Differentiating leiomyosarcoma from leiomyoma: in support of an MR imaging predictive scoring system

PURPOSE

The purpose of this study was to determine the Magnetic Resonance (MR) imaging features that best differentiate leiomyosarcoma (LMS) from leiomyoma, and to explore a scoring system to preoperatively identify those at highest risk of having LMS.

METHODS

Our Institutional Review Board approved this retrospective HIPAA-compliant study with a waiver for written informed consent. Institutional Research Patient Data Registry identified patients with histopathologically-proven LMS (n = 19) or leiomyoma (n = 25) and a pelvic MRI within six months prior to surgery. Qualitative differentiating MRI features were selected based on prior publications and clinical experience. Patient and MRI characteristics for leiomyomas versus LMS were compared using Wilcoxon rank-sum tests or Fisher's exact tests and using a basic classification tree. Hypothesis testing was two-tailed, with a p value < 0.001 used to determine inclusion of variables into an MR imaging predictive (MRP) score. Diagnostic performance [sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)] of the MRP in diagnosis of LMS used all possible scores as cutoffs.

RESULTS

Seven out of 15 MRI features were found to have an association with LMS. The final MRP scores ranged from 0 to 7: a score of 0-3 was associated with 100% NPV for LMS, and a MRP score of 6-7 with 100% PPV for LMS.

CONCLUSION

Seven qualitative MR imaging features, extracted from a standard MR imaging protocol, allow differentiation of LMS from leiomyoma. An exploratory risk stratification MRP score can be used to determine the likelihood of LMS being present.

Post-market surveillance of consumer products: Framework for adverse event management

Analysis of spontaneous reports of adverse events is an important source of information that can be used to improve consumer products. Various agencies have adverse event reporting requirements and many companies collect such data directly from consumers. Nonetheless, a universal framework is absent that identifies and evaluates spontaneously reported adverse events, and, most important, assesses the potential association between exposure and adverse events. We are presenting a three-part framework: Phase I - Intake and Documentation of Original Incidents; Phase II - In Depth Review and Follow-up of Phase I Incidents (enhanced, tailored questionnaire); Phase III - Association Assessment. The basis for scoring the strength of association between exposure and adverse events requires assessment of standard factors of association including: temporality; biological, physiological, or pharmacological plausibility; results of de-challenge; results of re-challenge; and consideration of confounding factors. Scores tied to the answers to these questions are totaled for each incident to determine the strength of association between exposure and reported adverse event. We propose that consumer product companies come together to adopt such an association assessment framework to improve adverse event management, obtain maximum value from the data obtained, and use the knowledge derived to improve overall product safety for consumers.

The development and validation of a diagnostic scoring system to differentiate pulmonary tuberculosis from non-tuberculosis pulmonary infections in HIV-infected patients with severe immune suppression

Background

It remains challenging to differentiate tuberculosis (TB) from non-TB pulmonary infections in HIV-infected patients. Herein, we developed a scoring system aimed to rapidly determine the likelihood of TB or non-TB pathology in HIV-infected patients presenting with pulmonary infections.

Methods

We collected and collated data of hospitalized HIV-infected patients with pulmonary infections, followed by univariate and multivariate data analyses to determine risk variables that were significantly different between HIV/TB patients and HIV/non-TB patients. Subsequently, a regression coefficient was calculated for each variable, and a score was assigned to each variable in line with its regression coefficient. The sum of the scores for each variable in our scoring model was used to predict the likelihood of TB or non-TB pulmonary infection in each patient. Finally, we tested the diagnostic accuracy of the scoring system in our retrospective cohort, as well as in a prospective cohort.

Results

A total of 598 HIV-infected patients were enrolled in our retrospective cohort, among whom 288 had TB and 310 had non-TB pulmonary infections. Eight variables, including fever, highest body temperature, erythrocyte sedimentation rate (ESR), cervical lymphadenopathy, hilar and/or mediastinum lymphadenopathy, pulmonary cavitation, pleural effusion, and miliary nodules, were found to be mathematically significantly different via univariate analysis and multivariate logistic regression analysis. After regression coefficient calculation followed by score assignment, a receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to be 0.902. When the total score for a patient is > 12, the sensitivity and specificity for TB prediction using our scoring system were 76.4% and 87.7% respectively in the retrospective cohort, and its diagnostic accuracy was 82.7% in the prospective cohort.

Conclusions

Our results demonstrate that our proposed diagnostic scoring system could be helpful in differentiating pulmonary TB from non-TB pulmonary infections in HIV-infected patients.

Consensus-driven conceptual development of a standardized whole body-MRI scoring system for assessment of disease activity in juvenile idiopathic arthritis: MRI in JIA OMERACT working group

OBJECTIVES

Whole body-MRI is helpful in directing diagnostic and treatment approaches, and as a research outcome measure. We describe our initial consensus-driven phase towards developing a whole body-MRI scoring system for juvenile idiopathic arthritis.

METHODS

An iterative approach using three rounds of anonymous Delphi surveys followed by a consensus meeting was used to draft the structure of the whole body-MRI scoring system, including the relevant anatomic joints and entheses for assessment, diagnostic item selection, definition and grading, and selection of appropriate MRI planes and sequences. The surveys were completed independently by an international expert group consisting of pediatric radiologists and rheumatologists.

RESULTS

Twenty-two experts participated in at least one of three rounds of Delphi surveys and a concluding consensus meeting. A first iteration scoring system was developed which ultimately included the assessment of 100 peripheral, 23 chest, and 76 axial joints, and 64 entheses, with 2-4 diagnostic items graded in each of the items, using binary (presence/absence) and 2-3-level ordinal scores. Recommendations on anatomic MRI planes and sequences were specified as the minimally necessary imaging protocol for the scoring system.

CONCLUSION

A novel whole body-MRI scoring system for juvenile idiopathic arthritis was developed by consensus among members of MRI in JIA OMERACT working group. Further iterative refinements, reliability testing, and responsiveness are warranted in upcoming studies.

Immune and stromal scoring system associated with tumor microenvironment and prognosis: a gene-based multi-cancer analysis

Background

Tumor microenvironment (TME) is associated with tumor progression and prognosis. Previous studies provided tools to estimate immune and stromal cell infiltration in TME. However, there is still a lack of single index to reflect both immune and stromal status associated with prognosis and immunotherapy responses.

Methods

A novel immune and stromal scoring system named ISTMEscore was developed. A total of 15 datasets were used to train and validate this system, containing 2965 samples from lung adenocarcinoma, skin cutaneous melanoma and head and neck squamous cell carcinoma.

Results

The patients with high immune and low stromal scores (HL) were associated with low ratio of T cell co-inhibitory/stimulatory molecules and low levels of angiogenesis markers, while the patients with low immune and high stromal scores (LH) had the opposite characteristics. The HL patients had immune-centered networks, while the patients with low immune and low stromal scores (LL) had desert-like networks. Moreover, copy number alteration burden was decreased in the HL patients. For the clinical characteristics, our TME classification was an independent prognostic factor. In the 5 cohorts with immunotherapy, the LH patients were linked to the lowest response rate.

Conclusions

ISTMEscore system could reflect the TME status and predict the prognosis. Compared to previous TME scores, our ISTMEscore was superior in the prediction of prognosis and immunotherapy response.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-03002-1.

A clinical scoring system for pediatric hand-foot-mouth disease

BACKGROUND

The aim of the present study was to develop a clinical scoring system for the diagnosis of hand-foot-mouth disease (HFMD) with improved accuracy.

METHODS

A retrospective analysis was performed on standardized patient history and clinical examination data obtained from 1435 pediatric patients under the age of three years who presented with acute rash illness and underwent enterovirus nucleic acid detection. Patients were then divided into the HFMD (1094 patients) group or non-HFMD (341 patients) group based on a positive or a negative result from the assay, respectively. We then divided the data into a training set (1004 cases, 70%) and a test set (431 cases, 30%) using a random number method. Multivariate logistic regression was performed on 15 clinical variables (e.g. age, exposure history, number of rash spots in a single body region) to identify variables highly predictive of a positive diagnosis in the training set. Using the variables with high impact on the diagnostic accuracy, we generated a scoring system for predicting HFMD and subsequently evaluated this system in the test set by receiver operating characteristic curve (ROC curve).

RESULTS

Using the logistic model, we identified seven clinical variables (age, exposure history, and rash density at specific regions of the body) to be included into the scoring system. The final scores ranged from - 5 to 24 (higher scores positively predicted HFMD diagnosis). Through our training set, a cutoff score of 7 resulted in a sensitivity of 0.76 and specificity of 0.68. The area under the receiver operating characteristic curve (AUC) was 0.804 (95% confidence interval [CI]: 0.773-0.835) (P < 0.001). Using the test set, we obtained an AUC of 0.76 (95% CI: 0.710-0.810) with a sensitivity of 0.76 and a specificity of 0.62. These results from the test set were consistent with those from the training set.

CONCLUSIONS

This study establishes an objective scoring system for the diagnosis of typical and atypical HFMD using measures accessible through routine clinical encounters. Due to the accuracy and sensitivity achieved by this scoring system, it can be employed as a rapid, low-cost method for establishing diagnoses in children with acute rash illness.

