a future obstetric fistula classification scheme. Methods Members of the International Society of Obstetric Fistula Surgeons were surveyed using a non-validated questionnaire to explore their experience and factors they think were most important to include in an updated comprehensive obstetric fistula classification scheme. Based on the surgeons’ response, an average ranking of each determinant of obstetric fistula classification system was computed. Results The most critical factors that surgeons found necessary to include in an updated fistula classification system are the bladder size (88.9%, n=16, rank=8.53), degree of fibrosis of the vagina (83.3%, n=15, rank=8.12), degree of urethral damage (88.9%, n=16, rank=9.34), location of the fistula (100%, n=18, rank=9.22), urethral length (94.4%, n=17, rank=9.06), and whether the fistula is circumferential or not (94.4%, n=17, rank=9.18). The least important factors were how long the patient had had a fistula (11.1%, n=2, rank=2.28) and intraoperative complications (22.2%, n=4, rank=4.59). For most factors important in repair, there was a non-significant correlation between experience level and ratings from 0-10. Scores for urethral length showed a significant correlation between increased surgical experience and higher ratings of importance. Conclusions Three most commonly used classification schemes by Goh, Waaldjik, and the World Health Organization (WHO) only capture some important factors determined by the surveyed surgeons. Given the inconsistency between what experienced and expert surgeons deem to be important determinants for the classification of obstetric fistula and what is currently included in classification systems, we call for constructing a new, validated classification system.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Do Syndesmotic Injury Patterns Influence Functional and Radiological Outcomes in Complex Ankle Fractures? A Retrospective Cohort Study

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis injury can be of a varying magnitude; little information exists about the influence of degree of initial syndesmotic injury/instability on functional outcomes in ankle fractures, nor is there any correlation of this with follow up radiological parameters. Aims and Objectives: To identify and define morphological patterns of syndesmotic injury in ankle fractures according to a zone based evaluation, and correlate initial degree of instability with mid-term functional and radiological outcomes using validated scores Design: Retrospective cohort study, to review a prospective question. Methods: 40 complex ankle fractures out of 120 ankle fractures in our ankle registry met the inclusion criteria ie significant documented syndesmosis involvement needing stabilization, with all initial clinical and radiological records available. The patients were followed up between January 2020 to July 2021. Injury characteristics, fracture morphology of posterior malleolus, medial malleolus and fibula were noted and classified by validated classification systems based on x-rays and CT scan. The syndesmosis was analyzed on axial CT scan; it was divided into 3 zones, A,B,C from anterior to posterior, and degree of displacement and morphology was noted. Immediate post-operative radiographs were evaluated for fracture and syndesmosis reduction. The patients were evaluated at final follow up with both ankle specific scores (Olerud Molander score, Ankle-Hindfoot scale, Manchester-Oxford Foot questionnaire) and quality of life score (SF-12). Ankle Osteoarthritis grade was used to evaluate radiological outcomes. Results: Mean follow-up was 19 months. 22(55%) patients had syndesmotic widening on plain radiographs; however in pre- operative CT scan evaluation 40(100%) patients had syndesmotic injury based on the Zone evaluation of the syndesmosis. 22 patients had Zone A injury (widening, AITFL, Chaput, Wagstaff). 22 patients had widening of Zone B. Zone C was involved in 30 patients (PM fracture,PITFL involvement). At final follow up; the mean OMAS was 83.38±16.35, mean Ankle-Hindfoot scale= 88±9.98, mean Mox-FQ score=27.15±13.35 &amp; mean SF-12 were (MCS=56.59±8.24, PCS=51.18±8.48). There was no significant difference in outcome scores based on fracture types, Posterior malleolus morphology, or based on zones of syndesmosis injury. Syndesmosis malreduction contributed to significantly poorer outcomes (SF-12, OMAS, MoxFQ) Conclusion: Despite a zonal classification of syndesmotic injury on CT and more clarity of injury patterns, we could not corelate the site and extent of syndesmotic injury with final functional and radiological outcomes. The one factor that has significant influence is initial accurate reduction of both the malleolar fractures and syndesmosis injury. In this the CT based axial classification may play a role.

