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BACKGROUND Accurate diagnosis of epidermolysis bullosa (EB) has significant implications for prognosis, management, and genetic counseling. OBJECTIVE To describe diagnostic testing patterns and assess diagnostic concordance of transmission electron microscopy (TEM), immunofluorescence mapping (IFM), and genetic analysis for EB. METHODS A retrospective cohort included patients enrolled in the Epidermolysis Bullosa Clinical Characterization and Outcomes Database from January 1, 2004, to July 8, 2019. Tests concluding the same EB type (EB simplex, junctional EB, dominant dystrophic EB, and recessive dystrophic EB) were considered concordant; those concluding different EB types were considered discordant; and those with nonspecific/nondefinitive results were equivocal. RESULTS A total of 970 diagnostic tests were conducted from 1984 to 2018 in 771 patients. Genetic analyses were performed chronologically later than IFM or TEM (P

Background Although evaluation of nuclear morphology plays a crucial role in the diagnosis and categorisation of breast lesions, the criteria used to assess nuclear atypia rely on the subjective evaluation of several features that may result in inter- and intra-observer variation. This study aims to refine the definitions of cytonuclear features in various breast lesions. Methods ImageJ was used to assess the nuclear morphological features including nuclear diameter, axis length, perimeter, area, circularity, and roundness in 160 breast lesions comprising ductal carcinoma in situ (DCIS), invasive breast carcinoma of no special type (IBC-NST), tubular carcinoma, usual ductal hyperplasia (UDH), columnar cell change (CCC) and flat epithelial atypia (FEA). Reference cells included normal epithelial cells, red blood cells (RBCs) and lymphocytes. Results Reference cells showed size differences not only between normal epithelial cells and RBCs but also between RBCs in varied-sized blood vessels. Nottingham grade nuclear pleomorphism scores 1 and 3 cut-offs in IBC, compared to normal epithelial cells, were 1.4x that of mean maximum Feret's diameter and 2.4x that of mean nuclear area, respectively. Nuclear morphometrics were significantly different in low-grade IBC-NST vs. tubular carcinoma, low-grade DCIS vs. UDH, and in CCC vs. FEA. No differences in the nuclear features between grade matched DCIS and IBC were identified. Conclusion This study provides a guide for the assessment of nuclear atypia in breast lesions, refines the comparison with reference cells and highlights the potential diagnostic value of image analysis tools in the era of digital pathology.

Introduction Cytopathology fellowships need measures to assess performance of fellows. We sought to compare several internal quantitative assessment metrics in our fellowship with external metrics, such as performance on the American Society of Cytopathology (ASC) Progressive Evaluation of Competency (PEC) examination and United States Medical Licensing Examination (USMLE). Methods Quantitative parameters generated from our laboratory information system (LIS) on cytopathology fellows were evaluated over 6 years, including case volume and diagnostic discrepancies, in addition to ASC PEC and USMLE scores. For discrepancy reports, interpretations made by the fellow were compared with that of the cytopathologist, and classified as none (concordant), minor ( Results We evaluated internal and external metrics on 13 fellows over 6 years. The program average diagnostic concordance rate was 89.9%, with an average major discrepancy rate of 1.5%, and an average monthly case volume of 260 cases. More fellows with above-average ASC PEC performance showed above-average concordant diagnoses and lower case volume, while below-average PEC scores were seen more often with higher major discrepancy rates. More fellows with above-average USMLE scores had higher case volumes, while low USMLE scores showed a trend towards higher major discrepancy rates. Conclusion Our fellowship program has used a variety of internal and external measures of performance for cytopathology fellows. Although the findings show no statistically significant finding correlating performance, these quantitative parameters generated from our LIS were helpful to identify areas of improvement, facilitate comparison to peers, and provide case volume documentation.