A Novel Risk Stratification System for Ischemic Stroke in Japanese Patients With Non-Valvular Atrial Fibrillation

BACKGROUND

Recently, identification of independent risk factors for ischemic stroke in Japanese non-valvular atrial fibrillation (NVAF) patients was made by analyzing the 5 major Japanese registries: J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and the Hokuriku-Plus AF Registry.Methods and Results:The predictive value of the risk scheme in Japanese NVAF patients was assessed. Of 16,918 patients, 12,289 NVAF patients were analyzed (mean follow up, 649±181 days). Hazard ratios (HRs) of each significant, independent risk factor were determined by using adjusted Cox-hazard proportional analysis. Scoring system for ischemic stroke was created by transforming HR logarithmically and was estimated by c-statistic. During the 21,820 person-years follow up, 241 ischemic stroke events occurred. Significant risk factors were: being elderly (aged 75-84 years [E], HR=1.74), extreme elderly (≥85 years [EE], HR=2.41), having hypertension (H, HR=1.60), previous stroke (S, HR=2.75), type of AF (persistent/permanent) (T, HR=1.59), and low body mass index <18.5 kg/m²(L, HR=1.55) after adjusting for oral anticoagulant treatment. The score was assigned as follows: 1 point to H, E, L, and T, and 2 points to EE and S (HELT-E₂S₂score). The C-statistic, using this score, was 0.681 (95% confidence interval [CI]=0.647-0.714), which was significantly higher than those using CHADS₂(0.647; 95% CI=0.614-0.681, P=0.027 for comparison) and CHA₂DS₂-VASc scores (0.641; 95% CI=0.608-0.673, P=0.008).

CONCLUSIONS

The HELT-E₂S₂score may be useful for identifying Japanese NVAF patients at risk of ischemic stroke.

Prognostic factors for ovarian metastases in colorectal cancer patients

Purpose

The aim of this study was to analyze prognostic factors for ovarian metastases (OM) in colorectal cancer (CRC) using data from a Chinese center. In addition, the study aimed at developing a new clinical scoring system for prognosis of OM of CRC patients after surgery.

Patients and methods

Data of CRC patients with OM were collected from a single Chinese institution (n = 67). Kaplan-Meier analysis was used to evaluate cumulative survival of patients. Factors associated with prognosis of overall survival (OS) were explored using Cox’s proportional hazard regression models. A scoring system to determine effectiveness of prognosis was developed.

Results

Median OS values for patients with or without surgery were 22 and 7 months, respectively.

Size of OM, number of OM, peritoneal metastasis (PM), Peritoneal cancer index (PCI), and completeness of cytoreduction (CC) were associated with OS of patients through univariate analysis. Multivariate analysis using a Cox regression model showed that only CC was an independent predictor for OS. Three variables (the size of OM >15cm, PCI ≥ 10, and carcinoembryonic antigen (CEA) >30 ng/mL) assigned one point each were used to develop a risk score. The resulting score was used for prognosis of OS.

Conclusion

Surgical treatment of metastatic sites is effective and safe for CRC patients with OM. CC-0 is recommended for improved prognosis. The scoring system developed in this study is effective for prediction of OS of patients after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02305-3.

Prediction of presence and severity of coronary artery disease using prediction for atherosclerotic cardiovascular disease risk in China scoring system

BACKGROUND

Coronary artery disease (CAD) is one of the leading causes of death and disease burden in China and worldwide. A practical and reliable prediction scoring system for CAD risk and severity evaluation is urgently needed for primary prevention.

AIM

To examine whether the prediction for atherosclerotic cardiovascular disease risk in China (China-PAR) scoring system could be used for this purpose.

METHODS

A total of 6813 consecutive patients who underwent diagnostic coronary angiography were enrolled. The China-PAR score was calculated for each patient and CAD severity was assessed by the Gensini score (GS).

RESULTS

Correlation analysis demonstrated a significant relationship between China-PAR and GS (r = 0.266, P < 0.001). In receiver operating characteristic curve analysis, the cut-off values of China-PAR for predicting the presence and the severity of CAD were 7.55% with a sensitivity of 55.8% and specificity of 71.8% [area under the curve (AUC) = 0.693, 95% confidence interval: 0.681 to 0.706, P < 0.001], and 7.45% with a sensitivity of 58.8% and specificity of 67.2% (AUC = 0.680, 95% confidence interval: 0.665 to 0.694, P < 0.001), respectively.

CONCLUSION

The China-PAR scoring system may be useful in predicting the presence and severity of CAD.

[PI-RADS 2.1 and structured reporting of magnetic resonance imaging of the prostate]

Klinisches/methodisches Problem

Die Identifikation klinisch signifikanter Prostatakarzinome bei gleichzeitigem Vermeiden einer Überdiagnostik niedrigmaligner Tumoren stellt eine Herausforderung in der klinischen Routine dar.

Radiologische Standardverfahren

Die gemäß PI-RADS-Richtlinien (Prostate Imaging Reporting and Data System Guidelines) akquirierte und interpretierte multiparametrische Magnetresonanztomographie (MRT) der Prostata ist als klinischer Standard bei Urologen und Radiologen akzeptiert.

Methodische Innovationen

Die PI-RADS-Richtlinien sind neu auf Version 2.1 aktualisiert worden und beinhalten neben präzisierten technischen Anforderungen einzelne Änderungen in der Läsionsbewertung.

Leistungsfähigkeit

Die PI-RADS-Richtlinien haben entscheidende Bedeutung in der Standardisierung der multiparametrischen MRT der Prostata erlangt und bieten Vorlagen zur strukturierten Befundung, was die Kommunikation mit dem Zuweiser erleichtert.

Bewertung

Die nun auf Version 2.1 aktualisierten Richtlinien stellen eine Verfeinerung der verbreiteten Version 2.0 dar. Dabei wurden viele Aspekte der Befundung präzisiert, einige vorbekannte Limitationen bleiben jedoch bestehen und erfordern die weitere Verbesserung der Richtlinien in kommenden Versionen.

Wildlife poisoning: a novel scoring system and review of analytical methods for anticoagulant rodenticide determination

Anticoagulant rodenticides (ARs) are commonly used to control rodent populations and frequently involved in wildlife and domestic animal poisoning. These poisoning cases (especially for ARs) are a challenge for forensic toxicologists, and adequate post-mortem examination and toxicological analyses become essential for a proper diagnosis. Publications describing different analytical methods for AR analysis in biological samples are growing, and a clear compilation of the overall picture is needed to standardize methodologies in future research. This review aims to compile and compare the analytical procedures applied for AR determination in the literature. Using this information, a scoring system was developed for those techniques using liver and blood as matrices, and the techniques were ranked considering different criteria (i.e. sample amount required, recoveries, limits of quantification (LOQs), number of ARs analysed, points of the calibration curve and multi-class methods). This review shows an overview of the main methods used for AR analysis in forensic toxicology and will help to elucidate future directions to improve multi-residue techniques to detect the ARs involved in wildlife lethal poisoning.

New Scoring System for Predicting the Risk of Surgical Site Infections Following Stoma Reversal

BACKGROUND

Surgical site infections (SSI) are one of the most frequent complications following stoma reversal (SR-SSI) and lead to multiple problems such as decreased mobility of the patients or increased hospital costs. Several risk factors for SR-SSI have been reported, but there are no risk scoring systems for predicting SR-SSI. The current study aimed to analyze the risk factors for SR-SSI and develop a scoring system.

MATERIALS AND METHODS

Multivariate analysis of risk factors for SR-SSI was performed in patients who underwent elective SR and were followed-up during the first month after surgery. A logistic regression model was used to identify risk factors and construct a predictive score.

RESULTS

Of the 182 patients, 53 (29.1%) developed SSI. In multivariate analysis, three variables as preoperative risk factors were associated with increased SR-SSI incidence: subcutaneous fat thickness (≥ 20 mm) (odds ratio [OR]: 8.46 [95% confidence interval (CI): 3.45-20.7], P <0.001), period from stoma creation (≤ 20 weeks) (OR: 2.88 [95% CI: 1.14-7.28], P = 0.025), and SSI after the primary operation (OR: 3.06 [95% CI: 1.19-7.90], P = 0.021). Each of these variables contributed 2,1, and 1 points to the risk score, respectively. The SR-SSI rate was 2.9%, 20.3%, 34.2%, 54.5%, and 81.8% for the scores of 0,1,2,3, and 4 points, respectively. The area under the receiver operating characteristic curve was 0.773 (95% CI: 0.703-0.844).

CONCLUSIONS

A simple clinical scoring system based on three preoperative variables may be useful in predicting the risk of SR-SSI.

A novel scoring system for selecting the target patients of COVID-19 convalescent plasma therapy: A hypothesis

The primary cause of mortality in patients of coronavirus disease 2019 (COVID-19) is the cytokine storm and not directly due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Therefore, it is being stressed by transfusion medicine specialists to use COVID-19 convalescent plasma (CCP) therapy early in the course of the disease, preferably within 72 h of diagnosis. The authors herein, propose a scoring system for the rapid assessment of the patients who have tested positive for SARS-CoV-2. Therefore, a systematic approach may be followed where the patients are categorised into two groups, namely, the low-risk group [LRG; score < 5] and the high-risk group [HRG; score ≥ 5] based on this scoring system. Those classified as an HRG should be administered CCP therapy within 72 h of a confirmed diagnosis of COVID-19 to neutralise the SARS-CoV-2 virus and prevent the occurrence of the cytokine storm. This in turn could help reduce the overall mortality in the recipients.

Predictive scoring model for inferior alveolar nerve injury after lower third molar removal based on features of cone-beam computed tomography image

INTRODUCTION

This study aimed to construct a predictive scoring system for inferior alveolar nerve injury (IANI) following lower third molar (LM3) surgery based on cone-beam computed tomography (CBCT) images.