The prevalence of chronic and episodic loneliness and social isolation from a longitudinal survey

Loneliness and social isolation, experienced more long-term, has been shown to increase mortality and lead to poorer health outcomes in specific cohorts. However, it is unclear what the prevalence of chronic loneliness and social isolation is, and which demographic groups are most at risk of reporting more chronic forms. A psychometrically validated classification system was used to identify people who met criteria for episodic and chronic loneliness and social isolation using the Household Income and Labour Dynamics in Australia (HILDA) survey waves 14–18. The prevalence of loneliness (overall 34%; 21% episodic, 13% chronic) far exceeded that of social isolation (overall 17%; 13% episodic, 4% chronic). There was consistency in the demographic characteristics (from age, sex, household type, income) of those who experienced loneliness and social isolation. However, people with a long-term health condition had an elevated risk of episodic loneliness (AOR 1.24, 95% CI 1.11–1.39) and a markedly higher risk of chronic loneliness (AOR 2.01, 95% CI 1.76–2.29), compared with those without a long-term health condition. Loneliness, both episodic and chronic subtypes, is more prevalent than social isolation. However, both chronic loneliness and social isolation remains neglected and poorly targeted within current practice and policy.

Classification of Adverse Events in Adult Surgery.

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.

Causes of death in stillbirth and quality of care—an example of a local audit

AbstractIntroductionNeonatal deaths have decreased steadily in Sweden since the 1960s, but the stillbirth rate has been stable at around 4 per 1000 births, for the last 40 years. Risk factors of stillbirth are well studied; however, the cause of death is unclear in many cases. The purpose of this study was to examine causes of death in stillbirth using a classification system. In addition, we aimed to assess substandard care factors and identify areas for quality improvement.Materials and MethodsWe performed a retrospective clinical audit of all stillbirths delivered between January 2006 and December 2019. We performed a detailed investigation of medical records and classified the causes of death according to ‘The Stockholm classification of stillbirth’. Unclear cases were discussed in a multidisciplinary local audit group. Substandard care factors were identified and classified as probable, possible, or unlikely, with respect to the cause of death.ResultsIn total, there were 64 cases of stillbirth. It was possible to determine a cause of death in 91% (95% confidence interval [CI]: 81.02–95.63) of the cases. The leading cause of death was intrauterine growth restriction (IUGR)/placental insufficiency (45%) (95% CI: 33.73–57.43), followed by infection (13%) (95% CI: 6.47–22.8) and placental abruption (9%) (95% CI: 4.37–18.98). Factors of substandard care were identified in 49% (95% CI: 37.06–61.4) of the cases, but in only 10% the substandard care factor had a probable association with the cause of death.ConclusionIntroducing a local audit group and using a validated classification system made it possible to find a cause of death in about 90% of the cases of stillbirth. Since IUGR/placental insufficiency is the leading cause of death, it is important to improve current strategies to identify pregnancies at risk for IUGR, antenatally. Our results suggest that there is a possibility to improve the quality of care in many areas, particularly regarding symphysis‐fundus measurements.Tweetable AbstractA validated classification system and local audits are valuable tools to determine the causes of IUFD. This enables directed preventive actions toward IUFD.

Psychometric properties of the Viking Speech Scale-Turkish version for children with cerebral palsy aged 4-18 years based on live and video-based observation.

