Development and Validation of a User Friendly Morphology Grading System (PATENT) Predicting Aortic Remodelling After Thoracic Endovascular Aortic Repair in High Risk Uncomplicated Type B Aortic Dissection.

OBJECTIVE: This study aimed to create a morphology grading system, solely based on 2D images from computed tomography angiography, to predict negative aortic remodelling (NAR) for patients with high risk uncomplicated type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). METHODS: This single centre retrospective cohort study extracted and analysed consecutive patients diagnosed with high risk uncomplicated TBAD. Negative aortic remodelling was defined as an increase in the diameter of a false lumen or total aorta, or decrease in the diameter of a true lumen. The multivariate Cox regression model identified risk factors and a prediction model was created for two year freedom from NAR. A three category grading system, in which patients were classified into low, medium, and high risk groups, was further developed and internally validated. RESULTS: Of 351 patients included, 99 (28%) of them developed NAR. The median age was 52 years (interquartile range 45, 62 years) and 56 of them (16%) were female. The rate of two year freedom from NAR was 71% (95% CI 65 - 77%). After the multivariate Cox regression analysis, Patent false lumen, Aberrant right subclavian artery, Taper ratio, abdominal circumferential Extent, coeliac artery or reNal artery involved, and four channelled dissection (Three false lumens) remained independent predictors and were included in the PATENT grading system. The risk score was significantly associated with NAR (HR 1.21; 95% CI 1.14 - 1.29; p < .001). The medium and high risk groups demonstrated a higher rate of NAR (medium risk, HR 2.82; 95% CI 1.57 - 5.01; p = .001; high risk, HR 4.39; 95% CI 2.58 - 7.48; p < .001). The grading system was characterised by robust discrimination with Harrell's C index of 0.68 (95% CI 0.63 - 0.75). CONCLUSION: The PATENT grading system was characterised with good discrimination and calibration, which may serve as a clinician friendly tool to aid in risk stratification for TBAD patients after TEVAR.

The value of deep learning-based X-ray techniques in detecting and classifying K-L grades of knee osteoarthritis: a systematic review and meta-analysis.

OBJECTIVES: Knee osteoarthritis (KOA), a prevalent degenerative joint disease, is primarily diagnosed through X-ray imaging. The Kellgren-Lawrence grading system (K-L) is the gold standard for evaluating KOA severity through X-ray analysis. However, this method is highly subjective and non-quantifiable, limiting its effectiveness in detecting subtle joint changes on X-rays. Recent researchers have been directed towards developing deep-learning (DL) techniques for a more accurate diagnosis of KOA using X-ray images. Despite advancements in these intelligent methods, the debate over their diagnostic sensitivity continues. Hence, we conducted the current meta-analysis. METHODS: A comprehensive search was conducted in PubMed, Cochrane, Embase, Web of Science, and IEEE up to July 11, 2023. The QUADAS-2 tool was employed to assess the risk of bias in the included studies. Given the multi-classification nature of DL tasks, the sensitivity of DL across different K-L grades was meta-analyzed. RESULTS: A total of 19 studies were included, encompassing 62,158 images. These images consisted of 22,388 for K-L0, 13,415 for K-L1, 15,597 for K-L2, 7768 for K-L3, and 2990 for K-L4. The meta-analysis demonstrated that the sensitivity of DL was 86.74% for K-L0 (95% CI: 80.01%-92.28%), 64.00% for K-L1 (95% CI: 51.81%-75.35%), 75.03% for K-L2 (95% CI: 66.00%-83.09%), 84.76% for K-L3 (95% CI: 78.34%-90.25%), and 90.32% for K-L4 (95% CI: 85.39%-94.40%). CONCLUSIONS: The DL multi-classification methods based on X-ray imaging generally demonstrate a favorable sensitivity rate (over 50%) in distinguishing between K-L0-K-L4. Specifically, for K-L4, the sensitivity is highly satisfactory at 90.32%. In contrast, the sensitivity rates for K-L1-2 still need improvement. CLINICAL RELEVANCE STATEMENT: Deep-learning methods have been useful to some extent in assessing the effectiveness of X-rays for osteoarthritis of the knee. However, this requires further research and reliable data to provide specific recommendations for clinical practice. KEY POINTS: X-ray deep-learning (DL) methods are debatable for evaluating knee osteoarthritis (KOA) under The Kellgren-Lawrence system (K-L). Multi-classification deep-learning methods are more clinically relevant for assessing K-L grading than dichotomous results. For K-L3 and K-L4, X-ray-based DL has high diagnostic performance; early KOA needs to be further improved.

Fluorine-18 FDG PET/CT and New NIMS Grading System for Chemotherapy Response in Breast Cancer.