MATERIAL AND METHODS

Of the 1573 patients who underwent LM3 removal following the CBCT, 39 with IANI and 457 randomly selected patients without IANI were enrolled. We collected information regarding the demographic characteristics of the patients, surgical situations, and inferior alveolar canal (IAC)-related CBCT factors. The association with IANI-risk was evaluated with a backward stepwise logistic regression model as per the Akaike information criterion. Scoring models' abilities of discrimination (area under the curve) and calibration (Hosmer-Lemeshow test and calibration plots) were assessed, followed by evaluation of the clinical usefulness using decision curve analysis.

RESULTS

As per the multivariate analysis, the coronal positioned IAC on the enlarged root (odds ratio [OR], 3.78; P = 0.001), the length of perforated IAC (>3.4 mm) (OR, 3.05; P = 0.012), lingual/inter-radicular position of the IAC (OR, 3.96; P = 0.001), multiple roots closed to the perforated IAC (OR, 2.78; P = 0.025), and age >30 y (OR, 2.31; P = 0.076) were identified in the extended scoring model ranging from 0 to 12. This model was compared with our previously constructed baseline model that involved the latter three variables mentioned above, resulting in superior performance than that of the baseline model.

CONCLUSION

The extended model would be a useful tool for reliable determination of the preoperative probability of IANI.

Lung Ultrasound in COVID-19: Clinical Correlates and Comparison with Chest Computed Tomography

Lung ultrasound (LUS) and chest computed tomography (chest CT) are largely employed to evaluate coronavirus disease 2019 (COVID-19) pneumonia. We investigated semi-quantitative LUS and CT scoring in hospitalized COVID-19 patients. LUS and chest CT were performed within 24 h upon admission. Both were analyzed according to semi-quantitative scoring systems. Subgroups were identified according to median LUS score. Patients within higher LUS score group were older (79 vs 60 years, p<0.001), had higher C-reactive protein (CRP) (7.2 mg/dl vs 1.3 mg/dl, p<0.001) and chest CT score (10 vs 4, p=0.027) as well as lower PaO2/FiO2 (286 vs 356, p=0.029) as compared to patients within lower scores. We found a significant correlation between scores (r=0.390, p=0.023). Both LUS and CT scores correlated directly with patients age (r=0.586, p<0.001 and r=0.399, p=0.021 respectively) and CRP (r=0.472, p=0.002 and r=0.518, p=0.002 respectively), inversely with PaO2/FiO2 (r=-0.485, p=0.003 and r=-0.440, p=0.017 respectively). LUS score only showed significant correlation with hs-troponin T, NT-pro-BNP, and creatinine (r=0.433, p=0.019; r=0.411, p=0.027, and r=0.497, p=0.001, respectively). Semi-quantitative bedside LUS is related to the severity of COVID-19 pneumonia similarly to chest CT. Correlation of LUS score with markers of cardiac and renal injury suggests that LUS might contribute to a more comprehensive evaluation of this heterogeneous population.

Development of a new sternal dehiscence prediction scale for decision making in sternal closure techniques after cardiac surgery

Background

After sternotomy, the spectrum for sternal osteosynthesis comprises standard wiring and more complex techniques, like titanium plating. The aim of this study is to develop a predictive risk score that evaluates the risk of sternum instability individually. The surgeon may then choose an appropriate sternal osteosynthesis technique that is risk- adjusted as well as cost-effective.

Methods

Data from 7.173 patients operated via sternotomy for all cardiovascular indications from 2008 until 2017 were retrospectively analyzed. Sternal dehiscence occurred in 2.5% of patients (n = 176). A multivariable analysis model examined pre- and intraoperative factors. A multivariable logistic regression model and a backward elimination based on the Akaike Information Criterion (AIC) a logistic model were selected.

Results

The model showed good sensitivity and specificity (area under the receiver-operating characteristic curve, AUC: 0.76) and several predictors of sternal instability could be evaluated. Multivariable logistic regression showed the highest Odds Ratios (OR) for reexploration (OR 6.6, confidence interval, CI [4.5–9.5], p < 0.001), obesity (body mass index, BMI > 35 kg/m²) (OR 4.23, [CI 2.4–7.3], p < 0.001), insulin-dependent diabetes mellitus (IDDM) (OR 2.2, CI [1.5–3.2], p = 0.01), smoking (OR 2.03, [CI 1.3–3.08], p = 0.001). After weighting the probability of sternum dehiscence with each factor, a risk score model was proposed scaling from − 1 to 5 points. This resulted in a risk score ranging up to 18 points, with an estimated risk for sternum complication up to 74%.

Conclusions

A weighted scoring system based on individual risk factors was specifically created to predict sternal dehiscence. High-scoring patients should receive additive closure techniques.

The prospective evaluation of the effectiveness of scoring systems in the emergency department in cases with suspected ureteral stones: STONE? CHOKAI?

INTRODUCTION

This study evaluates the effectiveness of CHOKAI and STONE scores in patients presenting to the emergency department with ureteral stones.

METHODS

Patients over the age of 18 who were admitted to the emergency department with flank pain, groin pain, scrotal pain, and hematuria and who were performed non-contrast abdominal computed tomography (CT) for diagnostic imaging were included. The numeric pain, CHOKAI, and STONE scores of the patients were calculated. The effectiveness of these scoring systems in the presence of stones was examined.

RESULTS

A total of 105 patients were included in the study. In the analysis performed to investigate whether there was a difference between the numeric pain, STONE, and CHOKAI scores in terms of the presence of stones on CT, it was seen that the CHOKAI score was significantly different from the others (p < 0.001). A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).When the cut-off value of the CHOKAI score was >7, the sensitivity was found to be 60.49%, and specificity was 83.33%. The cut-off value for the STONE score was >8 with a sensitivity of 70.37% and specificity of 58.33%. The corresponding area under curve values for the CHOHAI and STONE scores was 0.788 (p < 0.0001) and 0.615 (p = 0.087). Male sex, the CHOKAI, and STONE scores were the independent risk factors for ureteral stone. A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).

CONCLUSION

The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones.

NEW KNOWLEDGE ADDED BY THIS STUDY

The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones. Especially in countries such as Turkey, where there are no specific racial differences, the STONE score may be diagnostically insufficient. The CHOKAI score shows the presence of the patient's stone and positively correlates with the size of the stone and the stone location.

IMPLICATION FOR CLINICAL PRACTICE OR POLICY

In the functioning of the emergency department, it is important to make the differential diagnosis of patients quickly and provide effective treatment. The use of diagnostic scoring systems saves time for the emergency physician in the differential diagnosis phase and guides in terms of applying for possible additional imaging methods.

Comparing functional outcomes between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer: a systematic review and meta-analysis

BACKGROUND

There is concern that transanal total mesorectal excision (TaTME) may result in poorer functional outcomes as compared to laparoscopic TME (LaTME). These concerns arise from the fact that TaTME entails both a low anastomosis and prolonged dilatation of the anal sphincter from the transanal platform.

OBJECTIVES

This paper aimed to assess the comparative functional outcomes following TaTME and LaTME, with a focus on anorectal and genitourinary outcomes.

DATA SOURCES

A meta-analysis and systematic review was performed on available literature between 2000 and 2020 from the PubMed, EMBASE, Medline, and Cochrane Library databases.

STUDY SELECTION

All comparative studies assessing the functional outcomes following taTME versus LaTME in adults were included.

MAIN OUTCOME MEASURE

Functional anorectal and genitourinary outcomes were evaluated using validated scoring systems.

RESULTS

A total of seven studies were included, consisting of one randomised controlled trial and six non-randomised studies. There were 242 (52.0%) and 233 (48.0%) patients in the TaTME and LaTME groups respectively. Anorectal functional outcomes were similar in both groups with regard to LARS scores (30.6 in the TaTME group and 28.3 in the LaTME group), Jorge-Wexner incontinence scores, and EORTC QLQ C30/29 scores. Genitourinary function was similar in both groups with IPSS scores of 5.5 to 8.0 in the TaTME group, and 3.5 to 10.1 in the LaTME group. (p = 0.835).

CONCLUSION

This review corroborates findings from previous studies in showing that the transanal approach is not associated with increased anal sphincter damage. Further prospective clinical trials are needed in this field of research.

Development and validation of a prognostic model for patients with hepatorenal syndrome: A retrospective cohort study

BACKGROUND

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis with high mortality, which necessitates accurate clinical decision. However, studies on prognostic factors and scoring systems to predict overall survival of HRS are not enough. Meanwhile, a multicenter cohort study with a long span of time could be more convincing.

AIM

To develop a novel and effective prognostic model for patients with HRS and clarify new prognostic factors.

METHODS

We retrospectively enrolled 1667 patients from four hospitals, and 371 eligible patients were finally analyzed to develop and validate a novel prognostic model for patients with HRS. Characteristics were compared between survivors and non-survivors, and potential prognostic factors were selected according to the impact on 28-d mortality. Accuracy in predicting 28-d mortality was compared between the novel and other scoring systems, including Model for End-Stage Liver Disease (MELD), Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and Chinese Group on the Study of Severe Hepatitis B-Acute-on-Chronic Liver Failure (COSSH-ACLF).

RESULTS

Five prognostic factors, comprised of gender, international normalized ratio, mean corpuscular hemoglobin concentration, neutrophil percentage, and stage, were integrated into a new score, GIMNS; stage is a binary variable defined by the number of failed organs. GIMNS was positively correlated with MELD, CLIF-SOFA, and COSSH-ACLF. Additionally, it had better accuracy [area under the receiver operating characteristic curve (AUROC): 0.830] than MELD (AUROC: 0.759), CLIF-SOFA (AUROC: 0.767), and COSSH-ACLF (AUROC: 0.759) in the derivation cohort (P < 0.05). It performed better than MELD and CLIF-SOFA in the validation cohort (P < 0.050) and had a higher AUROC than COSSH-ACLF (P = 0.122).