Objective To compare the degree of agreement and consistency of urodynamic studies (UDS) with low urinary tract symptoms (LUTS) questionnaires for evaluating LUTS in cervical cancer patients following radical hysterectomy (RH) and pelvic lymphadenectomy. Methods From January 2012 to March 2015, 204 cervical cancer patients who underwent RH in 13 hospitals were evaluated using the Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and the Overactive Bladder Symptom Score (OABSS). Urodynamic tests were also performed on these patients during the same period. Results Study participants’ age ranged from 23 to 75 years, with a mean (standard deviation) of 48.0 ​± ​9.3 years. Using questionnaires, the prevalence of patients with LUTS symptoms, including storage symptoms, voiding symptoms, stress urinary incontinence (SUI) and overactive bladder (OAB) was 86.3%, 77.0%, 62.7%, 52.9% and 14.7%, respectively. For UDS, the corresponding prevalence was 89.7%, 70.1%, 66.7%, 46.6% and 13.2%, respectively. The diagnostic concordance of questionnaires and UDS for storage symptoms, voiding symptoms, SUI and OAB was 79.9%, 66.7%, 66.7%, 57.4% and 79.9%, respectively. For voiding symptoms, the correlation coefficient was 0.272, which was higher than that of storage symptoms, SUI and OAB. Conclusions In cervical cancer patients who have undergone RH, there was a moderate degree of agreement between UDS and symptom questionnaires in evaluating LUTS, but the consistency was poor. Medical personnel should be adequately trained in UDS to ensure LUTS are adequately diagnosed in patients.

Objective: To examine the characteristics, diagnosis and management of agitated inpatients before psychiatric consultation in a general hospital.Methods: A retrospective chart review of inpatients aged 18 years or older that were referred for psychiatric consultation due to agitation in a general hospital in Thailand.Results: Of the 188 patients, confusion was the most commonly detected early sign of agitation (63;33.5%), while fidgeting was the most common symptom/behavior that led to psychiatric consultations (94;50.0%). The average onset time of agitation after admission was 62 hours 48 minutes. The most common cause of agitation was delirium due to a medical condition (89;47.3%). Primary psychiatric disorders were only found in 9 (4.8%) of agitated patients. There was a low diagnostic concordance between attending physicians and psychiatrists (Cohen’s Kappa=0.32). Physical restraints were used in 109 (58.0%) patients, whereas 166 (88.3%) were prescribed with sedatives. Attending physicians prescribed benzodiazepine to ameliorate agitation in 32 (36.0%) of patients with delirium. However, 4 (7.3%) patients with alcohol-withdrawal delirium were untreated initially with benzodiazepine.Conclusion: Medical conditions are more common causes of agitation than psychiatric illness. There is poor diagnostic concordance between attending physicians and psychiatrists, and high rates of physical restraints and benzodiazepine injection were found. Medical education on the detection and management of agitation and the appropriate use of sedative medications and restraints is needed.

PURPOSE Little is known about the diagnostic concordance of images provided by ultrasound probes with emitting frequencies below or above 20 MHz for the diagnosis of giant cell arteritis (GCA). METHODS We compared, using Cohen's kappa statistic, data obtained with an 18-MHz and a 22-MHz probe for the ultrasonographic evaluation of temporal arteries in 80 patients referred for suspected GCA. RESULTS The halo sign was found in 25% of cases with the 18-MHz probe and in 35% with the 22-MHz probe. The compression sign was positive in 42% of cases with the 18-MHz probe and 48% with the 22-MHz probe. GCA was finally diagnosed in 20 patients (25%). The kappa coefficient of agreement was 0.76 (P

Given the recent advances in management and understanding of breast cancer, a standardized pathology report reflecting these changes is critical. To meet this need, the Breast Pathology Study Group of the Korean Society of Pathologists has developed a standardized pathology reporting format for breast cancer, consisting of 'standard data elements,' 'conditional data elements,' and a biomarker report form. The 'standard data elements' consist of the basic pathologic features used for prognostication, while other factors related to prognosis or diagnosis are described in the 'conditional data elements.' In addition to standard data elements, all recommended issues are also presented. We expect that this standardized pathology report for breast cancer will improve diagnostic concordance and communication between pathologists and clinicians, as well as between pathologists inter-institutionally.

Context.— Vulvar biopsy interpretation and reporting, particularly of vulvar dermatoses, can be challenging in daily practice for both surgical pathologists (SPs) and dermatopathologists (DPs). Objective.— To investigate whether prospective consensus reporting of vulvar biopsies by SPs and DPs would provide value and improve overall diagnostic concordance. Design.— Consecutive vulvar biopsies during a 6-month period were reviewed prospectively by both gynecologic SPs and DPs. Preliminary, independently generated diagnoses were recorded and then shared in consensus review (SPs+DPs). A third pathologist adjudicated cases without consensus. Multiple data elements were collected for each case: division (SP/DP), age, site, clinical history, diagnostic category, preliminary and final (consensus) diagnosis, need for adjudication, ancillary tests, and diagnostic discrepancy. Results.— Eighty-four biopsies (48 SP, 36 DP) from 70 patients were reviewed. Forty-two of 84 cases (50%) were neoplastic, 38 of 84 (45%) were reactive/inflammatory, with the remaining (5%) showing both or other features. Independent diagnoses were discrepant in 22 of 84 cases (26%), but consensus review resulted in an agreed-upon diagnosis in all cases, with adjudication required in 6 cases. Independent diagnostic agreement increased over time with a reduction in major and minor discrepancies between the first and second half of the study period. Conclusions.— Prospective review of vulvar biopsies by both SPs and DPs can improve overall reporting. Consensus review allows pathologists to gain diagnostic confidence in interpretation of inflammatory (for SPs) and neoplastic (for DPs) vulvar biopsies; therefore, intradepartmental consultation is of value, particularly in select cases.