Background: Positron emission tomography with computed tomography (PET-CT) using fluorine 18-fluorodeoxyglucose (F-18 FDG) is increasingly used to stage patients with locally advanced breast cancer and for assessing treatment response after neoadjuvant chemotherapy (NACT). Aims and Objectives: The aim of the study was to assess the correlation between PET-CT parameters and pathologic response of breast primary after NACT in breast cancer patients and to devise a grading system called NIMS grading system for response assessment using PET quantitative parameters. Materials and Methods: 55 patients who underwent F-18 FDG PET-CT before starting the therapy and again after completion of therapy were identified and included in the study. The clinical data and the histopathologic findings were recorded. All the patients received chemotherapy followed by surgery with axillary lymph node dissection. The PET-CT results were interpreted both qualitatively by visual analysis and quantitatively by estimating maximum Standardized uptake values(SUVmax) and other parameters - SUVmean, SUL, SUVBSA, Metabolic tumor volume (MTV) and Total lesion glycolysis (TLG). Results: The sensitivity and specificity of F-18 FDG PET-CT to detect the residual disease after neoadjuvant chemotherapy was 75.6% & 92.8% respectively. Differences between complete response and residual disease were significant for ΔSUVmax(p=0.005), ΔSUVmean(p=0.006), ΔSUL (0.005) and ΔSUVBSA(0.004), while ΔMTV and ΔTLG were not significantly different between the two groups. The new NIMS grading system included scoring of ΔSUVmax, ΔSUVBSA, ΔTLG and ΔMTV on scale of 1 to 4 and correlated well with PERCIST criteria. Conclusion: F-18 FDG PET-CT had a good accuracy in the detection of residual disease after completion of NACT. Pre chemotherapy PET-CT is not adequate to predict the response of primary tumour to chemotherapy. However, changes in the values of various PET-CT parameters are a sensitive tool to assess the response to chemotherapy. The new grading system is easy to use and showed good correlation to PERCIST.

Characterization of Pediatric Female Genital Trauma Using a Novel Grading System and Recommendations for Management.

BACKGROUND: There is no standardized grading system for pediatric female genital trauma (PFGT), so patients may have over-utilization of resources relative to injury severity. We described current treatment patterns and outcomes at a high-volume trauma center, developed a novel PFGT grading system, and proposed algorithm for management of PFGT. METHODS: We retrospectively reviewed female patients <19 years presenting with genital trauma to our Level 1 pediatric trauma center between 1/2018-12/2022. A novel grading system developed by pediatric surgery and pediatric gynecology was retrospectively applied to injuries. Patient demographics, injury characteristics, types of intervention, and need for anesthesia were recorded. Outcomes were compared between grades of injury with Kruskal-Wallis tests. RESULTS: Among 353 patients, median age was 6.4 years. Half of patients had grade 1 or 2 injuries, of which 6% required suture repair. 15% of patients had grade 5 or 6 injuries, 75% of whom required suture repair. General anesthesia was used for 83% of all patients undergoing repair. 18% of patients who underwent general anesthesia did not need suture repair. Of patients who were brought to the operating room, median operative duration varied by grade and was 15.0 min for all injuries, 7.0 min for both grade 1 and 2 injuries, and 22.0 and 37.0 min for grade 5 and 6 injuries, respectively (p < 0.0001). CONCLUSIONS: Based on our novel grading system, we propose an algorithm for managing PFGT. Grade 1 and 2 injuries rarely require suture repair and can often be managed without surgical consultation. We recommend surgical consultation for higher grade injuries, however given typically short operative times, repair with bedside sedation should be strongly considered when resources allow. LEVEL OF EVIDENCE: IV.

Comparison of the monoexponential and biexponential models of diffusion-weighted magnetic imaging in grading clear-cell renal cell carcinoma: a case-control study.

