Validation In Clinical Practice Research Articles

Towards a standardized classification of cardiogenic shock: Will the new SCAI staging system translate into better clinical practice and research?

The 2019 SCAI shock staging system is a valid risk stratification tool in hemodynamically unstable patients. Shock stage is a strong predictor of short-term mortality and its daily re-assessment may guide the escalation or de-escalation of therapy. Additional large-scale validation studies are needed to confirm the new SCAI shock staging system's validity in clinical practice and research.

Validation of the Spanish Wound-QoL Questionnaire

Background and aimsThe Wound-QoL is a validated and feasible questionnaire for measuring disease-specific health-related quality of life in chronic wounds, originally developed for use in German.The objective of this study was to translate the Wound-QoL for use in clinical care and in clinical trials in Spain and to validate this version. Materials and methodsTwo independent fourth- and back translations of the Wound-QoL from the original German version were conducted, followed by an expert consensus of the resulting versions. After refinement, the final tool was piloted in N = 10 patients and then used in the validation study. ResultsA total of 115 patients were recruited. Mean age was 69.5 (SD 14.5) years, 60.0 % were female. The Spanish version of Wound-QoL showed high internal consistency (Cronbach’s alpha > 0.8 in all scales). Factor analysis resulted in the same scales as the original version. There were satisfactory distribution characteristics of the global score and the subscales. Construct validity and convergent validity with other outcomes (generic QoL, healing rate) were satisfactory. The vast majority of patients considered the Wound-QoL a simple and feasible tool. Mean time needed for completing the questionnaire was 5 minutes. Overall, 99.1 % of the participants found it easy to understand the questions and 94.7 % stated that the questionnaire suits the personal situation. ConclusionsThe Spanish version of the Wound-QoL shows good validity in clinical practice. It can be recommended for use in clinical routine and trials.

Designing a diagnosis? Reflections on design, medicalization, and mild cognitive impairment (MCI)

Medicalization refers to the process by which ordinary human problems and experiences—such as depression, anxiety, addiction, and child hyperactivity—come to be defined and treated as distinct medical conditions. The growing influence of Western medicine (or ‘biomedicine’) in contemporary society has had a profound impact on people’s understanding of what it means to be ‘normal’, how they conceptualize and respond to illness, and perhaps even their understanding of life itself. Despite the increasing number of products, services, and interventions that extend the reach of medicine into everyday life, the concept of medicalization has received surprisingly little attention in the design literature. This article presents a single case study, a web design project called ‘Living Well with Mild Cognitive Impairment (MCI)’, to provoke discussion around how design processes and practices are sometimes embroiled in the construction of new medical diagnoses, and the implications this might have for the emerging field of design for health. The research found that the website helped legitimize the MCI diagnosis by giving it form, despite ongoing debates about its use and validity in clinical practice.

Validación de la versión española del cuestionario Wound-QoL

Background and aimsThe Wound-QoL is a validated and feasible questionnaire for measuring disease-specific health-related quality of life in chronic wounds, originally developed for use in German.The objective of this study was to translate the Wound-QoL for use in clinical care and in clinical trials in Spain and to validate this version. Materials and methodsTwo independent fourth- and back translations of the Wound-QoL from the original German version were conducted, followed by an expert consensus of the resulting versions. After refinement, the final tool was piloted in N=10 patients and then used in the validation study. ResultsA total of 115 patients were recruited. Mean age was 69.5 (SD 14.5) years, 60.0% were female. The Spanish version of Wound-QoL showed high internal consistency (Cronbach's alpha>0.8 in all scales). Factor analysis resulted in the same scales as the original version. There were satisfactory distribution characteristics of the global score and the subscales. Construct validity and convergent validity with other outcomes (generic QoL, healing rate) were satisfactory. The vast majority of patients considered the Wound-QoL a simple and feasible tool. Mean time needed for completing the questionnaire was 5minutes. Overall, 99.1% of the participants found it easy to understand the questions and 94.7% stated that the questionnaire suits the personal situation. ConclusionsThe Spanish version of the Wound-QoL shows good validity in clinical practice. It can be recommended for use in clinical routine and trials.

