Agreement between medical record and administrative coding of common comorbidities in orthopaedic trauma patients

ObjectiveTo i) quantify the agreement between comorbidities documented within medical records and an orthopaedic trauma dataset; and ii) compare agreement between these sources before and after the introduction of new comorbidity coding rules in Australian hospitals.Study design and settingA random sample of adult (≥ 16 years) orthopaedic trauma patients (n = 400) were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Diagnoses of obesity, arthritis, diabetes and cardiac conditions documented within patients’ medical records were compared to ICD-10-AM comorbidity codes (provided by hospitals) for the same admission. Agreement was calculated (Cohen’s kappa) before and after the introduction of new coding rules.ResultsAll comorbidities had the same or higher prevalence in medical record data compared to coded data. Kappa values ranged from <0.001 (poor agreement) for coronary artery disease to 0.94 (excellent agreement) for type 2 diabetes. There was improvement in agreement between sources for most conditions following the introduction of new coding rules.ConclusionThere has been improvement in the coding of certain comorbidities since the introduction of new coding rules, suggesting that, since 2015, administrative data has improved capacity to capture patients’ comorbidity profiles. Consideration must be taken when using the ICD-10-AM data due to its limitations.     

Agreement between Initial Classification and Subsequent Reclassification of Fractures of the Distal Radius in a Prospective Cohort Study

We tested the hypothesis that the original surgeon-investigator classification of a fracture of the distal radius in a prospective cohort study would have moderate agreement with the final classification by the team performing final analysis of the data. The initial post-injury radiographs of 621 patients with distal radius fractures from a multicenter international prospective cohort study were classified according to the Comprehensive Classification of Fractures, first by the treating surgeon-investigator and then by a research team analyzing the data. Correspondence between original and revised classification was evaluated using the Kappa statistic at the type, group and subgroup levels. The agreement between initial and revised classifications decreased from Type (moderate; Κ _type = 0.60), to Group (moderate; Κ _group = 0.41), to Subgroup (fair; Κ _subgroup = 0.33) classifications (all p < 0.05). There was only moderate agreement in the classification of fractures of the distal radius between surgeon-investigators and final evaluators in a prospective multicenter cohort study. Such variations might influence interpretation and comparability of the data. The lack of a reference standard for classification complicates efforts to lessen variability and improve consensus.     

Transoesophageal echocardiography in cardiac and vascular surgery: implications and observer variability

Transoesophageal echocardiography (TOE) has gained widespreadacceptance among cardiac anaesthetists as a tool to facilitateperi-operative decision-making. This observational study analysesthe impact of TOE and its inter-observer variability on intra-operativepatient management during cardiac and major vascular surgery.From June 1996 to December 1998, standardized reports were obtainedfrom 11 anaesthetists in 1891 adult cardiac and vascular surgerypatients undergoing routine biplane or multiplane TOE. Inter-observervariability and the difference between variables of interestwere tested using the chi-squared test or factorial analysisof variance as appropriate. TOE examinations were performedbefore and after the operation; 1673 (88.5%) patients underwentcardiopulmonary bypass (CPB), and 218 (11.5%) patients had surgerywithout CPB, including 42 (2.2%) coronary revascularizations.In 923 patients (49%), TOE provided additional information thatinfluenced the patient’s therapy. In 968 patients (51%),TOE had only minor or no impact on clinical decision-making.In two patients (0.10%) the scheduled operation was not performed,and in another two patients the TOE examination led to majorcomplications. Observer-dependent variables were: implicationsof TOE for intra-operative decision-making (P<0.0001), estimationof image quality (P<0.0001), pre-operative left ventricularfractional area change (FAC) (P=0.0026), difference betweenpre-operative FAC and post-operative FAC (P=0.033), and requestsfor supervision (P<0.0001). There was no significant differencein the case mix between observers. TOE had an important impacton intra-operative patient management. Inter-observer variabilitywas significant for several variables but not for the frequencyof additional surgical procedures. Br J Anaesth 2001; 86: 497–505     

Comparison of Interobserver Agreement of Four Classification Systems for Lateral Clavicle Fractures between Two Groups of Surgeons: A Multicenter Study

Objective

Distal clavicle fracture classification directly affects the treatment decisions. It is unclear whether the classification systems implemented differ depending on surgeons' backgrounds. This study aimed to compare the interobserver agreement of four classification systems used for lateral clavicle fractures by shoulder specialists and general trauma surgeons.