Background: An accurate and noninvasive method to determine the preoperative clear-cell renal cell carcinoma (ccRCC) pathological grade is of great significance for surgical program selection and prognosis assessment. Previous studies have shown that diffusion-weighted imaging (DWI) has moderate value in grading ccRCC. But DWI cannot reflect the diffusion of tissue accurately because it is calculated using a monoexponential model. Intravoxel incoherent motion (IVIM) is the biexponential model of DWI. Only a few studies have examined the value of IVIM in grading ccRCC yet with inconsistent results. This study aimed to compare the value of DWI and IVIM in grading ccRCC. Methods: In this study, 96 patients with pathologically confirmed ccRCC were evaluated by DWI and IVIM on a 3-T scanner. According to the World Health Organization/International Society of Urological Pathology (WHO/ISUP) classification system, these patients were divided into two groups: low-grade (grade I and II) and high-grade (grade III and IV) ccRCC. The apparent diffusion coefficient (ADC), true diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction of pseudodiffusion (f) values were calculated. The Mann-Whitney test, receiver-operating characteristic (ROC) analysis, and the Delong test were used for statistical evaluations. Results: (I) According to the WHO/ISUP nuclear grading system, 96 patients were divided into low-grade (grade I and II, 45 patients) and high-grade (grade III and IV, 51 patients) groups. (II) Compared with patients of low-grade ccRCC, the ADC and D values of those with high-grade ccRCC decreased while the D* and f values increased (P<0.05). (III) The cutoff value of the ADC, D, D*, and f in distinguishing low-grade from high-grade ccRCC was 1.50×10-3 mm2/s, 1.12×10-3 mm2/s, and 33.19×10-3 mm2/s, 0.31, respectively; the area under the curve (AUC) for the ADC, D, D*, and f values was 0.871, 0.942, 0.621, and 0.894, respectively, with the AUC of the D value being the highest; the sensitivity for the ADC, D, D*, and f values was 94.12%, 92.16%, 47.06%, and 92.16%, respectively; and the specificity for the ADC, D, D*, and f values was 66.67%, 91.11%, 77.78%, and 73.33%, respectively. (IV) Based on the Delong test, AUCD was significantly higher than AUCADC (P=0.02) and AUCD* (P<0.001), but there was no significant difference between AUCD and AUC f (P=0.18). Conclusions: Compared with the monoexponential model DWI, the biexponential model IVIM was more accurate in grading ccRCC.

Prognostic value of the international association for the study of lung cancer grading system and its association with the tumor microenvironment in stage I EGFR-muted lung adenocarcinoma.

INTRODUCTION: The International Association for the Study of Lung Cancer (IASLC) grading system predicts early lung adenocarcinoma outcomes. METHODS: The purpose of this study is to examine prognostic value of the IASLC grading system and its association with the tumor microenvironment (TME) in Stage I EGFR-muted lung adenocarcinoma. Based on the IASLC grading system, we compared the clinicopathological characteristics of EGFR-mutated lung adenocarcinoma (n = 296). In addition, we examined the expression level of E-cadherin in tumor cells and counted the number of tumor-infiltrating lymphocytes (TILs; CD8, CD20, CD138, and Foxp3), tumor-associated macrophages (TAMs; CD204), and cancer-associated fibroblasts (CAFs; podoplanin) using semi-automatic digital pathology image analysis. RESULTS: Recurrence-free survival (RFS) curve showed that survival of grade 3 was significantly shorter than that of grade 1 (P < 0.01) and grade 2 (P = 0.03). Multivariate analysis of RFS revealed the invasive size, lymphatic permeation, and grade 3 (P < 0.01) as independent poor prognostic factors. The number of CD204 +TAMs and PDPN+CAFs was significantly higher in grade 3 than in grade 1 or 2 (all P < 0.01). Among the intermediate grade by the predominant subtype based classification, cases classified as grade 3 by the new classification had higher number of CD204 +TAMs (P < 0.01) and PDPN+CAFs (P = 0.02) than those classified as grade 2. CONCLUSION: The IASLC grading system correlated with the outcomes of EGFR-mutated lung adenocarcinoma. Grade 3 was found to have the TME that most contributes to tumor progression, which probably explained their poor prognosis.

A Proposal of a New Tool for the Assessment of Damage in Behçet Syndrome Uveitis: Cerrahpasa Ocular Damage Grading System.

INTRODUCTION/OBJECTIVE: There is currently no tool available to assess the severity of damage in uveitis due to Behçet's syndrome (BS). In this preliminary study, we developed a new grading system to evaluate ocular damage and assessed it in a prospective cohort. METHODS: A specialist in BS uveitis (YO) developed a grading system for ocular damage with five grades based on the extent of damage in the posterior segment. YO trained a senior and general ophthalmologist with sample fundus images. BS patients who had undergone color fundus photography during their routine visits in attack-free periods were included in the study. The color fundus photos of this prospective cohort were evaluated blindly by YO and his trainees using the new grading tool. Inter and intra-observer agreement between the graders were assessed by Cohen's kappa analysis. The evaluation of YO was considered as the gold standard. RESULTS: One hundred eighty-five eyes of 108 (29 F/79 M) patients with BS uveitis were graded for damage by two investigators. Their mean age was 38,58 years and their median ocular disease duration was 13 years. The gold standard and the two investigators exhibited substantial concordance with the ocular damage grading system. The inter- and intra-observer agreement were also almost perfect. CONCLUSION: The newly developed ocular damage grading system enables the standardization of damage severity in BS uveitis. It is imperative to conduct internal and external validations across diverse cohorts. Furthermore, future studies should investigate its correlation with other multimodal imaging methods such as fluorescein angiography and optical coherence tomography.

Evaluation of comorbidity scoring systems in patients undergoing knee arthroplasty.