Abstract 5477: A novel loci-selected method for microsatellite instability detection validated on a large Chinese cohort

Abstract Purpose: Microsatellite instability (MSI) was the FDA-approved companion diagnostic biomarker for using pembrolizumab in solid tumors and the biomarker for Lynch Syndrome. Next-generation sequencing (NGS) based method was recommended by NCCN and ESMO for detecting MSI status due to rich mutation information it could provide. However, current NGS based methods could be discordant on some cases, triggering confusion in clinical practice. To address this concern, we developed a novel and highly accurate MSI detection method, 3D-MSI, with a set of well-selected loci and compared its performance with other 3 public methods (MANTIS, MSISensor2, mSINGS) Materials and Methods: 100 MSI loci were selected from 2539 candidates and then sequenced on 145 FFPE samples as the training dataset. A binomial distribution model was built on each loci to predict PCR-validated MSI statuses of all samples in the training dataset and then all models were ordered by their prediction accuracy. 3D-MSI method determined MSI status by the percentage of top 30 loci models which predict the sample as MSI-H (>40%: MSI-H; otherwise MSS). Performances of 3D-MSI and other 3 methods were compared on 485 MSI-validated sample. Their discordance were further investigated on a large cohort of 10399 Chinese cancer patients. Detection limits of these 4 methods were determined by 4 serial-diluted tumor samples. We also observed concordance between 3D-MSI detected statuses and immunotherapy response on 27 advanced colorectal cancer (CRC) patients. Results: In the dataset of 485 samples, 3D-MSI had the highest accuracy (All: 96.7%, Colorectal cancer CRC: 98.9%, Gastric cancer GC: 97.0%, other cancer: 86.4%), sensitivity (All: 93.2%, CRC: 97.0%, GC: 94.4%, Other: 80.8%) and specificity (All: 98.2%, CRC: 99.5%, GC: 98.8%, Other: 90.0%) among all 4 methods. It could detect correct MSI status under low tumor content down to 5%, but other methods required much higher tumor content to work (MSISensor2: ≥15%, mSINGS: ≥20%, MANTIS: ≥40%). Study on 10399 Chinese cancer patients confirmed superiority of 3D-MSI: compared with other 3 methods, it yielded the fewest discordant and unreliable MSI statuses questioned by PCR (3D-MSI: 1, MSISensor2: 36, mSINGS: 36, MANTIS: 50). Loci selection was the key point for 3D-MSI to outrival other 3 methods, revealed by comparing their scoring distribution. 3D-MSI detection predicted significantly prolonged PFS (log-rank P<0.0001) and OS (log-rank P<0.0001) of the MSI-H group in 27 CRC patients who received immunotherapy, proving its validity in clinical practice. Conclusions: Our study offered an improved and clinically validated method for NGS-based MSI detection and stressed importance of loci selection in MSI detection, which would have crucial implications for future research and clinical management. Citation Format: Jian Li, Zhenghang Wang, Bo Yang, Bin Li, Yunjie Song, Bei Zhang, Xiaochen Zhao, Yifan Zhou, Zhenghua Xie, Xiaofang Li, Hao Chen, Hua Dong, Yuezong Bai, Lei Xiong, Fugen Li, Jing Gao, Lin Shen. A novel loci-selected method for microsatellite instability detection validated on a large Chinese cohort [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5477.

Normative data for Emotion Hexagon test and frequency of impairment in behavioral variant frontotemporal dementia, Alzheimer’s disease and Huntington’s disease