CONCLUSION

We have developed a new scoring system, GIMNS, to predict 28-d mortality of HRS patients. Mean corpuscular hemoglobin concentration and stage were first proposed and found to be related to the mortality of HRS. Additionally, the GIMNS score showed better accuracy than MELD and CLIF-SOFA, and the AUROC was higher than that of COSSH-ACLF.

The REALISE score: a new statistically validated scoring system to assess the severity of anal fissures

BACKGROUND

Anal fissure (AF) is a common, painful disease that strongly affects patients' quality of life, however, no scoring system to assess the severity of AF is available in the literature. The aim of this study was to set up and validate a reliable scoring system to quantify the severity of AF, to be used in prospective trials comparing the efficacy and the outcomes of surgical or medical treatments.

METHODS

The study was conducted on patients with acute or chronic AF and a control group in a tertiary centre for coloproctology in June 2020-September 2020. Two researchers independently carried out a structured interviewer-led questionnaire at two different time points (T1/T2). The questionnaire consisted of five items selected according to the most commonly reported symptoms for AF: the item pain, was scored from 0 to 10 using a visual analogue scale, and quality of life, duration of pain, use of painkillers, and bleeding were scored from 1 to 5 using Likert-scale questions. The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points. Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study. Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability.

RESULTS

One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled. A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99). The coefficient of repeatability was 1.45 in T1 and 1.18 in T2.

CONCLUSIONS

The REALISE score may have an important role in the assessment and management of AF, in grading the severity of AF and comparing results of different treatments.

Metabolic syndrome and its components reduce coronary collateralization in chronic total occlusion: An observational study

Background

Metabolic syndrome (MetS) is an independent risk factor for the incidence of cardiovascular diseases. We investigated whether or to what extent MetS and its components was associated with coronary collateralization (CC) in chronic total occlusion (CTO).

Methods

This study involved 1653 inpatients with CTO. Data on demographic and clinical characteristics were collected by cardiovascular doctors. The CC condition was defined by the Rentrop scoring system. Subgroup analysis, mixed model regression analysis, scoring systems and receiver operating characteristic (ROC) curve analysis were performed.

Results

Overall, 1653 inpatients were assigned to the poor CC group (n = 355) and good CC group (n = 1298) with or without MetS. Compared to the good CCs, the incidence of MetS was higher among the poor CCs for all patients. Poor collateralization was present in 7.6%, 14.2%, 19.3%, 18.2%, 35.6% and 51.1% of the six groups who met the diagnostic criteria of MetS 0, 1, 2, 3, 4 and 5 times, respectively. For multivariable logistic regression, quartiles of BMI remained the risk factors for CC growth in all subgroups (adjusted OR = 1.755, 95% CI 1.510–2.038, P < 0.001 all patients; adjusted OR = 1.897, 95% CI 1.458–2.467, P < 0.001 non-MetS; and adjusted OR = 1.814, 95% CI 1.482–2.220, P < 0.001 MetS). After adjustment for potential confounding factors, MetS was an independent risk factor for CC growth in several models. Assigning a score of one for each component, the AUCs were 0.629 (95% CI 0.595–0.662) in all patients, 0.656 (95% CI 0.614–0.699) in MetS patients and 0.569 (95% CI 0.517–0.621) in non-MetS patients by receiver operating characteristic analysis.

Conclusions

MetS, especially body mass index, confers a greater risk of CC formation in CTO. The value of scoring systems should be explored further for CTO.

A new scoring system for predicting short-term outcomes in Chinese patients with critically-ill acute decompensated heart failure

Background

Acute decompensated heart failure (ADHF) contributes millions of emergency department (ED) visits and it is associated with high in-hospital mortality. The aim of this study was to develop and validate a multiparametric score for critically-ill ADHF patients.

Methods

In this single-center, retrospective study, a total of 1268 ADHF patients in China were enrolled and divided into derivation (n = 1014) and validation (n = 254) cohorts. The primary endpoint was any in-hospital death, cardiac arrest or utilization of mechanical support devices. Logistic regression model was preformed to identify risk factors and build the new scoring system. The assigning point of each parameter was determined according to its β coefficient. The discrimination was validated internally using C statistic and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit test.

Results

We constructed a predictive score based on six significant risk factors [systolic blood pressure (SBP), white blood cell (WBC) count, hematocrit (HCT), total bilirubin (TBIL), estimated glomerular filtration rate (eGFR) and NT-proBNP]. This new model was computed as (1 × SBP < 90 mmHg) + (2 × WBC > 9.2 × 10⁹/L) + (1 × HCT ≤ 0.407) + (2 × TBIL > 34.2 μmol/L) + (2 × eGFR < 15 ml/min/1.73 m²) + (1 × NTproBNP ≥ 10728.9 ng/ml). The C statistic for the new score was 0.758 (95% CI 0.667–0.838) higher than APACHE II, AHEAD and ADHERE score. It also demonstrated good calibration for detecting high-risk patients in the validation cohort (χ² = 6.681, p = 0.463).

Conclusions

The new score including SBP, WBC, HCT, TBIL, eGFR and NT-proBNP might be used to predict short-term prognosis of Chinese critically-ill ADHF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02041-2.

Pediatric surgical wait priority score (pSWAPS): Modifying a health system's adult-based elective surgery prioritization system for children's surgery during the COVID-19 pandemic

BACKGROUND

With the rise of COVID-19 cases, societies recommended canceling all elective surgical procedures because of perioperative concerns, transmission risk, and the need to divert resources. Once the number of cases stabilized, there was recognition that a system was needed to triage and prioritize scheduling operations.

METHODS

A universal scoring system to triage surgical elective cases was developed for the Advocate Aurora Health system (Surgical Wait Priority Score, SWAPS) and was modified for use in pediatrics (pSWAPS). Resource-related, patient-related, and case urgency factors were used to create the overall score. Interrater reliability of ten cases was determined by four surgeons' scores and calculating Fleiss' Kappa coefficient. The system has been used for two months at two operating rooms with different resource restrictions with the goal of prioritizing elective cases.

RESULTS

18 factors were identified as significant contributors to the pWAPS creating a cumulative score ranging from 0 to 120. In the first month, 61 and 99 procedures were screened at the Oak Lawn (OL) and Park Ridge (PR) campuses respectively, and in the second month, 94 (OL) and 135 (PR) procedures were evaluated. The average pSWAPS scores were 37.9 at OL and 54.3 at PR. All cases that had scores within the immediate group were scheduled and completed.

CONCLUSION

The pSWAPS system is a simple, flexible scoring system that takes into consideration resource constraints. pSWAPS has been used for two months. It has served as an effective tool for safe and methodical reintroduction of elective procedures during the COVID-19 pandemic and could be used again for another surge.

LEVEL OF EVIDENCE

prognosis study, level of evidence - 4.

The ROCOCO performance scoring system translates dosimetric differences into clinically relevant endpoints: Comparing IMPT to VMAT in an example pilocytic astrocytoma dataset

BACKGROUND AND PURPOSE

Proton therapy is expected to outperform photon-based treatment regarding organs at risk (OAR) sparing but to date there is no method to practically measure clinical benefit. Here, we introduce the novel ROCOCO Performance Scoring System (RPSS) translating dose differences into clinically relevant endpoints and apply this to a treatment plan comparison of volumetric modulated arc therapy (VMAT) and intensity modulated proton therapy (IMPT) in 20 pilocytic astrocytoma patients.

MATERIAL AND METHODS

The RPSS was developed on the basis of expert-based weighting factors and toxicity scores per OAR. The imaging datasets of 20 pilocytic astrocytoma patients having undergone radiotherapy were included in this in silico dosimetric comparison trial as proof of principle. For each of these patients, treatment plans to a total dose of 54 Gy (RBE) were generated for VMAT and IMPT and these were compared regarding radiation dose to the clinical target volume (CTV) and OARs. The RPSS was calculated for each treatment plan comparing VMAT and IMPT.

RESULTS

In 40 analysed treatment plans, the average and low dose volumes to various OARs were significantly reduced when using IMPT compared to VMAT (p < 0.05). Using the RPSS, a significant difference between both treatment modalities was found, with 85% of the patients having a lower RPSS in favour of the IMPT plan.

CONCLUSION

There are dosimetric differences between IMPT and VMAT in pilocytic astrocytoma patients. In absence of clinically validated NTCP models we introduce the RPSS model in order to objectively compare treatment modalities by translating dosimetric differences in potential clinical differences.

Novel model-based point scoring system for predicting stroke risk in atrial fibrillation patients: Results from a nationwide cohort study with validation

•

This study used rigorous statistical method to construct the novel AF-CA-Stroke score and demonstrated that the novel stroke risk stratification tool had significantly higher discrimination abilities than conventional scores.

•

This study exhibited that the status of various age stratifications and receiving AF ablation shall be considered in managing AF treatment.

•

Based on the AF-CA-Stroke score, around 80–85% patients may take benefits form AF ablation procedures with lower stroke risks, and they may not be necessary to receive oral anticoagulants after receiving successful AF ablations.

Background

The stroke risk scoring system for atrial fibrillation (AF) patients can vary considerably based on patients’ status while receiving ablation. This study aimed to demonstrate a novel scoring system for stroke risk stratification based on the status of catheter ablation.