BACKGROUND: Ageing populations are increasing the demand for knee arthroplasty. Concurrently, the prevalence of medical comorbidities are rising too. The Self-Administered Comorbidity Questionnaire was developed to provide a patient's assessment of their own comorbidities whereas the American Society of Anesthesiologists grades and the Charlson Comorbidity Index utilise clinical evaluation to objectively measure perioperative morbidity and mortality risk. The primary aim of this study was to compare Self-Administered Comorbidity Questionnaire scores with American Society of Anesthesiologists grades and Charlson Comorbidity Index scores. The secondary aim was to compare Self-Administered Comorbidity Questionnaire scores with knee outcome scores. METHODS: A single centre observational cohort study of patients with knee osteoarthritis undergoing elective knee arthroplasty. Preoperative evaluation included Self-Administered Comorbidity Questionnaire scores, American Society of Anesthesiologists grades, Charlson Comorbidity Index scores and validated patient-reported outcome measures specific to knee surgery. RESULTS: A total of 141 patients were included in this study. Self-Administered Comorbidity Questionnaire scores were directly correlated with American Society of Anesthesiologists grade (rho = 0.37, p < 0.001) and Charlson Comorbidity Index scores (rho = 0.19, p = 0.047). Individual American Society of Anesthesiologists grades had significantly different Self-Administered Comorbidity Questionnaire scores (p = 0.001). Self-Administered Comorbidity Questionnaire scores were specifically associated with hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and the total number of comorbidities, but American Society of Anesthesiologists and Charlson Comorbidity Index scores were associated with more comorbidities. Overall, Self-Administered Comorbidity Questionnaire scores were inversely correlated with patient-reported outcome measure scores. CONCLUSION: Self-Administered Comorbidity Questionnaire scores are associated with increasing comorbidity in patients with symptomatic knee osteoarthritis; however, American Society of Anesthesiologists grades and Charlson Comorbidity Index scores had stronger and more abundant associations with comorbidities and patient-reported outcome measure scores. Self-Administered Comorbidity Questionnaires may complement but not replace current objective assessments of comorbidity when evaluating perioperative risk for knee arthroplasty.

Novel Grading System Based on Nasal Endoscopy: Our Experience with 650 Mucormycosis Cases.

Rhinocerebralmucormycosis, is a progressive fungal invasion of a hard palate, paranasal sinuses, orbit, and brain. Post covid the huge number of mucor cases reported in our institute. To combat them a uniform assessment scale was needed as multiple healthcare workers were involved. Thus, a novel linear grading system on nasal endoscopy was developed for the early management of patients to prevent morbidity and mortality. A Prospective study of 650 patients in Epidemic duration from April to June 2021 in a tertiary health center, Central India. Patients subjected to Nasal Endoscopy with 0degree 4 mm Telescope and classified into 5 categories according to the severity of the disease. In a novel grading system, minimum patients were of grade 0, maximum was in Grade I. Maxillary sinus was most commonly involved. This novel grading system on nasal endoscopy makes the management of patients much easier in an epidemic, reducing human errors, morbidity, and mortality of the fulminant disease.

A Grading System-Guided Approach to the Severely Contracted Nose.

PURPOSE: Capsular contracture is a rare but serious complication of silicone implant-based augmentation rhinoplasty. When severe, the contracture can affect all layers of the nose, causing significant scarring and disfigurement. There is currently no standardized method of evaluating contracted noses and a paucity of literature on the treatment of severe contracture. Therefore, this study aimed to establish a comprehensive grading system and treatment approach for patients with nasal contracture secondary to silicone implant-based rhinoplasty. METHODS: We conducted a retrospective analysis on patients who presented with nasal contracture from 2012 to 2021. All preoperative photographs were evaluated by two plastic surgeons, twice at 1-month intervals. The proposed grading system comprised: normal (grade I), mild contracture with detectable implant (grade II), moderate contracture with skin thinning (grade III), severe contracture with short nose deformity (grade IV), and destructive contracture with scarring of the dorsal skin (grade Va), or columella deficiency (grade Vb). Inter- and intraobserver agreement was assessed using the kappa value to determine the reliability of the system. RESULTS: Based on 87 patients, interobserver agreement was substantial for both evaluation time points (k = 0.701 and 0.723). Intraobserver agreement was excellent for evaluator 1 (k = 0.822) and substantial for evaluator 2 (k = 0.699). CONCLUSIONS: Using this grading system, we propose a graduated treatment algorithm for contracted noses. Most notable is our use of radial forearm free or forehead flaps to reconstruct the columella in grade Vb patients. By combining reconstructive and aesthetic principles, this treatment approach provides an effective and elegant solution for the management of the severely contracted nose. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Critical evaluation of artificial intelligence as a digital twin of pathologists for prostate cancer pathology.