Social cognitive functions such as Theory of Mind, empathy and emotion recognition can be impaired in dementia spectrum disorders, especially in diseases with prominent frontal dysfunction. The Emotion Hexagon test (EHT) is a short test of basic emotion recognition. As with other social cognitive tests, normative data for this test is sparse. The aim of this study was to present regression-based normative data for the EHT. Further, we wished to investigate the frequency of impairment in patients with the behavioral variant of frontotemporal dementia (bvFTD, N = 11), Alzheimer’s disease (AD, N = 44) and Huntington’s disease (HD, N = 52) when using regression-based normative data. The results documented that age (but not gender or education) had a significant effect on EHT score. The effect of age had numerical impact on expected scores in persons older than 60 years. Normative data (including percentile estimates) are presented. The EHT is sensitive to impairment in both bvFTD and HD, where more than 80% of patients had lower scores than expected. In both groups, 54% of patients fell below the 5th percentile-estimate, and in HD 65% fell below the 10th percentile-estimate. In the AD group 25% fell below the 10th percentile-estimate, and 14% fell below the 5th percentile-estimate. In conclusion, very low scores are typically associated with HD and bvFTD, but very poor performances can also be found in other diseases such like AD. Hopefully, the normative data presented and the documentation of their validity in clinical practice is a useful tool for clinicians.

Development of a Machine Learning Model Predicting an ICU Admission for Patients with Elective Surgery and Its Prospective Validation in Clinical Practice.

Frequent utilization of the Intensive Care Unit (ICU) is associated with higher costs and decreased availability for patients who urgently need it. Common risk assessment tool, like the ASA score, lack objectivity and do account only for some influencing parameters. The aim of our study was (1) to develop a reliable machine learning model predicting ICU admission risk after elective surgery, and (2) to implement it in a clinical workflow. We used electronic medical records from more than 61,000 patients for modelling. A random forest model outperformed other methods with an area under the curve of 0.91 in the retrospective test set. In the prospective implementation, the model achieved a sensitivity of 73.3% and a specificity of 80.8%. Further research is essential to determine physicians' attitudes to machine learning models and assess the long term improvement of ICU management.

PF710 LONG‐TERM OVERUSE OF CORTICOSTEROIDS IN THE REAL‐WORLD TREATMENT OF PATIENTS WITH IMMUNE THROMBOCYTOPENIA IN THE US EXPLORYS AND MARKETSCAN DATABASES

Background:Corticosteroids (CSs) are standard first‐line (1L) therapy for immune thrombocytopenia (ITP), but prolonged exposure leads to detrimental effects. Multiple 2L treatment options exist; however, there is little consensus on the preferred sequence.Aims:To assess real‐world ITP treatment patterns using the US IBM® Explorys and MarketScan databases.Methods:This retrospective, observational cohort analysis used claims in the US IBM® Explorys and MarketScan databases (2011–2017) of adult patients newly diagnosed with ITP (pts). Included patients were limited to those with commercial or private health coverage and proxies of eligibility within the Electronic Health Record (EHR) system in MarketScan and Explorys, respectively. Selection criteria: Adults with ≥1 primary ITP diagnosis (ICD‐9‐CM 287.31 or ICD‐10‐CM D69.3); ≥12 months’ data available prior to first ITP diagnosis; ≥1 ITP treatment; and ≥1 month of data available post‐first ITP treatment. Patients with hepatitis and HIV were excluded. Line of treatment was considered continuous until one of the following: patient discontinued all treatments for ≥60 days, switched or augmented treatment (addition of a new ITP agent ≥28 days after the treatment line start date), dis‐enrolled, died, or was censored due to study end. Data were collected and analyzed separately for each database. Descriptive statistics are presented by ITP therapy up to 7L.Results:4066 of 22900 (18%) and 7837 of 50428 (16%) ITP patients were eligible (majority of patients did not meet criteria for newly diagnosed ITP and ≥1 month of data post‐first ITP treatment) in Explorys and MarketScan, respectively. Mean ± SD age (years) at start of treatment was 61 ± 18 and 56 ± 18, respectively. Most patients received ≥2L in both Explorys (54%) and MarketScan (63%).Surprisingly, >90% of patients in both databases received CSs, not only as part of 1L therapy, but also as part of all subsequent lines of treatment (Fig). Standard 2L treatments were used less frequently in Explorys vs MarketScan: rituximab (12% vs 25%), eltrombopag (5% vs 6%), romiplostim (7% vs 12%), and splenectomy (3% vs 8%).Repeated courses of CSs were common. The prednisone–prednisone–prednisone sequence was the most common treatment sequence across 1–3L (Explorys vs MarketScan: 33% vs 18%).Eltrombopag use increased from 1L onwards (Fig). From 2015 until 2017, the proportion of patients treated with eltrombopag and rituximab as 2L and 3L in the Explorys sample increased (eltrombopag: 5–14%; rituximab: 8–29%). Prednisone use as 2L and 3L therapy decreased from 62% to 43% but remained the most widely used treatment over the period covered in the data analysis.Summary/Conclusion:Data from Explorys (US EMR database) and MarketScan (US claims database) showed that long‐term CS use is highly prevalent in ITP patients, not only at 1L, but also at all subsequent lines. Thrombopoietin receptor agonists, rituximab, and splenectomy were used much less frequently than expected. These data suggest the need for improved interventions to reduce long‐term CS use and increase the use of other effective therapies currently available. Further validation in clinical practice may be required considering these analyses were limited to <20% of ITP patients in each database.image

Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement.

The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group. A total of 45 simulated clinical scenarios were refined to five common clinical presentations and six corresponding treatment recommendations. The final guideline stratifies patients based upon a new, standardized classification of symptoms, signs, radiological findings, duration of symptoms, and previous treatment. The 2018 BASK Arthroscopic Meniscal Surgery Treatment Guidance will facilitate the consistent identification and treatment of patients with meniscal lesions. It is hoped that this guidance will be adopted nationally by surgeons and help inform healthcare commissioning guidance. Validation in clinical practice is now required and several areas of uncertainty in relation to treatment should be a priority for future high-quality prospective studies. Cite this article: Bone Joint J 2019;101-B:652-659.

Current Recommendations for Nutritional Management of Overweight and Obesity in Children and Adolescents: A Structured Framework.

Nutritional management is an important component of the treatment of pediatric overweight and obesity, but clinicians struggle to keep abreast with the abundant literature. Therefore, our aim is to provide a tool that integrates the current recommendations and clinical expertise to assist dietitians and other practitioners in their decision making about the nutritional management of pediatric overweight and obesity. To construct this practice-based evidence-informed framework, we conducted a systematic review of the guidelines on nutritional management of pediatric overweight or obesity in 2 databases and in the grey literature. We analyzed and synthesized recommendations of 17 guidelines. We selected the recommendations that were common to at least 30% of the guidelines and added by consensus the recommendations relevant to clinical expertise. Finally, we structured the framework according to the Nutritional Care Process in collaboration with a specialized team of dietitians who assessed its validity in clinical practice. The framework contributes to facilitate the integration of evidence-based practice for dietitians by synthesizing the current evidence, supporting clinical expertise, and promoting structured care following Nutrition Care Process model for children and adolescents with obesity.

P1173Repeated ablation of atrial fibrillation with ultra-high density mapping: workflow and validation in clinical practice. Insights from the TRUE HD study

P1173Repeated ablation of atrial fibrillation with ultra-high density mapping: workflow and validation in clinical practice. Insights from the TRUE HD study

Surgery for patients with newly diagnosed advanced ovarian cancer: which patient, when and extent?

Cytoreduction to no residual disease is the mainstay of primary treatment for advanced epithelial ovarian cancer (AdvEOC). This review addresses recent insights on optimal patient selection, timing, and extent of surgery, intended to optimize cytoreduction in patients with AdvEOC. Clinical guidelines recommend primary cytoreductive surgery (PCS) for AdvEOC patients with a high likelihood of achieving complete cytoreduction with acceptable morbidity. In line with this, preoperative prediction markers such as cancer antigen-125, histologic and genomic factors, innovative imaging modalities, and the performance of a diagnostic laparoscopy have been suggested to improve clinical decision-making with regard to optimal timing of cytoreductive surgery. To determine whether these strategies should be incorporated into clinical practice validation in randomized clinical trials is essential. The past decade has seen a paradigm shift in the number of AvdEOC patients that are being treated with upfront neoadjuvant chemotherapy instead of PCS. However, although neoadjuvant chemotherapy may reduce morbidity at the time of interval cytoreductive surgery, no favorable impact on survival has been demonstrated and it may induce resistance to chemotherapy. Therefore, optimizing patient selection for PCS is crucial. Furthermore, surgical innovations in patients diagnosed with AvdEOC should focus on improving survival outcomes.