Methods

Radiographs of 20 lateral clavicle fractures representing a full spectrum of adult fracture patterns were analyzed by eight experienced shoulder specialists and eight general trauma surgeons from 10 different hospitals. All cases were graded according to the Orthopedic Trauma Association (OTA), Neer, Jäger/Breitner, and Gongji classification systems. To measure observer agreement, Fleiss' kappa coefficient (κ) was applied and assessed.

Results

When only X-ray films were presented, both groups achieved fair agreement. However, when the 3D-CT scan images were provided, improved interobserver agreement was found in the specialist group when the OTA, Jäger/Breitner, and Gongji classification systems were used. In the generalist groups, improved agreement was found when using the Gongji classification system. In terms of interobserver reliability, the OTA, Neer, and Jäger/Breitner classification systems showed better agreement among shoulder specialists, while a slightly lower level of agreement was found using the Gongji classification system. For the OTA classification system, interobserver agreement had a mean kappa value of 0.418, ranging from 0.446 (specialist group) to 0.402 (generalist group). For the Neer classification system, interobserver agreement had a mean kappa value of 0.368, ranging from 0.402 (specialist group) to 0.390 (generalist group). For the Jäger/Breitner classification system, the inter-observer agreement had a mean kappa value of 0.380, ranging from 0.413 (specialist group) to 0.404 (generalist group). For the Gongji classification system, interobserver agreement had a mean kappa value of 0.455, ranging from 0.480 (specialist group) to 0.485 (generalist group).

Conclusion

Generally speaking, 3D-CT scans provide a richer experience that can lead to better results in most classification systems of lateral clavicle fractures, highlighting the value of digitization and specialization in diagnosis and treatment. Competitive interobserver agreement was exhibited in the generalist group using the Gongji classification system, suggesting that the Gongji classification is suitable for general trauma surgeons who are not highly experienced in the shoulder field.     

An Atlas Improves Interobserver Agreement Regarding Application of the ISCD Vertebral Body Exclusion Criteria

Coexisting conditions such as osteoarthritis and compression fracture may spuriously elevate the dual-energy X-ray absorptiometry (DXA)-measured lumbar spine bone mass. To improve the diagnostic utility of lumbar spine DXA to diagnose osteoporosis, the International Society for Clinical Densitometry (ISCD) suggests excluding vertebrae affected by focal structural anomalies or unusual T-score discrepancies. However, we previously demonstrated only moderate agreement between physicians regarding vertebral body exclusion. We hypothesized that an atlas containing examples of vertebrae to exclude would improve interobserver agreement. Subsequently, we developed an interactive web-based atlas of lumbar spine DXA images with options to exclude vertebrae and compare one's answers to those derived by group consensus. Before and after review of the atlas, 5 ISCD-certified physicians applied the exclusion criteria to 90 DXA scans, recording the indications for vertebral exclusion on a standardized worksheet. After development and review of the atlas, interobserver agreement regarding vertebral body exclusion improved significantly (p < 0.0001). We plotted the deviation of each physician's reported T-score vs the mean T-score for each of 90 scans, and demonstrated that the scatter from the mean is decreased after atlas review. Furthermore, correlations in T-score improved in 7 of 10 physician pairs after atlas review. We conclude that an interactive atlas promotes uniform lumbar spine DXA interpretation.     