Prostate cancer pathology plays a crucial role in clinical management but is time-consuming. Artificial intelligence (AI) shows promise in detecting prostate cancer and grading patterns. We tested an AI-based digital twin of a pathologist, vPatho, on 2603 histological images of prostate tissue stained with hematoxylin and eosin. We analyzed various factors influencing tumor grade discordance between the vPatho system and six human pathologists. Our results demonstrated that vPatho achieved comparable performance in prostate cancer detection and tumor volume estimation, as reported in the literature. The concordance levels between vPatho and human pathologists were examined. Notably, moderate to substantial agreement was observed in identifying complementary histological features such as ductal, cribriform, nerve, blood vessel, and lymphocyte infiltration. However, concordance in tumor grading decreased when applied to prostatectomy specimens (κ = 0.44) compared to biopsy cores (κ = 0.70). Adjusting the decision threshold for the secondary Gleason pattern from 5 to 10% improved the concordance level between pathologists and vPatho for tumor grading on prostatectomy specimens (κ from 0.44 to 0.64). Potential causes of grade discordance included the vertical extent of tumors toward the prostate boundary and the proportions of slides with prostate cancer. Gleason pattern 4 was particularly associated with this population. Notably, the grade according to vPatho was not specific to any of the six pathologists involved in routine clinical grading. In conclusion, our study highlights the potential utility of AI in developing a digital twin for a pathologist. This approach can help uncover limitations in AI adoption and the practical application of the current grading system for prostate cancer pathology.

To Determine the Efficacy of Pentoxifylline in the Management of Bell's Palsy.

Background and aims: Bell's palsy is an acute, unilateral, lower motor neuron peripheral facial paralysis. It is the most common cause of facial paralysis in the ages ranging from 13 to 65 years. It not only causes physical disfigurement of face but is also associated with social stigma and psychological trauma to the patient. In Bell's Palsy, there is hypoxic damage to the nerve due to reduced blood flow and cellular injury to the capillaries. Pentoxifylline is a phosphodiesterase inhibitor that increases the cAMP and cGMP levels at the site of the RBC cell membrane thereby improving the dexterity of the cell membrane allowing the RBCs to pass through the damaged and narrowed blood vessels thereby improving the perfusion and oxygen delivery to the damaged tissues. Vasoactive agents are not routinely used as an active component in the treatment. Since vascular compromise plays a predominant role in the pathophysiology of Bell's palsy, it is proposed that the addition of a vasoactive agent like Pentoxifylline can improve the recovery rate and shorten the duration of treatment in the management of Bell's Palsy. Materials and methods: The study was conducted in the Department of ENT, BMCRI, Bangalore during the period February 2021 to August 2022. This is a prospective randomized control study which included 70 patients attending the out-patient department of ENT, Bangalore Medical College and Research Institute, Bangalore. Written informed consent was taken from all patients included in the study. A detailed history, thorough clinical examination, and relevant investigations were done for these patients. Patients were randomly divided into Group A and Group B based on random numbers generated by the WINPEPI software version 11.65. The study group (Group A) received standard treatment in addition to Tab Pentoxifylline 400 mg TID for 1 week. The control group (Group B) received only the standard treatment regimen. Patients were followed up on Days 5, 10, 15, and 6 months to assess recovery following treatment. The recovery of facial nerve function was evaluated as per the House-Brackmann Grading system for any improvement. Both pre-treatment and post-treatment HB grades were analyzed. The data collected were tabulated and subjected to statistical analysis using ANOVA. Results: The age distribution of the patients showed that the most common age group affected in this study was 18-30 years. Males were affected more than females (1.2:1). The most common HB grade at presentation noted in this study was Grade 4 in both groups (54.2%). At the beginning of the treatment, in Group A, around 43% patients had HB grade of 3 and 57% patients had HB grade of 4. In Group B, around 20% patients had HB grade 2, 28.57% patients with grade 3 and 51.43% patients with grade 4. After a follow-up period of 6 months, in Group A, around 43% of patients achieved a HB grade of 1, 51% patients achieved a grade of 2 and about 6% patients had a grade of 3. In Group B after a follow up period of 6 months, 29% patients achieved HB grade of 1, 46% patients achieved grade of 2 and 26% patients had a grade of 3. It was observed that 42.86% of patients had better outcomes (Normal facial function) in Group A (Study group) compared to 28.57% of patients in Group B (Control group). It is evident that a patient who presented with HB grades of 2 or 3 and who presented within 5 days had better chances of recovery which was statistically significant (p = 0.001). Interpretation and conclusion: From the present study, it may be concluded that Bell's palsy occurs in all age groups. It affects younger age groups more commonly (2nd decade) and affects males more than females. The study group who had received Tab Pentoxifylline along with standard treatment had better outcome. This highlights the benefit of vasoactive agent in the management of Bell's palsy by improving the oxygen delivery to the affected tissues. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04298-9.

Grading system for assessing the confidence in the epileptogenic zone reported in published studies: A Delphi consensus study.