096 DEVELOPMENT OF PREDICTIVE EQUATION FOR ACUTE KIDNEY INJURY AMONG DENGUE PATIENTS: FINDINGS FROM A LARGE RETROSPECTIVE COHORT

Category: Epidemiology and Outcomes from AKI Presenter: Dr TAUQEER MALLHI Keywords: Acute Kidney Injury, Dengue Infection, Acute renal failure Acute Kidney injury during dengue infection has emerged as significant concern that carries a huge in terms of morbidity, mortality and prolonged hospital stay. In this context, predicting AKI in dengue infection and development of predictive equation is of paramount importance. Current study was aimed to investigate the predictive value of different variables causing AKI among dengue patients. A total 667 dengue cases were retrospectively reviewed and stratified into AKI by using AKIN criteria. Clinico-laboratory characteristics of AKI and non AKI groups were compared by student ttest and chi-square. Significant predictors (P<0.25) in univariate analysis were subjected to multivariate binary logistic regression. After forward selection and backward elimination of variables, final predictive model was obtained by enter method (table). Area under the curve (AUC) of model was calculated by Receiver Operating Characteristic (ROC) curve analysis. The incidence of AKI was 14.2%. Following predictive equation was obtained to predict AKI in dengue patients (Figure 1). The values of Î2-coefficients are illustrated in Table 1. The resulted P after putting all the values in equation should be 1 or 0, demonstrating presence or absence of AKI respectively. ROC analysis revealed excellent prediction accuracy of model (Figure 2).Table 1Predictive model of AKI in dengue infectionPredictorsÎ2Sig.OR95% CILowerUpperMale gender.979.0162.661.205.89DHF2.272.0009.703.9923.57DSS3.463.00331.923.16322.18Transaminitis-.997.020.36.15.85Rhabdomyolosis1.994.0007.342.7919.27MOI3.738.00042.0218.2596.75Elevated BUN2.363.00010.622.8639.42Prolonged PT-.839.029.43.20.91Jaundice1.134.0083.101.347.19Edema2.004.0257.421.2842.83Ascites1.590.0244.901.2319.45Î2 for constant: -4.307 Open table in a new tab Our findings suggested a predictive equation of AKI in dengue infection with excellent prediction accuracy. However it requires validation in clinical practice and currently we are validating this equation in prospective cohort of dengue patients.

Point of care ultrasound versus CT pulmonary angiogram in suspected pulmonary embolus

A short cut review was carried out to establish whether non-invasive, multi-organ point of care ultrasound could reduce the need for CTPA in adult patients presenting with clinical suspicion of...

Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity.

Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as to monitor implementation. The aim of this study was to develop a set with appropriate triggers for detecting potential ADEs in elderly patients with multimorbidity. A modified Delphi methodology was used to reach consensus. Existing triggers for detecting ADEs in adult patients were identified from a literature search in several databases (EMBASE, MEDLINE, Web of Science, Centre for Reviews and Dissemination, and Cochrane Library) and from Institute for Healthcare Improvement published lists. Twelve experts in patient/medication safety or in chronic diseases scored candidate triggers for appropriateness according to 3 criteria (evidence, usefulness for elderly patients, and feasibility of implementation in clinical practice). Seventy-two triggers were initially selected to be evaluated. The final set includes a total of 51 triggers for which the panelists who completed the 2 rounds of evaluation reached agreement. These triggers were organized into 5 modules: 11 as care module triggers, 10 as antidotes/treatment, 11 medication concentrations, 18 abnormal laboratory values, and 1 as emergency department trigger. A set of triggers for detecting ADEs in elderly patients with multimorbidity have been developed, following the consensus of a panel of experts. Subsequent validation in clinical practice is needed to confirm the accuracy and efficiency of these triggers for this population.

A nomogram to predict the probability of axillary lymph node metastasis in early breast cancer patients with positive axillary ultrasound.