单侧穿刺经皮椎体成形术的影像学研究及临床应用

目的 :通过对下胸椎及腰椎相关参数进行测量,明确单侧经皮椎体成形术的外展角及进针点距棘突的距离,指导临床应用。方法:对40例(男17例,女23例)正常成人的T10-L5进行薄层CT扫描,厚度为1 mm,选择通过椎弓根、关节突关节及横突的横断面图像,由CT自带图像处理软件测量经椎弓根穿刺的最大和最小穿刺角度及进针点距棘突的距离,并根据测量结果指导临床应用。结果:椎体穿刺的最佳角度和进针点的数值在T10-L5间总体呈逐渐增大趋势,从T10-T12略有下降,然后逐渐增大,至L5时获得最大值;根据测量结果对60例胸腰椎骨折患者进行单侧穿刺椎体成形术,术后椎体后凸矫正率满意,VAS评分明显下降(P0.05)。结论:术前对穿刺相关数据参数进行测量,可以很好地指导术中操作,降低手术风险,提高穿刺成功率。     

前方脑脊液空间闭塞程度与腰椎管狭窄症的相关性分析

目的 分析前方脑脊液空间闭塞程度与腰椎管狭窄症（lumbar spinal stenosis, LSS）的相关性。方法 回顾性分析2015年1月至2017年6月经贵阳市第四人民医院明确诊断的LSS病人60例,在其MRI片上通过Surgimap测量病人最小硬膜囊面积（cross-sectional area, CSA）、横断面黄韧带面积（ligamentum flavum area, LFA）,收集其日本骨科协会评估治疗分数（Japanese Orthopaedic Association Scores, JOA）。根据前方脑脊液空间闭塞程度进行分组,分为1级（18例）、2级（16例）、3级（26例）三组,比较各组最小CSA、LFA及JOA评分差异,并分析前方脑脊液空间闭塞程度与最小CSA、LFA及JOA评分的相关性。结果 各组间比较,最小CSA、LFA及JOA评分的差异均具有统计学意义（P均＜0.05）;前方脑脊液空间闭塞程度与JOA评分（r=－0.878,P＜0.001）、最小CSA（r=－0.889,P＜0.001）、LFA（r=0.913,P＜0.001）显著相关。结论 前方脑脊液空间闭塞程度与CSA、LFA及JOA评分显著相关,可作为评估LSS严重程度的指标。     

三维腔镜根治术下甲状腺癌治疗的手术入路选取探讨及创口情况比较

目的探讨三维腔镜根治术下甲状腺癌治疗手术入路的选取及创口情况的比较。 方法回顾性分析2014年6月至2017年4月78例行三维腔镜根治术的甲状腺癌患者,根据手术入路分为胸乳入路组与颈前入路组,其中胸乳入路组40例采取胸乳入路,颈前入路组38例采取颈前入路。数据采用SPSS21.0软件进行统计分析,围术期指标等采用( ±s)描述,独立t检验;术后并发症,术后切口美观满意度χ²检验分析,P<0.05差异有统计学意义。 结果两组患者的术中出血量、术后引流量、手术时间、住院时间、淋巴结清扫数目和术后声音嘶哑、咳嗽、低钙血症等并发症差异无统计学意义(P>0.05);但术后疼痛评分和吞咽困难发生率胸乳入路组明显低于颈前入路组(P<0.05),术后切口美观满意度明显高于颈前入路组(P<0.05)。 结论胸乳入路三维腔镜甲状腺癌根治术的手术疗效良好,安全可靠,并且术后切口更为美观,值得临床进一步推广。     