OBJECTIVE: This study was undertaken to develop a standardized grading system based on expert consensus for evaluating the level of confidence in the localization of the epileptogenic zone (EZ) as reported in published studies, to harmonize and facilitate systematic reviews in the field of epilepsy surgery. METHODS: We conducted a Delphi study involving 22 experts from 18 countries, who were asked to rate their level of confidence in the localization of the EZ for various theoretical clinical scenarios, using different scales. Information provided in these scenarios included one or several of the following data: magnetic resonance imaging (MRI) findings, invasive electroencephalography summary, and postoperative seizure outcome. RESULTS: The first explorative phase showed an overall interrater agreement of .347, pointing to large heterogeneity among experts' assessments, with only 17% of the 42 proposed scenarios associated with a substantial level of agreement. A majority showed preferences for the simpler scale and single-item scenarios. The successive Delphi voting phases resulted in a majority consensus across experts, with more than two thirds of respondents agreeing on the rating of each of the tested single-item scenarios. High or very high levels of confidence were ascribed to patients with either an Engel class I or class IA postoperative seizure outcome, a well-delineated EZ according to all available invasive EEG (iEEG) data, or a well-delineated focal epileptogenic lesion on MRI. MRI signs of hippocampal sclerosis or atrophy were associated with a moderate level of confidence, whereas a low level was ascribed to other MRI findings, a poorly delineated EZ according to iEEG data, or an Engel class II-IV postoperative seizure outcome. SIGNIFICANCE: The proposed grading system, based on an expert consensus, provides a simple framework to rate the level of confidence in the EZ reported in published studies in a structured and harmonized way, offering an opportunity to facilitate and increase the quality of systematic reviews and guidelines in the field of epilepsy surgery.

Who benefit from adjuvant chemotherapy in stage I lung adenocarcinoma? A multi-dimensional model for candidate selection.

BACKGROUND: Despite promising overall survival of stage I lung adenocarcinoma (LUAD) patients, 10-25 % of them still went through recurrence after surgery. [1] While it is still disputable whether adjuvant chemotherapy is necessary for stage I patients. [2] IASLC grading system for non-mucinous LUAD shows that minor high-grade patterns are significant indicator of poor prognosis. [3] Other risk factors, such as, pleura invasion, lympho-vascular invasion, STAS, etc. are also related to poor prognosis. [4-6] There still lack evidence whether IASLC grade itself or together with other risk factors can guide the use of adjuvant therapy in stage I patients. In this article, we tried to establish a multi-variable recurrence prediction model for stage I LUAD patients that is able to identify candidates of adjuvant chemotherapy. METHODS: We retrospectively collected patients who underwent lung surgery from 2018.8.1 to 2018.12.31 at our institution and diagnosed with lung adenocarcinoma pT1-2aN0M0 (stage I). Clinical data, manifestation on CT scan, pathologic features, driver gene mutations and follow-up information were collected. Cox proportional hazards regression analyses were performed utilizing the non-adjuvant cohort to predict disease free survival (DFS) and a nomogram was constructed and applied to the total cohort. Kaplan-Meier method was used to compare DFS between groups. Statistical analysis was conducted by R version 3.6.3. FINDINGS: A total of 913 stage I LUAD patients were included in this study. Median follow-up time is 48.1 months.4-year and 5-year DFS are 92.9 % and 89.6 % for the total cohort. 65 patient experienced recurrence or death. 4-year DFS are 97.0 %,94.6 % and 76.2 %, and 5-year DFS are 95.5 %, 90.0 % and 74.1 % in IASLC Grade1, 2 and 3, respectively(p < 0.0001). High-risk patients defined by single risk factors, such as, IASLC grade 3, pleura invasion, STAS, less LN resected could not benefit from adjuvant therapy. A LASSO-COX regression model was built and patients are divided into high-risk and low-risk groups. In the high-risk group, patients underwent adjuvant chemotherapy have longer DFS than those who did not (p = 0.024), while in the low-risk group, patients underwent adjuvant chemotherapy have inferior DFS than those who did not (p < 0.001). INTERPRETATION: IASLC grading is a significant indicator of DFS, however it could not guide adjuvant therapy in our stage I LUAD cohort. Growth patterns and T indicators together with other risk factors could identify high-risk patients that are potential candidate of adjuvant therapy, including some stage IA LUAD patients.

Comparison of Broder's and Bryne's Grading System for Oral Squamous Cell Carcinoma With Lymph Node Metastases and Prognosis: A Scoping Review.