Methods

First, 787 patients with AF undergoing ablation were matched according to age, sex, and underlying diseases with the same number of patients not undergoing ablation using the propensity-score (PS)-matched cohort. Multivariate Cox model-derived coefficients were used to construct a simple point-based clinical model using the PS-matched cohort. Thereafter, the novel model (AF-CA-Stroke score) was validated in a nationwide AF cohort.

Results

The AF-CA-Stroke score was calculated based on age (point = 5), ablation status (point = 4), prior history of stroke (point = 4), chronic kidney disease (point = 2), diabetes mellitus (point = 1), and congestive heart failure (point = 1). Risk function to predict the 1-, 5-, 10-year absolute stroke risks was reported. The estimated area under the receive operating characteristic curve of the AF-CA-Stroke score in the PS-matched cohort was 0.845 (95% confidence interval: 0.824–0.865) to predict long-term stroke. A validation study showed that discrimination abilities in the AF-CA-Stroke scores were significantly higher than those in the CHADS₂/CHA₂DS_2-VASc scores. The best cut-off value of the AF-CA-Stroke score to predict future strokes was ≥ 5.

Conclusions

This novel model-based point scoring system effectively identifies stroke risk using clinical factors and AF ablation status of patients with AF. Various age stratifications and AF ablation should be considered in AF management.

Accuracy of conventional and novel scoring systems in predicting severity and outcomes of acute pancreatitis: a retrospective study

BACKGROUND

Recently, several novel scoring systems have been developed to evaluate the severity and outcomes of acute pancreatitis. This study aimed to compare the effectiveness of novel and conventional scoring systems in predicting the severity and outcomes of acute pancreatitis.

METHODS

Patients treated between January 2003 and August 2020 were reviewed. The Ranson score (RS), Glasgow score (GS), bedside index of severity in acute pancreatitis (BISAP), pancreatic activity scoring system (PASS), and Chinese simple scoring system (CSSS) were determined within 48 h after admission. Multivariate logistic regression was used for severity, mortality, and organ failure prediction. Optimum cutoffs were identified using receiver operating characteristic curve analysis.

RESULTS

A total of 1848 patients were included. The areas under the curve (AUCs) of RS, GS, BISAP, PASS, and CSSS for severity prediction were 0.861, 0.865, 0.829, 0.778, and 0.816, respectively. The corresponding AUCs for mortality prediction were 0.693, 0.736, 0.789, 0.858, and 0.759. The corresponding AUCs for acute respiratory distress syndrome prediction were 0.745, 0.784, 0.834, 0.936, and 0.820. Finally, the corresponding AUCs for acute renal failure prediction were 0.707, 0.734, 0.781, 0.868, and 0.816.

CONCLUSIONS

RS and GS predicted severity better than they predicted mortality and organ failure, while PASS predicted mortality and organ failure better. BISAP and CSSS performed equally well in severity and outcome predictions.

A Novel Fluorescence Optical Imaging Scoring System for Hand Synovitis in Rheumatoid Arthritis - validity and agreement with ultrasound

OBJECTIVES

To develop and validate a new semiquantitative Fluorescence Optical Imaging (FOI) scoring system - the FOI Enhancement-Generated rheumatoid arthritis (RA) Score (FOIE-GRAS) for synovitis assessment in the hand.

METHODS

The development of FOIE-GRAS was based on consensus of 4 experts in musculoskeletal imaging. Forty-six RA patients, eligible for treatment intensification and with ≥1 clinically swollen joint in the hands and 11 healthy controls were included. FOI, ultrasound and clinical assessment of both hands were obtained at baseline and for RA patients after 3- and 6-months' follow-up. Twenty RA patients had an FOI rescan after 4 hours. Synovitis was scored using FOIE-GRAS and the OMERACT ultrasound synovitis scoring system. All FOI images were scored by 2 readers. Inter-scan, inter-and intra-reader reliability were determined. Furthermore, FOIE-GRAS agreement with ultrasound and responsiveness was assessed.

RESULTS

FOIE-GRAS synovitis was defined as early enhancement and scores based on the degree of coverage of the specific joint region after 3 seconds (0-3). Inter-scan, intra- and inter-reader intraclass correlations coefficients (ICC) were good-excellent for all baseline scores (0.76-0.98) and moderate-to-good for change (0.65-76).The FOIE-GRAS had moderate agreement with ultrasound (ICC 0.30-0.54) for total score, a good standardized response mean (>0.80), and moderate correlation with clinical joint assessment and DAS28-CRP. The median (IQR) reading time per FOI examination was 133 (109;161) seconds. Scores were significantly lower in controls 1(0;4) than RA patients 11(6;19).

CONCLUSION

The FOIE-GRAS offers a feasible and reliable assessment of synovitis in RA, with a moderate correlation with ultrasound and DAS28CRP, and good responsiveness.

Validating the 'CUT score' risk stratification tool for indeterminate thyroid nodules using the Bethesda system for reporting thyroid cytopathology

PURPOSE

Managing intermediate thyroid nodules remains challenging. The CUT score is an Italian metanalysis-based cytologic (SIAPEC-IAP) scoring system, designed to assist clinicians. However, it was never evaluated against the Bethesda system for reporting thyroid cytopathology (BSRTC). This study aims to validate its utility for BSRTC III and IV nodules in a non-Italian population.

METHODS

We collected all BSRTC III and IV thyroid nodules with a documented final pathology between 2010 and 2020. We calculated the C + U components of the CUT score using retrospective clinical (C) data collection and reevaluation of preoperative sonography (U) examination. The cytology (T) component which originally referred to the five-tiered SIAPEC-IAP cytologic classification was replaced by the corresponding BSRTC categories. Optimal test performances were calculated using receiver operating characteristic (ROC) curve analysis. Data were analyzed twice with considering of NIFTP as benign and as malignant.

RESULTS

After exclusions, 62 nodules from 61 patients were included (50% BSRTC III, 50% BSRTC IV). Malignant nodules demonstrated a significantly higher C + U score compared with benign in both categories. The C + U cutoff value for BSRTC III was 5.25 (sensitivity and specificity of 69.23% and 66.67%, respectively, AUC = 0.72, p-value = 0.016), and 5.75 for BSRTC IV (sensitivity and specificity of 85.7% and 76.5%, respectively, AUC = 0.84, p-value < 0.001).

CONCLUSION

Our study suggests that the CUT score is applicable for both BSRTC III and IV nodules, and highlights the need for internal validations, since the cutoffs found were higher than previously reported.

Evaluation of Preoperative Clinical and Serological Determinations in Complicated Acute Appendicitis: A Score for Predicting Complicated Appendicitis

BACKGROUND

To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA).

METHODS

This is a retrospective, observational study including patients (>14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups.

RESULTS

Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P < .05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p<0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85).

CONCLUSION

This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis.

A novel nomogram for early prediction of death in severe neurological disease patients with electroencephalographic periodic discharges

OBJECTIVE

To investigate death-related factors in patients with electroencephalographic (EEG) periodic discharges (PDs) and to construct a model for death prediction.

METHODS

This case-control study enrolled a total of 80 severe neurological disease patients with EEG PDs within 72 h of admission to the neuroscience intensive care unit (NICU). According to modified Rankin scale (mRS) scores half a year after discharge, patients were divided into a survival group (<6 points) and a death group (6 points). Their relevant clinical and biochemical indicators as well as EEG characteristics were retrospectively analyzed. Logistic regression analysis was used to identify the risk factors associated with the death of patients with EEG PDs. A death risk prediction model and an individualized nomogram prediction model were constructed, and the prediction performance and concordance of the models were evaluated.

RESULTS

Multivariate logistic regression analysis showed that the involvement of both gray and white matter in imaging, disappearance of EEG reactivity, occurrence of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs), and an interval time of 0.5-4 s were independent risk factors for death. A regression model was established according to the multivariate logistic regression analysis, and the area under the curve of this model was 0.9135. The accuracy of the model was 87.01%, the sensitivity was 87.17%, and the specificity was 89.17%. A nomogram model was constructed, and a concordance index of 0.914 was obtained after internal validation.

CONCLUSION

The regression model based on risk factors has high accuracy in predicting the risk of death of patients with EEG PDs.

SIGNIFICANCE

This model can help clinicians in the early assessment of the prognosis of severe neurological disease patients with EEG PDs.

A new respiratory scoring system for evaluation of respiratory outcomes in children with spinal muscular atrophy type1 (SMA1) on SMN enhancing drugs

Nusinersen (NUS), the first treatment approved for Spinal Muscular Atrophy type 1 (SMA1), was made available in the UK for SMA1 through the Expanded Access Program (EAP) in 2017. The Great Ormond Street Respiratory (GSR) score was developed as an objective respiratory assessment for children with SMA1 during their treatment. Aims: Track respiratory status of SMA1 children over the course of Nusinersen treatment and compare GSR scores amongst SMA1 sub-types. Single centre study on SMA1 patients using the GSR score at set time points: prior to first NUS dose; 2 weeks post end of loading doses; 2 weeks post-subsequent doses. GSR score ranges 1-28, being 1-9 = Stable minimal support, thorough to 23-28 = Poor reserve with maximum support. 20 SMA1 children underwent NUS treatment between January 2017 - November 2018. Median age of diagnosis was 5.0 months. NUS started at median of 9.57 months. From 5th dose onwards, GSR scores were significantly lower for Type 1C patients compared to Type 1B By month 18, irrespective of subtypes, the whole cohort appears to stabilise GSR Scores. As treatment duration increases, an overall stabilisation of respiratory status across the cohort was observed. Further longitudinal studies are needed to validate the GSR.