太赫兹波对MG-63荷瘤小鼠快速活体成像的实验研究

摘要 [目的]实验研究太赫兹波对人成骨肉瘤细胞株MG-63荷瘤小鼠活体体内恶性肿瘤组织能否显像及其特异性,并探讨太赫兹波技术在骨肉瘤肿瘤组织切除术中的指导作用。[方法]利用华中科技大学光电国家重点实验室连续太赫兹成像系统,进行人成骨肉瘤细胞株MG-63荷瘤小鼠活体的THz波显像,并在活体成像指导下进行瘤体切除术（实验组）与肉眼下行瘤体切除术（对照组）再次检测进行对比,术中取出组织送病理切片;将术后人成骨肉瘤MG-63荷瘤小鼠继续饲养一周后再次行THz波显像。[结果]活体人成骨肉瘤MG-63荷瘤小鼠体内瘤体组织处出现强烈吸收信号,与周围组织差异明显;术后THz波显像及病理切片均显示太赫兹波指导下行瘤体切除术比肉眼下行瘤体切除术更为彻底;继续饲养一周后对照组荷瘤小鼠原位再次复发。[结论]太赫兹波技术能对人成骨肉瘤细胞株MG-63荷瘤小鼠中肿瘤组织特异性显像,且能良好指导手术切除恶性肿瘤组织,有望在临床中应用。     

游离齿突小骨的影像学征象(附23例报告)

目的 经影像学研究探讨游离齿突小骨的影像学特征。方法 回顾分析23例游离齿突小骨患者，其中10例有明确的外伤史。明确游离小骨的诊断后，须经影像学检查来明确寰枢关节的不稳定程度和颈脊髓的压迫。1例无症状的患者行保守治疗，22例行手术治疗。结果 随访2～4年(平均2年8个月)，23例患者的临床和影像学结果均较满意。结论 对游离齿突小骨患者，无论有无寰枢椎不稳、有无症状和脊髓损伤的体征，均可成功进行影像学评估。建议对此类患者宜常规行颈椎正侧位、开口位、屈．伸侧位摄片和CT平扫，并根据实际情况尽可能行三维CT重建和MRI检查。     

Artificial intelligence assistance for fetal head biometry: Assessment of automated measurement software

Purpose

To evaluate the feasibility and reproducibility of artificial intelligence software (Smartplanes^®) to automatically identify the transthalamic plane from 3D ultrasound volumes and to measure the biparietal diameter (BPD) and head circumference (HC) in fetus.

Do thoraco-lumbar spinal injuries classification systems exhibit lower inter- and intra-observer agreement than other fractures classifications?: A comparison using fractures of the trochanteric area of the proximal femur as contrast model

IntroductionIt has been postulated that the complex patterns of spinal injuries have prevented adequate agreement using thoraco-lumbar spinal injuries (TLSI) classifications; however, limb fracture classifications have also shown variable agreements. This study compared agreement using two TLSI classifications with agreement using two classifications of fractures of the trochanteric area of the proximal femur (FTAPF).Material and methodsSix evaluators classified the radiographs and computed tomography scans of 70 patients with acute TLSI using the Denis and the new AO Spine thoraco-lumbar injury classifications. Additionally, six evaluators classified the radiographs of 70 patients with FTAPF using the Tronzo and the AO schemes. Six weeks later, all cases were presented in a random sequence for repeat assessment. The Kappa coefficient (κ) was used to determine agreement.ResultsInter-observer agreement: For TLSI, using the AOSpine classification, the mean κ was 0.62 (0.57–0.66) considering fracture types, and 0.55 (0.52–0.57) considering sub-types; using the Denis classification, κ was 0.62 (0.59–0.65). For FTAPF, with the AO scheme, the mean κ was 0.58 (0.54–0.63) considering fracture types and 0.31 (0.28–0.33) considering sub-types; for the Tronzo classification, κ was 0.54 (0.50–0.57). Intra-observer agreement: For TLSI, using the AOSpine scheme, the mean κ was 0.77 (0.72–0.83) considering fracture types, and 0.71 (0.67–0.76) considering sub-types; for the Denis classification, κ was 0.76 (0.71–0.81). For FTAPF, with the AO scheme, the mean κ was 0.75 (0.69–0.81) considering fracture types and 0.45 (0.39–0.51) considering sub-types; for the Tronzo classification, κ was 0.64 (0.58–0.70).ConclusionUsing the main types of AO classifications, inter- and intra-observer agreement of TLSI were comparable to agreement evaluating FTAPF; including sub-types, inter- and intra-observer agreement evaluating TLSI were significantly better than assessing FTAPF. Inter- and intra-observer agreements using the Denis classification were also significantly better than agreement using the Tronzo scheme.     