Oral squamous cell carcinoma (OSCC) has the highest mortality rate of any type of head and neck squamous cell carcinoma. For many eons, the clinical TNM (tumor size, nodal metastasis, and distant metastasis) classification and histological grading of malignancies have been used to predict clinical behavior, confusing it with prognosis and overall survival. This review aimed to systematically identify and evaluate the prognostic value of Broder's and Bryne's grading system for OSCC. Electronic resources such as PubMed, Cochrane Database of Systematic Reviews, Google Scholar, Scopus, and direct web searches were used to conduct a thorough search. The titles were examined to identify relevant papers, which were then reviewed for inclusion by reading the abstract. To incorporate studies published outside of the electronic database, the bibliography of all recognized papers was scanned. This review examined all research that investigated the prognostic value of Broder's and Bryne's grading systems in OSCC. The electronic database search identified 221 articles. After reading full articles, based on the titles and abstracts and after removing duplicates, six articles were screened. Finally, six articles were selected based on their ability to meet the inclusion criteria and answer the research question. All studies analyzed the competence of this histological grading system in predicting the prognosis of OSCC patients. Four studies evaluated lymph node metastasis and two studies analyzed the histological grading of OSCC. While evaluating the histological grade, we recommend the application of Bryne's (1992) system for grading OSCC. The standardization of a single, effective method would make it easier to compare results from various studies. This grading system yields better interobserver agreement and bears a prognostic value which may help in devising a treatment strategy for better patient outcomes.

Evaluation of digital and manual orthodontic diagnostic setups in non-extraction cases using ABO model grading system: an in-vitro study.

BACKGROUND: To evaluate the outcome quality of manual and digital orthodontic diagnostic setups in non-extraction cases according to the American Board of Orthodontics model grading system and to calculate the laboratory time needed for orthodontic diagnostic setup construction. METHODS: The sample consisted of 60 pretreatment models of non-extraction orthodontic cases with age ranges of 18-30. The study models were duplicated and scanned with 3Shape R-750 scanner. Digital and manual diagnostic setups were constructed according to their respective treatment plans. Digital diagnostic setups were 3D printed and then both manual and digital setups were assessed using the modified American Board of Orthodontics Cast Radiograph evaluation score (ABO CRE), which includes alignment, marginal ridge, buccolingual inclination, occlusal contacts, occlusal relationships, interproximal contacts, and overjet. The laboratory time needed for orthodontic setups was measured in minutes. RESULTS: The total ABO CRE score of the digital diagnostic setup group (5.93 ± 2.74) was significantly lower than that of the manual diagnostic setup group (13.08 ± 3.25). The manual diagnostic setup had significantly larger scores in marginal ridge, overjet, overbite, buccolingual inclination, occlusal relationship, and total scores (P < 0.01). However, the digital diagnostic setup had a statistically larger occlusal contacts score than the manual diagnostic setup (P < 0.01). There was no significant difference between the alignment and the interproximal contacts scores in either group. The manual diagnostic setup needed significantly longer laboratory time (187.8 ± 14.22) than the digital setup (93.08 ± 12.65) (P < 0.01). Comparison between broken teeth was performed by using the chi-square test which found no significant difference between different tooth types. CONCLUSIONS: Digital diagnostic setup is a reliable tool for orthodontic diagnostic setup construction providing excellent quality setup models. Manual diagnostic setup is time consuming with a technique-sensitive laboratory procedure.

Proposed novel grading system for stage I invasive lung adenocarcinoma and a comparison with the 2020 IASLC grading system.

BACKGROUND: Several studies have proposed grading systems for risk stratification of early-stage lung adenocarcinoma based on histological patterns. However, the reproducibility of these systems is poor in clinical practice, indicating the need to develop a new grading system which is easy to apply and has high accuracy in prognostic stratification of patients. METHODS: Patients with stage I invasive nonmucinous lung adenocarcinoma were retrospectively collected from pathology archives between 2009 and 2016. The patients were divided into a training and validation set at a 6:4 ratio. Histological features associated with patient outcomes (overall survival [OS] and progression-free survival [PFS]) identified in the training set were used to construct a new grading system. The newly proposed system was validated using the validation set. Survival differences between subgroups were assessed using the log-rank test. The prognostic performance of the novel grading system was compared with two previously proposed systems using the concordance index. RESULTS: A total of 539 patients were included in this study. Using a multioutcome decision tree model, four pathological factors, including the presence of tumor spread through air space (STAS) and the percentage of lepidic, micropapillary and solid subtype components, were selected for the proposed grading system. Patients were accordingly classified into three groups: low, medium, and high risk. The high-risk group showed a 5-year OS of 52.4% compared to 89.9% and 97.5% in the medium and low-risk groups, respectively. The 5-year PFS of patients in the high-risk group was 38.1% compared to 61.7% and 90.9% in the medium and low-risk groups, respectively. Similar results were observed in the subgroup analysis. Additionally, our proposed grading system provided superior prognostic stratification compared to the other two systems with a higher concordance index. CONCLUSION: The newly proposed grading system based on four pathological factors (presence of STAS, and percentage of lepidic, micropapillary, and solid subtypes) exhibits high accuracy and good reproducibility in the prognostic stratification of stage I lung adenocarcinoma patients.