Speech is the most common method of communication. Video-based clinical communication evaluation is a requirement for children with speech-language impairments living in rural areas, and those who have limited mobility. To determine the validity and reliability of the Turkish version of the Viking Speech Scale (VSS-T) via live and video-based observation for children with cerebral palsy (CP) aged 4-18 years. A total of 142 children (mean age 8.18 ± 3.98 years; 68 female) with CP were included in this study. Their motor, communication, visual and eating-drinking function levels and comorbidities (dental, swallowing, cognitive impairments and epilepsy) were recorded. The Intelligibility in Context Scale (ICS), the Pediatric Evaluation of Disability Inventory-Social Function (PEDI-SF), and the Functional Independence Measure for Children-Communication (WeeFIM-C) were assessed to examine the concurrent validity of the VSS-T. The interrater reliability of the VSS-T was analysed between parents, physical therapists, and speech and language therapists from live and video-based observation. Intra-rater reliability was calculated from ratings made from live and video-based observations taken 3 weeks apart. The VSS-T was strongly related to the ICS (r = -0.830), PEDI-SF (r = -0.819), WeeFIM-C (r = -0.643), other functional classifications (r > 0.432), and the comorbidities (Cramer's V > 0.284, p < 0.001). Good to excellent interrater reliability (κw ≥ 0.838) and intra-rater reliability (intraclass correlation coefficient (ICC) = 0.848-0.995) were found between parents and therapists. Speech and language therapists, physical therapists, and parents can use the VSS-T as a valid and reliable classification system to describe speech intelligibility of 4-18-year-old children with CP. Both live and video-based observations can be used to administer the VSS-T. What is already known on the subject The English version of the VSS has been shown to be a valid and reliable tool used to classify the speech of children with CP aged 4-13 years. The scale can be administered by means of live observation of the child or based on clinicians' notes on the case by parents, SLTs, physiotherapists and paediatricians. What this paper adds to existing knowledge The VSS-T is valid and reliable for children with CP aged 4-18 years. Video-based observation is a suitable method for evaluating the VSS-T levels. The VSS-T has a moderate association with the CFCS. What are the potential or actual clinical implications of this work? The VSS-T is a valid and reliable method of categorizing the severity of motor speech impairment for Turkish children with CP in clinical research studies, registry systems or epidemiological studies. Both experienced and inexperienced therapists can use either live or video-based observation methods to administer the VSS-T. This study extended the validity and reliability of the scale in children with CP aged up to 18 years. The VSS-T is also associated with the Visual Functional Classification System (VFCS), which has been recently developed for describing the visual abilities of children with CP in daily life. In addition, the VSS-T is associated with the presence of dental, swallowing, cognitive problems and epilepsy.

Racism without race: reconstructing race through culture in Spanish social-science textbooks

ABSTRACT What happens to race when racial vocabulary disappears? This paper leverages a sudden change in the Spanish social science curriculum in the 1990s to empirically trace how the removal of the language of race, and the negation of biological race, changes the ways the books portray human differences. Through the analysis of 82 textbooks from 1975 to 2017, I find that a racial classification system is replaced by one based on cultural categories. Yet, far from moving away from polygenistic beliefs about human nature, culture continues to reproduce the same social hierarchies previously associated with a phenotype. Because the books present culture as a scientifically valid classification system, the use of culture legitimizes and entrenches those same beliefs in racial differences. The findings have implications for our understanding of colourblind ideologies, and for the study of race relations in European contexts.

Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework

The optimal therapeutic approach for walled-off necrosis (WON) is not fully understood, given the lack of a validated classification system. We propose a novel and robust classification system based on radiologic and clinical factors to standardize the nomenclature, provide a framework to guide comparative effectiveness trials, and inform the optimal WON interventional approach. This was a retrospective analysis of patients who underwent endoscopic management of WON by lumen-apposing metal stent placement at a tertiary referral center. Patients were classified according to the proposed QNI classification system: quadrant ("Q"), represented an abdominal quadrant distribution; necrosis ("N"), denoted by the percentage of necrosis of WON; and infection ("I"), denoted as positive blood culture and/or systemic inflammatory response syndrome reaction with a positive WON culture. Two blinded reviewers classified all patients according to the QNI system. Patients were then divided into 2 groups: those with a lower QNI stratification (≤2 quadrants and≤30% necrosis; group 1) and those with a higher stratification (≥3 quadrants, 2 quadrants with≥30% necrosis, or 1 quadrant with >60% necrosis and infection; group 2). The primary outcome was mean time to WON resolution. Secondary procedural and clinical outcomes between the groups were compared. Seventy-one patients (75% men) were included and stratified by the QNI classification; group 1 comprised 17 patients and group 2, 54 patients. Patients in group 2 had a higher number of necrosectomies, longer hospital stays, and more readmissions. The mean time to resolution was longer in group 2 than in group 1 (79.6 ± 7.76 days vs 48.4 ± 9.22 days, P= .02). The mortality rate was higher in group 2 (15% vs 0%, P= .18). Despite the heterogeneous nature of WON in severe acute pancreatitis, a proposed QNI system may provide a standardized framework for WON classification to inform clinical trials, risk-stratify the disease course, and potentially inform an optimal management approach.