The variability and accurate assessment of microinflammation in haemodialysis patients.

BACKGROUND: Systemic microinflammation is correlated with atherosclerosis. It needs a reliable assessment. This study explores the temporal variations of three inflammatory indexes [C-reactive protein (CRP), serum amyloid A (SAA) and interleukin-6 (IL-6)] in a period free of clinical events and tests the reliability of their multiple measurements for the assessment of microinflammation in haemodialysis (HD) patients, a population at high risk of atherosclerotic cardiovascular disease. METHODS: For 4 months, serum CRP, SAA and IL-6 were measured in 29 HD patients during the weeks they were free of inflammatory clinical events (> or =12 measurements for each index in every patient). The components of the variance as well as the reliability of two to five measurements for each index, aimed at assessing microinflammation precisely, were computed. RESULTS: The median (interquartile range) of CRP was 2.3 (0.9-4.9) mg/l, of SAA 3.7 (2.1-9.3) mg/l and of IL-6 4.4 (2.2-7.7) pg/ml. Patients were approximately equally distributed between three groups of low, intermediate and high variability for each index. The contribution of intraindividual (biological) variation to the total of variance was 71.3%, 69.3% and 86.7% for CRP, SAA and IL-6, respectively (higher than in all other similar studies in healthy populations). Using two measurements, the estimated reliability was 57-68% for CRP in two-thirds of the patients (comparable with that found in healthy subjects) and 57% for SAA and IL-6 in only one-third of the patients. Increasing the number of measurements up to five did not change the reliability. CONCLUSIONS: Individual factors significantly influence the levels of inflammatory indexes in HD patients in periods free of inflammatory clinical events. The mean of two weekly CRP measurements, but not of SAA or IL-6, seems to assess microinflammation in most patients with a sufficient reliability.     

成人缺血性股骨头坏死影像学特征分析

目的分析成人缺血性股骨头坏死影像学的特征分布情况。方法通过回顾性调查的方法，收集2004年1月至2005年12月在上海六院骨科接受手术治疗的股骨头坏死患者术前的X线、MRI等影像学资料及一般资料，共118例（男77例，女41例）患者，共164髋为研究对象，其中MRI资料为129髋。按照股骨头坏死Steinberg分期进行系统描述，分析股骨头坏死的面积、部位及塌陷与面积之间的关系等情况并进行相应的统计学处理。结果男、女平均年龄分别为36．69岁和36．05岁，患者不同性别的年龄间的差异无统计学意义。164例坏死股骨头中，其中Ⅰ期为3例，Ⅱ期34例，Ⅲ期27例，Ⅳ期93例，V期7例，以Ⅲ、Ⅳ期为主（占73．17％）。在股骨头坏死区域的分布方面，位于股骨头上外侧、上外侧加头下靠近中央区等压力承重区域占76．83％（126例）；在坏死面积方面，大于30％的坏死面积占84．15％（138例）；在外形有塌陷方面，外形有塌陷者占60．98％（100例）。外形有塌陷者与非塌陷者在坏死面积方面比较，塌陷者坏死面积大，两者之间的差异有统计学意义（P〈0．01）。MRI检查发现股骨头骨髓水肿的患者占39．56％，有股关节积液的患者占61．54％。结论本组患者在坏死分期方面以Steinberg Ⅲ、Ⅳ期为主（73．17％）。股骨头坏死主要集中在应力承重区域，本组138例患者（占84．15％）的坏死面积大于30％以上，坏死面积越大者外形越容易发生塌陷。     

Overuse of fluoroscopic gastrostomy studies in a children's hospital

Background

Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management.

Methods

All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables.

Results

During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05–23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03).

Conclusions

Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.