Traumatic vertebral artery injury: Denver grade, bilaterality, and stroke risk. A systematic review and meta-analysis.

OBJECTIVE: Vertebral artery injury (VAI), a complication of blunt trauma, may cause posterior circulation stroke. An association of disease severity, classified in Denver grades, with stroke risk has not been shown. Using a literature-based analysis, the authors estimated the incidence of VAI following blunt trauma with the aim to investigate the impact of Denver grade and bilateral VAI on stroke occurrence. METHODS: A systematic review of the literature on VAI following blunt trauma was conducted, and data on its incidence, the severity per Denver grade, and stroke occurrence were collected. The incidence of VAI and stroke occurrence were analyzed cumulatively and between Denver grades. A meta-analysis with random-effects models was performed. RESULTS: Fifty-six studies including 2563 patients were identified. The overall incidence of VAI was 0.49% among blunt trauma cases and 14.5% among patients screened via any type of angiography. The incidence rates of bilateral VAI and concurrent carotid injury among all VAIs were 12.3% and 19.2%, respectively. VAI severity by Denver grade was as follows: grade I, 23.4%; grade II, 28.2%; grade III, 5.8%; grade IV, 42.1%; and grade V, 0.5%. The overall stroke risk was 5.32%, differing significantly among lesions of different Denver grades (p = 0.02). Grade III and IV lesions had the highest stroke prevalence (9.8% and 10.9% respectively), while strokes occurred significantly less frequently in patients with grade I and II lesions (1.9% and 3.0%, respectively). Denver grade V cases were too rare for meaningful analysis. Bilateral VAI was associated with a 33.2% stroke prevalence. The association between Denver grade and stroke occurrence persisted in a sensitivity subanalysis including only unilateral cases (p = 0.03). CONCLUSIONS: VAI complicates a small yet nontrivial fraction of blunt trauma cases, with Denver grade IV lesions being the most common. This is the first study to document a significantly higher stroke prevalence among grade III and IV VAIs compared with grade I and II VAIs independently from bilaterality. Bilateral VAIs carry a significantly higher stroke rate.

Assessment of neuropathic pain following cancer treatment.

Neuropathic cancer pain (NCP) is prevalent affecting up to 58% of those with persistent pain following cancer treatment. Neuropathic pain can develop from malignancy, after neural tissue insult during surgery and/or exposure to radiation or neurotoxic agents used as part of cancer treatment regimens. Pain following cancer treatment is commonly under-treated and one barrier identified is poor recognition of pain and inadequate assessment. Recognition of the presence of NCP is important to inform pain management, which is challenging to treat and warrants the use of specific treatments to target neuropathic mechanisms. In this review, approaches for screening and classifying NCP are described. These include screening questionnaires and the application of the updated neuropathic pain grading system in a cancer context. The evidence from neuropathic pain related assessments in cancer populations is provided and highlighted under different neuropathic pain grades. Recommendations for assessment in practice are provided.

Grading medullary thyroid carcinoma on fine-needle aspiration cytology specimens with the International Medullary Thyroid Carcinoma Grading System: A cytologic-histologic correlation.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a rare cancer of parafollicular C-cell origin. The International MTC Grading System (IMTCGS) incorporates mitotic activity, the presence of necrosis, and the Ki67 proliferation rate (PR) to classify MTCs as low or high grade. The ability to predict IMTCGS grade in cytology was assessed. METHODS: MTCs with cytology and subsequent surgical follow-up were reviewed. Cytology slides were reviewed for mitotic figures, apoptoses, and necrosis, and a Ki67 PR was calculated when possible. Findings were correlated with final IMTCGS grade. RESULTS: Twenty-five MTC fine-needle aspirations (FNAs) were identified, with nine identified as high grade (36%). By using a PR cutoff of 5%, Ki67 on FNA material (Ki67FNA) showed 92% concordance (n = 22 of 24) with surgical Ki67 and a correlation coefficient (R2) of 0.72. Sensitivity and specificity of Ki67FNA for predicting high-grade MTC were 38% and 100%, respectively. Multiple mitotic figures were present in a single slide of 43% (n = 3 of 7) of evaluable high-grade MTCs, whereas only one of 16 low-grade MTCs showed a single mitotic figure. Definitive apoptoses were present in five of seven high-grade MTC FNAs but were absent in 16 low-grade MTCs. The sensitivity and specificity of apoptoses/necrosis on cytology for high-grade MTCs were 71% and 88%, respectively. CONCLUSIONS: Ki67FNA ≥5% shows low sensitivity but high specificity for predicting high-grade MTC. The presence of multiple mitotic figures in a single slide or definitive apoptotic bodies are both highly suggestive of high-grade MTC, and should warrant a close examination for necrosis and a careful Ki67 PR count.