Among patients with a preoperative positive axillary ultrasound, around 40% of them are pathologically proved to be free from axillary lymph node (ALN) metastasis. We aimed to develop and validate a model to predict the probability of ALN metastasis as a preoperative tool to support clinical decision-making. Clinicopathological features of 322 early breast cancer patients with positive axillary ultrasound findings were analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of ALN metastasis. A model was created from the logistic regression analysis, comprising lymph node transverse diameter, cortex thickness, hilum status, clinical tumour size, histological grade and estrogen receptor, and it was subsequently validated in another 234 patients. Coefficient of determination (R2) and the area under the ROC curve (AUC) were calculated to be 0.9375 and 0.864, showing good calibration and discrimination of the model, respectively. The false-negative rates of the model were 0% and 5.3% for the predicted probability cut-off points of 7.1% and 13.8%, respectively. This means that omission of axillary surgery may be safe for patients with a predictive probability of less than 13.8%. After further validation in clinical practice, this model may support increasingly limited surgical approaches to the axilla in breast cancer.

Classification of diabetic foot ulcers.

It is known that the relative importance of factors involved in the development of diabetic foot problems can vary in both their presence and severity between patients and lesions. This may be one of the reasons why outcomes seem to vary centre to centre and why some treatments may seem more effective in some people than others. There is a need therefore to classify and describe lesions of the foot in patients with diabetes in a manner that is agreed across all communities but is simple to use in clinical practice. No single system is currently in widespread use, although a number have been published. Not all are well validated outside the system from which they were derived, and it has not always been made clear the clinical purposes to which such classifications should be put to use, whether that be for research, clinical description in routine clinical care or audit. Here the currently published classification systems, their validation in clinical practice, whether they were designed for research, audit or clinical care, and the strengths and weaknesses of each are explored.

Principles of Blood Pressure Measurement - Current Techniques, Office vs Ambulatory Blood Pressure Measurement.

Blood pressure measurement has a long history and a crucial role in clinical medicine. Manual measurement using a mercury sphygmomanometer and a stethoscope remains the Gold Standard. However, this technique is technically demanding and commonly leads to faulty values. Automatic devices have helped to improve and simplify the technical aspects, but a standardised procedure of obtaining comparable measurements remains problematic and may therefore limit their validity in clinical practice. This underlines the importance of less error-prone measurement methods such as ambulatory or home blood pressure measurements and automated office blood pressure measurements. These techniques may help to uncover patients with otherwise unrecognised or overestimated arterial hypertension. Additionally these techniques may yield a better prognostic value.

Towards a consensus on how to diagnose and quantify female pattern hair loss - The 'Female Pattern Hair Loss Severity Index (FPHL-SI)'.

Female pattern hair loss (FPHL) is a common non-scarring alopecia characterized by widening of the midline hair part at the crown (vertex). In 1977, Ludwig developed a scale that graded the degree of visible vertex hair thinning from I (least severe) to III (most severe). However, by the time patients exhibit the full manifestations of 'Ludwig I', they have already lost a significant volume of hair. Although current therapies may realistically halt progression of hair loss, improvements in hair density is often more limited. Identification and grading of FPHL at an earlier stage is desirable to institute appropriate therapy before significant hair loss has occurred and to enable monitoring over time. To generate consensus guidance for the recognition and quantification of FPHL that can be used in the clinic. Nine clinicians from Europe, North America and Australia experienced in the management of FPHL developed this scale by consensus. We propose a three-point severity scale (termed the FPHL Severity Index (FPHL-SI)) that combines validated measures of hair shedding, midline hair density and scalp trichoscopy criteria to produce a total FPHL-SI score (maximum score=20). The score is designed to grade FPHL severity over time, while being sufficiently sensitive to identify early disease. A score of 0-4 makes FPHL unlikely; a score of 5-9 would indicate early-stage FPHL, with higher scores indicating greater disease severity. As a starting point for further public debate, we employ criteria already used in clinical practice to generate a pragmatic FPHL grading system (FPHL-SI) of sufficient sensitivity to identify and monitor early FPHL changes. This may have to be further optimized after systematic validation in clinical practice.

Reliability of the American Society of Anesthesiologists Physical Status Scale in Clinical Practice

Sankar, A.*; Johnson, S. R.†‡; Beattie, W. S.§; Tait, G.§; Wijeysundera, D. N.†§∥ Author Information