Diagnostic performance of the Kaiser score for characterizing lesions on breast MRI with comparison to a multiparametric classification system

PURPOSE

To determine the diagnostic performance of the Kaiser score and to compare it with the BI-RADS-based multiparametric classification system (MCS).

METHOD

Two breast radiologists, blinded to the clinical and pathological information, separately evaluated a database of 499 consecutive patients with structural 3.0 T breast MRI and 697 histopathologically verified lesions. The Kaiser scores and corresponding MCS categories were recorded. The sensitivity and specificity of the Kaiser score and the MCS categories to differentiate benign from malignant lesions were calculated. The interobserver reproducibility and receiver operating characteristic (ROC) parameters were analysed.

RESULTS

The sensitivity and specificity of the MCS were 100 % and 12 %, respectively, and those of the Kaiser score were 98.5 % and 34.8 % for reader 1 and 98.7 % and 47.5 % for reader 2. The area under the ROC-curve was 85.9 and 87.6 for readers 1 and 2. The interobserver intraclass correlation coefficient was excellent at 0.882. Reader 1 upgraded six lesions from BI-RADS 3 to a Kaiser score of >4, and reader 2 upgraded seven lesions. When applying the Kaiser score to 158 benign lesions readers 1 and 2 would have reduced the biopsy rate by 22.8 % and 35.4 %, respectively.

CONCLUSIONS

The Kaiser score showed high diagnostic accuracy with excellent interobserver reproducibility. The MCS had perfect sensitivity but low specificity. Although the Kaiser score had slightly lower sensitivity, its specificity was 3-4 times greater than that of the MCS. Thus, the Kaiser score has the potential to considerably reduce the biopsy rate for true negative lesions.

Hypothalamic lesions in neuromyelitis optica spectrum disorders: exploring a scoring system based on magnetic resonance imaging

PURPOSE

We propose a scoring system for early diagnosis of sleep abnormalities in neuromyelitis optica spectrum disorders (NMOSD) with hypothalamic lesions based on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We evaluated MRI features of 45 patients with hypothalamic lesions identified from two cohorts. Univariate logistic regression analysis identified factors associated with sleepiness, which were subsequently used to develop a scoring system. Interrater reliability was determined using intraclass correlation coefficient (ICC). Correlations between scores and clinical features were analyzed.

RESULTS

In total, 48.9% of 45 patients with hypothalamic lesions exhibited sleepiness. The number of involved slices, maximum width/length of hypothalamic lesions, and boundaries extending beyond the hypothalamus were associated with sleepiness (all p < 0.05). The sensitivity and specificity of the scoring system were 68.2% and 87.0%, respectively. The ICC values for the maximum width and length measurement of hypothalamic lesions were 0.82 and 0.81, respectively. Daily sleep time and Epworth sleepiness scale scores were positively correlated with MRI-based scores (p < 0.05, 95% confidence interval (CI) 0.69-0.93 and p < 0.05, 95% CI 0.55-0.88, respectively).

CONCLUSION

A scoring system based on MRI features was developed to provide diagnosis of sleepiness in NMOSD with hypothalamic lesions earlier than other measures.

Validation of a scoring system for prediction of obstetric complications in placenta accreta spectrum disorders

BACKGROUND

Placenta accreta spectrum (PAS) refers to a spectrum of conditions characterized by the abnormal adherence of the placenta to the implantation site and has been a challenge due to the risk of postpartum hemorrhage, peripartum hysterectomy and maternal mortality. Despite of sonographic findings, no consensus on the prenatal evaluation of PAS has been established yet. We are aiming to establish a scoring system to increase the accuracy of prediction of PAS severity, especially to differentiate placenta percreta and placenta increta.

METHODS

We conducted a retrospective study and collected 2,219 cases of placenta increta and placenta percreta obtained from 20 tertiary care centers in China. Demographic information, clinical characteristics, and sonographic findings were collected. Logistic regression analysis was used to determine the risk factors and sonographic features that were significantly associated with a clinical diagnosis of placenta percreta. The formula and subsequent scoring system were generated. This scoring system was then verified in 67 cases of placenta increta or placenta percreta in Peking University First Hospital from 2016 to 2017. Diagnosis of placental invasion was confirmed by surgical findings or histopathologic results. The scoring system was evaluated using a receiver operating characteristic (ROC) curve.

RESULTS

The scoring system combined maternal risk factors and ultrasound features and was then verified in 67 cases. According to ROC curve, the area under the curve (AUC) of our scoring system for prenatal diagnosis of placenta percreta is 0.96 (95%CI, 0.91-1.00, p < .001), for severe postpartum hemorrhage (≥1500 ml) is 0.76 (95%CI, 0.62-0.91, p = .005), for hysterectomy is 0.98 (95%CI, 0.93-1.000, p = .023).

CONCLUSIONS

Our scoring system combining maternal risk factors and ultrasound features can improve the predictive accuracy of placenta percreta and obstetric outcomes (severe hemorrhage and hysterectomy).

Prevalence of mycoplasma-like lung lesions in pigs from commercial farms from Spain and Portugal

Background

Mycoplasma hyopneumoniae causes a chronic respiratory disease that produces important economic losses due to poor productive performance, increased mortality and costs for several control strategies. The prevalence of mycoplasma-like lesions (MLL) at abattoir has been widely studied in different countries, making use of different scoring systems. However, most of them are difficult to apply in abattoirs with high number of pigs sacrificed per hour. For that reason, it is necessary to adapt the scoring system to the reality of the modern abattoir, even if there is a loss of accuracy. Our purpose was to investigate the prevalence and severity of MLL at abattoirs in Spain and Portugal using a 0 to 5 scoring system adapted to abattoirs with high number of sacrificed pigs per hour and to highlight the histopathological diagnosis as confirmatory method to identify patterns of pneumonia correlated to gross lesions.

Results

Cranioventral pulmonary consolidation, a typical MLL, was the most frequent lung lesion (30.97 %) detected at the abattoir, followed by dorsocaudal infarcts with pleurisy (12.51 %) and pleurisy alone (6.26 %). The average score for all examined lungs at abattoir was 1.99 out of 5 points. The histopathological study revealed that the 78.17 % of the randomly selected lungs with MLL presented microscopic lesions compatible with M. hyopneumoniae infection. Most bronchointerstitial and interstitial pneumonia lesions had a chronic course while most suppurative and fibrinous bronchopneumonia lesions had an acute course and a higher degree of severity. The combination of microscopic lesions more frequently observed was bronchointerstitial pneumonia + interstitial pneumonia + suppurative bronchopneumonia.

Conclusions

The prevalence of MLL at abattoir was 30.97 %, however, after microscopic examination the real prevalence of lungs with lesions compatible with M. hyopneumoniae infection was reduced up to 24.21 %. The six more prevalent combinations of lesions in the microscopic study involved the 66.13 % of examined lungs, and in all of them, microscopic lesions characteristic of M. hyopneumoniae infection were found, what supports the importance of M. hyopneumoniae as a primary pathogen in cases of PRDC.

Impact of scan quality on AI assessment of hip dysplasia ultrasound

AIMS

Early diagnosis of developmental dysplasia of the hip (DDH) using ultrasound (US) is safe, effective and inexpensive, but requires high-quality scans. The effect of scan quality on diagnostic accuracy is not well understood, especially as artificial intelligence (AI) begins to automate such diagnosis. In this paper, we developed a 10-point scoring system for reporting DDH US scan quality, evaluated its inter-rater agreement and examined its effect on automated assessment by an AI system-MEDO-Hip.

METHODS

Scoring was based on iliac wing straightness and angulation; visibility of labrum, os ischium and femoral head; motion; and other artifacts. Four readers from novice to expert separately scored the quality of 107 scans with this 10-point scale and with holistic grading on a scale of 1-5. MEDO-Hip interpreted the same scans, providing a diagnostic category or identifying the scan as uninterpretable.

RESULTS

Inter-rater agreement for the 10-point scale was significantly higher than holistic scoring ICC 0.68 vs 0.93, p < 0.05. Inter-rater agreement on the categorisation of individual features, by Cohen's kappa, was highest for os ischium (0.67 ± 0.06), femoral head (0.65 ± 0.07) and iliac wing (0.49 ± 0.12) indices, and lower for the presence of labrum (0.21 ± 0.19). MEDO-Hip interpreted all images of a quality > 7 and flagged 13/107 as uninterpretable. These were low-quality images (3 ± 1.2 vs. 7 ± 1.8 in others, p < 0.05), with poor visualization of the os ischium and noticeable motion. AI accuracy in cases with quality scores <  = 7 was 57% vs. 89% on other cases, p < 0.01.

CONCLUSION

This study validates that our scoring system reliably characterises scan quality, and identifies cases likely to be misinterpreted by AI. This could lead to more accurate use of AI in DDH diagnosis by flagging low-quality scans likely to provide poor diagnosis up front.

scoring system to predict stone-free rate after retrograde intrarenal surgery

Background

The R.I.R.S. scoring system is defined as a novel and straightforward scoring system that uses the main parameters (kidney stone density, inferior pole stones, stone burden, and renal infundibular length) to identify most appropriate patients for retrograde intrarenal surgery (RIRS). We strived to evaluate the accuracy of the R.I.R.S. scoring system in predicting the stone-free rate (SFR) after RIRS.

Methods

In our medical center, we retrospectively analyzed charts of patients who had, between September 2018 and December 2019, been treated by RIRS for kidney stones. A total of 147 patients were enrolled in the study. Parameters were measured for each of the four specified variables.