Preoperative Multifidus Muscle Quality is Associated With Patient Reported Outcomes After Lateral Lumbar Interbody Fusion.

Retrospective cohort. Lateral lumbar interbody fusion (LLIF) commonly involves a transpsoas approach. Despite the association between LLIF, postoperative iliopsoas weakness, and iatrogenic neuropraxia, no study has yet examined the effect of psoas or multifidus muscle quality on patient-reported outcomes (PROs). This study retrospectively reviewed patients who underwent LLIF with 1-year minimum follow-up. Psoas and multifidus muscle qualities were graded on preoperative magnetic resonance imaging using two validated classification systems for muscle atrophy. Average muscle quality was calculated as the mean score from all levels (L1-2 through L5-S1). Univariate and multivariate statistics were utilized to investigate the relationship between psoas/multifidus muscle quality and preoperative, 6-weeks postoperative, and final postoperative PROs. 74 patients (110 levels) with a mean follow-up of 18.71 ± 8.02 months were included for analysis. Greater multifidus atrophy was associated with less improvement on ODI, SF12, and VR12 (P < .05) on univariate analysis. On multivariate analysis, worse multifidus atrophy predicted less improvement on SF12 and VR12 (P < .05). Despite the direct manipulation of the psoas muscle inherent to LLIF, preoperative psoas muscle quality did not affect postoperative outcomes. Rather, the extent of preoperative multifidus fatty infiltration and atrophy was more likely to predict postoperative pain and disability. These findings suggest that multifidus atrophy may be more pertinent than psoas atrophy in its association with patient-reported outcome measures after LLIF.

P138. Preoperative multifidus muscle quality is associated with patient-reported outcomes after lateral lumbar interbody fusion

<h3>BACKGROUND CONTEXT</h3> Lateral lumbar interbody fusion (LLIF) is a commonly performed spinal surgery which involves a transpsoas approach. Despite the association between LLIF and postoperative iliopsoas weakness and iatrogenic neuropraxia of the lumbar plexus, no study has yet examined the effect of psoas or multifidus muscle quality on patient-reported outcomes (PROs). <h3>PURPOSE</h3> This study sought to investigate the effect of psoas and multifidus muscle quality on postoperative subjective patient-reported outcomes following LLIF. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> Patients who underwent LLIF with one of two senior surgeons at a single institution with 1-year minimum followup. <h3>OUTCOME MEASURES</h3> PROs evaluated included the Short Form 12-Item Health Survey (SF12), Veterans RAND 12-Item Health Survey (VR12), Oswestry Disability Index (ODI), and Visual Analog Scales (VAS) for Back and Leg pain. <h3>METHODS</h3> Preoperative psoas and multifidus muscle qualities were graded on magnetic resonance imaging (MRI) using two validated classification systems for muscle atrophy (Kader [KCS] and Goutallier [GCS]). Average psoas and multifidus muscle quality was calculated as the mean score from all levels (L1-2 through L5-S1). Univariate and multivariate statistics were utilized to investigate the relationship between psoas/multifidus muscle quality and preoperative, 6 weeks postoperative, and 1 year postoperative PROs. The variables adjusted for in the multivariate analysis included age, sex, BMI, smoking history, diabetes, concomitant posterior percutaneous instrumentation and history of prior open posterior lumbar surgery. <h3>RESULTS</h3> Seventy-four patients (110 levels) with a mean follow-up time of 18.71±8.02 months were included for analysis. Univariate analysis demonstrated that increased psoas atrophy was significantly associated with worse ODI scores (KCS: p=.018; GCS: p=.017). This became non-significant on multivariate analysis. Greater multifidus atrophy was associated with less improvement on ODI (KCS: p=.033; GCS: p=.019), SF12 (KCS: p=.005; GCS: p=.003) and VR12 (KCS: p=.003; GCS: p=.004) on univariate analysis. On multivariate analysis, a higher degree of multifidus atrophy independently predicted less improvement on SF12 (KCS, p=.023; GCS, p=.032) and VR12 (KCS, p=.016; GCS, p=.045). Patients with a history of prior lumbar surgery reported significantly worse pain and disability at all time points (p<.05), as well as less improvement in ODI (p=.043) and VAS Back (p=.028) from preoperatively to 1-year postoperatively. <h3>CONCLUSIONS</h3> Despite the direct manipulation of the psoas muscle inherent to LLIF, preoperative psoas muscle quality did not affect postoperative outcomes. Rather, the extent of preoperative multifidus fatty infiltration and atrophy was more likely to predict postoperative pain and disability. These findings suggest that multifidus atrophy may be more pertinent than psoas atrophy in its association with patient-reported outcome measures after LLIF. Our results also indicate that a history of prior lumbar surgery is associated with significantly less improvement in PROs after LLIF. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