Results

Stone-free status was achieved in 105 patients (71.43%), and 42 patients had one or more residual fragments (28.57%). Differences in stone characteristics, including renal infundibulopelvic angle, renal infundibular length, lower pole stone, kidney stone density, and stone burden were statistically significant in patients whether RIRS achieved stone-free status or not (P < 0.001, P: 0.005, P < 0.001, P < 0.001, P: 0.003, respectively). R.I.R.S. scores were significantly lower in patients treated successfully with RIRS than patients in which RIRS failed (P < 0.001). Binary logistic regression analyses revealed that R.I.R.S. scores were independent factors affecting RIRS success (P = 0.033). The area under the curve of the R.I.R.S. scoring system was 0.737.

Conclusions

Our study retrospectively validates that the R.I.R.S. scoring system is associated with SFR after RIRS in the treatment of renal stones, and can predict accurately.

Prediction of successful guidewire crossing of below-the-knee chronic total occlusions using a Japanese scoring system

OBJECTIVE

To develop a scoring system that can adequately predict a successful guidewire crossing (S-GC) of below-the-knee (BTK) chronic total occlusions (CTOs) in angiographic evaluation.

METHODS

A retrospective, multicenter, nonrandomized study examined 448 consecutive BTK CTOs in 299 patients treated with endovascular therapy in seven Japanese medical centers from April 2012 to April 2020. The cohort was classified into two groups: an S-GC group and a failed guidewire crossing group.

RESULTS

The final logistic regression model created by a backward stepwise multivariate logistic regression model included five variables: "No outflow of the target vessel," "CTO length ≥200 mm," "Reference vessel diameter <2.0 mm," "Calcification at the proximal entry point," and "Blunt type at entry point." Optimisms were adjusted using 1000 bootstrap samples with replacement and candidate's risk score models developed according to optimism-adjusted correlation coefficients of risk factors. Choosing the best model as the Japanese-BTK (J-BTK) CTO score by comparing the optimism-adjusted area under receiver-operating characteristic curves it was decided to assign one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel." This rule was then used to categorize BTK CTOs into four grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.3%, 76.8%, 19.3%, and 0%, respectively. Lesions categorized as grade C or D have a lower chance of S-GC. Internal validation was performed using the Hosmer-Lemeshow test (P = .99).

CONCLUSIONS

The J-BTK CTO score predicts the probability of an S-GC of BTK CTOs and stratifies the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.

MAGNIMS score predicts long-term clinical disease activity-free status and confirmed disability progression in patients treated with subcutaneous interferon beta-1a

BACKGROUND

Subcutaneous (sc) interferon (IFN) β-1a reduces relapse rates and delays disability progression in patients with MS. We examined the association of the year 1 Magnetic Resonance Imaging in MS (MAGNIMS) score with long-term clinical disease activity (CDA) -free status and confirmed disability progression in patients treated with sc IFN β-1a in PRISMS.

METHODS

Patients treated with sc IFN β-1a three-times-weekly (22 or 44 μg; pooled data) were classified by MAGNIMS score (0, n = 129; 1, n = 108; 2, n = 130) at year 1. Hazard ratios (HR; 95% confidence intervals [CI]) for risk of CDA and confirmed Expanded Disability Status Score (EDSS) progression were calculated by MAGNIMS score for up to 15 years of follow-up.

RESULTS

The risk of CDA was higher with a year 1 MAGNIMS score of 1 versus 0 (HR 1.82 [1.38-2.41]), 2 versus 0 (2.63 [2.01-3.45]) and 2 versus 1 (1.45 [1.11-1.89], all p < 0.0001). The same outcome was observed with the risk of confirmed EDSS progression (1 versus 0: 1.93 [1.23-3.02]; 2 versus 0: 2.95 [1.95-4.46]; 2 versus 1: 1.53 [1.05-2.23]; all p < 0.0001).

CONCLUSION

In PRISMS, MAGNIMS score at Year 1 predicted risk of CDA and confirmed disability progression in sc IFN β-1a-treated patients over up to 15 years. PRISMS-15 clinicaltrial.gov identifier: NCT01034644.

The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification

BACKGROUND

Although LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa's model in our setting.

METHODS

This prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa's model were compared with actual outcome. Area under ROC curve was calculated.

RESULTS

Among 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa's model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model.

DISCUSSION

Randhawa's model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.

Development and validation of new poisoning mortality score system for patients with acute poisoning at the emergency department

Background

A prediction model of mortality for patients with acute poisoning has to consider both poisoning-related characteristics and patients’ physiological conditions; moreover, it must be applicable to patients of all ages. This study aimed to develop a scoring system for predicting in-hospital mortality of patients with acute poisoning at the emergency department (ED).

Methods

This was a retrospective analysis of the Injury Surveillance Cohort generated by the Korea Center for Disease Control and Prevention (KCDC) during 2011–2018. We developed the new-Poisoning Mortality Scoring system (new-PMS) to generate a prediction model using the derivation group (2011–2017 KCDC cohort). Points were computed for categories of each variable. The sum of these points was the new-PMS. The validation group (2018 KCDC cohort) was subjected to external temporal validation. The performance of new-PMS in predicting mortality was evaluated using area under the receiver operating characteristic curve (AUROC) for both the groups.

Results

Of 57,326 poisoning cases, 42,568 were selected. Of these, 34,352 (80.7%) and 8216 (19.3%) were enrolled in the derivation and validation groups, respectively. The new-PMS was the sum of the points for each category of 10 predictors. The possible range of the new-PMS was 0–137 points. Hosmer–Lemeshow goodness-of-fit test showed adequate calibration for the new-PMS with p values of 0.093 and 0.768 in the derivation and validation groups, respectively. AUROCs of the new-PMS were 0.941 (95% CI 0.934–0.949, p < 0.001) and 0.946 (95% CI 0.929–0.964, p < 0.001) in the derivation and validation groups, respectively. The sensitivity, specificity, and accuracy of the new-PMS (cutoff value: 49 points) were 86.4%, 87.2%, and 87.2% and 85.9%, 89.5%, and 89.4% in the derivation and validation groups, respectively.

Conclusions

We developed a new-PMS system based on demographic, poisoning-related variables, and vital signs observed among patients at the ED. The new-PMS showed good performance for predicting in-hospital mortality in both the derivation and validation groups. The probability of death increased according to the increase in the new-PMS. The new-PMS accurately predicted the probability of death for patients with acute poisoning. This could contribute to clinical decision making for patients with acute poisoning at the ED.

Consensus-based semi-quantitative ultrasound scoring system for gout lesions: Results of an OMERACT Delphi process and web-reliability exercise

OBJECTIVE

This study aimed to develop (1) a new ultrasound definition for aggregates and (2) a semi-quantitative ultrasound scoring system (0-3) for tophus, double contour and aggregates. Furthermore, the intra- and inter-reader reliabilities of both the re-defined aggregates and the semi-quantitative scoring system were assessed using static image exercises.

METHODS

Thirty-seven rheumatologists were invited. A Delphi process was used for re-defining aggregates and for selecting a semi-quantitative scoring system with >75% agreement obligate for reaching consensus. Subsequently, a web-based exercise on static ultrasound images was conducted in order to assess the reliability of both the re-defined aggregates and the semi-quantitative scoring system.

RESULTS

Twenty rheumatologists contributed to all rounds of the Delphi and image exercises. A consensual re-definition of aggregates was obtained after three Delphi rounds but needed an overarching principle for scoring aggregates in patients. A consensus-based semi-quantitative ultrasound scoring system for gout lesions was developed after two Delphi rounds. The re-definition of aggregates showed good intra- and inter-reader reliability (κ-values 0.71 and 0.61). The reliabilities of the scoring system were good for all lesions with slightly higher intra-reader (κ-values 0.74-0.80) than inter-reader reliabilities (κ-values 0.61-0.67).

CONCLUSION

A re-definition of aggregates was obtained with a good reliability when assessing static images. The first consensus-based semi-quantitative ultrasound scoring system for gout-specific lesions was developed with good inter- and intra-reader reliability for all lesions when tested in static images. The next step is to assess the reliabilities when scoring lesions in patients.

Histopathological features of HER2 overexpression in uterine carcinosarcoma: proposal for requirements in HER2 testing for targeted therapy

Uterine carcinosarcoma (UCS) is an uncommon and highly aggressive tumor. There is no HER2 testing protocol for UCS despite the development of HER2 antibody conjugates. We aimed to elucidate histopathological HER2 expression details in UCS, to compare HER2 scores between ASCO/CAP criteria for gastric and breast cancer, and to propose requirements for HER2 testing for UCS. Eighty-nine specimens from 84 patients with metastatic/recurrent UCS were prospectively collected from May 2018 to July 2020. We performed HER2 immunohistochemistry (IHC) for 89 specimens and FISH for 44 specimens. HER2 expression details and HER2 score were evaluated according to the latest ASCO/CAP criteria for gastric (2016) and breast cancer (2018). HER2 IHC scores according to the gastric cancer criteria were 0 in 31 cases (35%), 1+ in 26 (29%), 2+ in 22 (25%), and 3+ in 10 cases (11%) of the 89 specimens. A lateral/basolateral membranous staining pattern was observed in 28/32 (88%) specimens with HER2 scores of 2+/3+. HER2 intratumoral heterogeneity was identified in 28/32 (88%) of the specimens with HER2 scores of 2+/3+. The overall concordance rate of HER2 score was 70% between the gastric and breast criteria. FISH revealed HER2 gene amplification in 10/44 (23%) specimens containing only lateral/basolateral membranous staining pattern. Based on the histopathological features of HER2 expression in UCS, a scoring system that accepts lateral/basolateral staining patterns should be applied. Furthermore, we proposed specific requirements for UCS testing, including specimen selection, scoring system, and calculating the proportion of HER2-positive cells.

Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion

The purpose of this study was to develop a scoring model to predict the technical success of recanalizing via antegrade approach in-stent chronic total occlusion (IS-CTO) by percutaneous coronary intervention (PCI). We retrospectively collected data from 474 patients who underwent an uneasy IS-CTO PCI via antegrade approach from January 2015 to December 2018, consecutively. We selected clinical and angiographic factors and utilized a derivation and validation cohort (4:1 sampling ratio) analysis. Factors with strong correlations with technical failure, according to multivariable analysis, were assigned 1 point, and a scoring system with a 4-point maximum was established. The model was then validated with a validation cohort. The overall procedural success rate was 77.4%. On multivariable analysis, the factors that correlated with technical failure were proximal bending (beta coefficient [β] = 2.142), tortuosity (β = 2.622), stent under expansion (β = 3.052), and poor distal landing zone (β = 2.004). The IS-CTO score demonstrated good calibration and excellent predicting capacity in the derivation (receiver-operator characteristic [ROC] area = 0.973 and Hosmer-Lemeshow chi-squared = 5.252; p = 0.072) and validation (ROC area = 0.976 and Hosmer-Lemeshow chi-squared = 0.916; p = 0.632) cohorts. In the validation subset, the IS-CTO score demonstrated superior performance to the Japanese chronic total occlusion score (J-CTO) and PROGRESS CTO scores for predicting technical success (area under the a curve [AUC] 0.976 vs. 0.642 vs. 0.579, respectively; difference in AUC between the IS-CTO score and J-CTO score = 0.334, p < 0.01; difference in AUC between the IS-CTO score and PROGRESS score = 0.397, p < 0.01). Our results suggest that the IS-CTO score system is a helpful tool to predict the technical success of IS-CTO PCI via antegrade approach in china. Graphical Abstract.

A novel hospital capacity versus clinical justification triage score (CCTS) for prioritization of spinal surgeries in the "new normal state" of the COVID-19 pandemic

Introduction

During the Coronavirus disease 2019 outbreak, while healthcare systems and hospitals are diverting their resources to combat the pandemic, patients who require spinal surgeries continue to accumulate. The aim of this study is to describe a novel hospital capacity versus clinical justification triage score (CCTS) to prioritize patients who require surgery during the “new normal state” of the COVID-19 pandemic.

Methodology

A consensus study using the Delphi technique was carried out among clinicians from the Orthopaedic Surgery, Neurosurgery, and Anaesthesia departments. Three rounds of consensus were carried out via survey and Webinar discussions.

Results

A 50-points score system consisting of 4 domains with 4 subdomains was formed. The CCTS were categorized into the hospital capacity, patient factors, disease severity, and surgery complexity domains. A score between 30 and 50 points indicated that the proposed operation should proceed without delay. A score of less than 20 indicates that the proposed operation should be postponed. A score between 20 and 29 indicates that the surgery falls within a grey area where further discussion should be undertaken to make a joint justification for approval of surgery.

Conclusion

This study is a proof of concept for the novel CCTS scoring system to prioritize surgeries to meet the rapidly changing demands of the COVID-19 pandemic. It offers a simple and objective method to stratify patients who require surgery and allows these complex and difficult decisions to be unbiased and made transparently among surgeons and hospital administrators.

Chronic nonbacterial osteomyelitis - clinical and magnetic resonance imaging features

BACKGROUND

Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder. Little information exists on the use of imaging techniques in CNO.

MATERIALS AND METHODS

We retrospectively reviewed clinical and MRI findings in children diagnosed with CNO between 2012 and 2018. Criteria for CNO included unifocal or multifocal inflammatory bone lesions, symptom duration >6 weeks and exclusion of infections and malignancy. All children had an MRI (1.5 tesla) performed at the time of diagnosis; 68 of these examinations were whole-body MRIs including coronal short tau inversion recovery sequences, with additional sequences in equivocal cases.

RESULTS

We included 75 children (26 boys, or 34.7%), with mean age 10.5 years (range 0-17 years) at diagnosis. Median time from disease onset to diagnosis was 4 months (range 1.5-72.0 months). Fifty-nine of the 75 (78.7%) children presented with pain, with or without swelling or fever, and 17 (22.7%) presented with back pain alone. Inflammatory markers were raised in 46/75 (61.3%) children. Fifty-four of 75 (72%) had a bone biopsy. Whole-body MRI revealed a median number of 6 involved sites (range 1-27). Five children (6.7%) had unifocal disease. The most commonly affected bones were femur in 46 (61.3%) children, tibia in 48 (64.0%), pelvis in 29 (38.7%) and spine in 20 (26.7%). Except for involvement of the fibula and spine, no statistically significant differences were seen according to gender.

CONCLUSION

Nearly one-fourth of the children presented with isolated back pain, particularly girls. The most common sites of disease were the femur, tibia and pelvic bones. Increased inflammatory markers seem to predict the number of MRI sites involved.

Current status of MR imaging of juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic arthropathy in the pediatric population. Although the diagnosis is essentially clinical for many affected joints, MR imaging has become an important tool for the assessment of joints that are difficult to evaluate clinically, such as temporomandibular and sacroiliac joints, and for screening of inflammatory changes in the entire body by whole body MRI (WBMRI) assessment. The utilization of MR imaging is challenging in the pediatric population given the need for discrimination between pathological and physiological changes in the growing skeleton. Several multicentric multidisciplinary organizations have made major efforts over the past decades to standardize, quantify, and validate scoring systems to measure joint changes both cross-sectionally and longitudinally according to rigorous methodological standards. In this paper, we (1) discuss current trends for the diagnosis and management of JIA, (2) review challenges for detecting real pathological changes in growing joints, (3) summarize the current status of standardization of MRI protocols for data acquisition and the quantification of joint pathology in JIA by means of scoring systems, and (4) outline novel MR imaging techniques for the evaluation of anatomy and function of joints in JIA. Optimizing the role of MRI as a robust biomarker and outcome measure remains a priority of future research in this field.

Application of the Kaiser score to increase diagnostic accuracy in equivocal lesions on diagnostic mammograms referred for MR mammography

INTRODUCTION

We aimed to interpret MR mammography (MRM) using the Kaiser scores for equivocal or inconclusive lesions on mammography (MG).

METHODS

Retrospective IRB-approved evaluation of 3623 MG for which MRM was deployed as a problem-solving tool, after inclusion-exclusion criteria were met. Three readers with different levels of experience assigned a final score from 1 to 11 based on the previously established tree classification system. Area under the curve (AUC) derived from receiver operating characteristic (ROC) analysis was used to determine the overall diagnostic performance for all lesions and separately for mass and non-mass enhancement. Sensitivity, specificity, and likelihood ratio values were obtained at different cut-off values of >4, > 5, and > 8 to rule in and rule out malignancy.

RESULT

Histopathology of 183 mass and 133 non-mass enhancement (NME) lesions show benign etiology in 95 and malignant in 221. The AUC was 0.796 [0.851 for mass and 0.715 for NME]. Applying the Kaiser score upgraded 202 lesions with correct prediction in 77 %, and downgraded 28 lesions with correct prediction in 60.8 %. Using a score <5 instead of <4 to rule out malignancy improved our diagnostic ability to correctly identify 100 % benign lesions. Applying Kaiser score correctly downgraded 60.8 % (17/28) lesions; thus avoiding biopsies in these. Using a high cut-off value>8 to rule-in malignancy, we correctly identified 59.7 % of lesions with 80 % specificity and positive likelihood ratio of 3.

CONCLUSION

The Kaiser score has clinical translation benefits when used as a problem-solving tool for inconclusive MG findings.

Development and prospective validation of a scoring system for the Basic Endoscopic Skills Training (BEST) box

AIMS

The increased use of endoscopy as a minimally invasive therapeutic technique has created a great demand for endoscopic training. The Basic Endoscopic Skills Training (BEST) box provides a low-cost solution by adapting the Fundamentals of Laparoscopic Surgery (FLS) box for flexible endoscopic simulation. The BEST box consists of six endoscopic tasks with a 5-min time limit per task. This study aims to develop a scoring system for objective evaluation of user performance.

METHODS

A total of 165 participants were tested on the BEST box. Participants were divided into two groups: retrospective analysis (n = 100) and prospective analysis (n = 65). From the retrospective group, 55 individuals were also scored on the Global Assessment of Gastrointestinal Endoscopic Skills-Upper Endoscopy (GAGES-UE). Linear regression between user performance on BEST box and GAGES-UE was performed to develop the scoring system. Receiver Operating Characteristic curve was used to determine a threshold score to help users appreciate their endoscopic expertise. Prospective scoring of 65 individuals was then performed using the formula developed (20 experts and 45 trainees).

RESULTS

The minimum and maximum possible scores are 30 and 110, respectively. Retrospective analysis showed that the scoring system was able to distinguish between experts and trainees (p < 0.001), correlated with GAGES-UE (p < 0.001), and had a reliability constant of r = 0.765 (p < 0.001). On prospective testing using the scoring system the expert group received a final average score of 92, whereas the average score for the trainee group was 61 (p < 0.001).

CONCLUSIONS

The developed BEST box scoring system correlates with the experience level of the test taker as well as with the GAGES-UE scoring system. The results of this study add further evidence to the validity of the BEST box as an effective, low-cost endoscopic simulator with the scores used by trainees to track their performance level overtime.