What are the limits across major animal production systems for tolerable animal welfare, disease, climate and environmental vulnerabilities and how do we measure them?

Animal agriculture is in the spotlight as commentators and researchers assess its contribution to greenhouse gas emissions, emerging infectious disease, environmental degradation, non-communicable food-related diseases and inadequate animal welfare. To date, however, research has largely failed to explore the significant differences between livestock species and the range of production systems under which they are raised. There is an absence of validated classification systems that are based on ontological processes. In many areas of the world, traditional livestock raising practices have survived for thousands of years and continue to date, yet they are under pressure with human population pressure, land and water use. In the 20th century, intensive livestock production systems were hailed as economic successes with environmental externalities largely ignored. Moving forward what constitutes ‘tolerable’ animal agriculture in a changing world facing multiple existential threats? Do the limits vary across geographies, production systems and cultures? If they do, how can these differences be measured? How might these limits contribute to defining associated sustainable and circular bioeconomies?

Does Focal Osteolysis in a PRECICE Stryde Intramedullary Lengthening Nail Resolve after Explantation?

Concerns surrounding osteolysis near and around the modular junction of a stainless-steel intramedullary lengthening rod prompted a manufacturer recall from the United States market in early 2021. These actions were preceded by similar steps taken in Europe. A concomitant review of stainless-steel lengthenings at our institution demonstrated signs of adverse tissue reaction including periosteal reaction and osteolysis at the modular junction and/or male-sided locking screws. Nearly half of our patients presented with these findings on radiographic images. At the time of the previous review, only half of the nearly 60 implanted stainless-steel devices met a 6-month follow-up. At this juncture, many patients have had their devices explanted. Given the suspected adverse tissue reactions caused by a component of the internal device, we sought to examine the rate of osteolysis post-explantation following removal of a stainless-steel nail. We reviewed a consecutive series of patients who underwent implantation of a stainless-steel limb lengthening device in the femur and/or tibia at a single institution between December 2018 and December 2020. Patients were included if their device was explanted. Periosteal reaction and osteolysis was classified according to a novel and validated classification system, as analyzed by five fellowship-trained surgeons. In addition, changes observed prior to explantation were tracked post-explantation to assess for resolution. The incidence of periosteal reaction and osteolysis prior to explantation was 22/57 (39%) and 15/57 (26%), respectively. Of the 15 patients with osteolysis pre-explantation, 14 patients’ implants were explanted. Of these, eight patients had available follow-up films. Two patients were identified as having partial osteolysis resolution at mean 1-year follow-up, while six patients were identified as having complete osteolysis at mean 18-months follow-up. Periosteal tissue reaction and osteolysis largely resolved following explantation in a subset of patients. These results provide further support to the claim that the stainless-steel device contributed to the changes seen. Further follow-up is warranted to examine the longer-term effects of adverse tissue reaction in this patient population.

Construct Validity of the Autism Classification System of Functioning: Social Communication (ACSF:SC) Across Childhood and Adolescence.

This study examined the construct validity of the Autism Classification System of Functioning: Social Communication (ACSF). Participants included 145 parents of children with autism (2-19 years). The degree of convergent and discriminant validity between parent reported ACSF and subscales from Social Responsiveness Scale 2nd edition and Behavior Assessment System for Children, 3rd Edition were examined against a priori hypotheses. We examined construct validity in the entire sample as well as in specific age cohorts. Our findings suggest that ACSF can provide a valid classification system of social communication ability in children with autism 2-19 years of age, and its two subscales may be used to examine different aspects of social communication ability.