Purpose: Histopathological examination is sufficient for diagnosis of many melanocytic neoplasms, however, diagnostic discordance is common between dermatopathologists. A timely and confident diagnosis is optimal, especially in cases where both benign and malignant melanocytic neoplasms are considered in the differential diagnosis as treatment plans diverge significantly. A 35-gene expression profile (GEP) test that classifies melanocytic lesions into categories (benign, intermediate-risk and malignant), has reported accuracy metrics of 99.1% sensitivity, 94.3% specificity, 93.6% positive predictive value and 99.2% negative predictive value in a validation cohort of 503 samples. The clinical utility of the 35-GEP is described. Methods: Dermatopathologists (n=6) and dermatologists (n=14) were queried regarding diagnostic challenges and patient management strategies in 60 difficult-to-diagnose melanocytic neoplasms. Participants reviewed each lesion twice, once without the 35-GEP result and once with. Responses were evaluated for consistent trends in the utilization of the 35-GEP test result. Results: Dermatopathologists utilized the 35-GEP result to refine their diagnoses by increasing overall lesion diagnostic concordance and confidence, while reducing additional work up requests. Dermatologists utilized the 35-GEP result to gauge overall prognosis and case difficulty. Alterations in office visit frequency, biopsies, and referrals to specialists were also influenced by the 35-GEP result and treatment plan modifications also matched the appropriate directionality of the 35-GEP result. Conclusions: The diagnosis of challenging melanocytic neoplasms and subsequent clinical management decisions are influenced by 35-GEP results in a manner that agrees with the test result. The utility of the test provides the opportunity to improve patient care.

Background Cutaneous leishmaniasis (CL) is generally diagnosed by molecular methods, including PCR, using biopsy samples, skin scrapings and clinical exudates. In this study, we assessed the PCR performance for diagnosis of CL using skin of biopsy samples vs PCR of skin lesion exudate samples on filter paper and compared the diagnostic concordance of PCR using both sampling methods. Methods We assessed the PCR performance using 80 skin biopsy samples and 80 filter paper samples containing exudates from skin lesions obtained from 74 patients with clinical suspicion of CL in Cusco, Peru. Results : PCR using skin biopsy samples had superior diagnostic accuracy compared with filter paper PCR (62.5% [50/80] vs 38.7% [31/80], respectively; p˂0.005) and the diagnostic concordance between both sampling methods was ‘moderate’ (kappa coefficient=0.50, 95% CI 0.98 to 1.0). Conclusions PCR using biopsy samples remains the standard for diagnosis of CL.

In this review, we will cover definitions of relevant terms, present need, technologic requirements, regulation, validation, and current and emerging applications of teledermatopathology. Numerous studies have found no significant diagnostic discordance between teledermatopathology and glass microscopy in evaluation of melanocytic, non-melanocytic, and inflammatory diagnoses. Teledermatopathology has led to a significant difference in patient management in low-resource settings. Furthermore, studies using static images acquired using smartphones and microscope adapters have high diagnostic concordance with conventional glass slide review. Teledermatopathology is a new method to address healthcare disparity in access to dermatopathology services on a local and international level, reduce costs, and further physician education. Adoption of teledermatopathology remains limited by regulatory and remuneration barriers and high cost and storage requirements of initiation.

Background: Consultation – liaison psychiatry (CLP) provides expert advice and act as a liaison. There is a high prevalence of psychiatric comorbidities among patients of other specialities, yet the referral rates are low, probably due to inadequate psychiatric awareness which can be assessed from the diagnostic concordance. Objective: To assess diagnostic concordance between the psychiatrist and referring doctor. Materials and Methods: This is a cross-sectional record-based study of all inpatients referred to CLP. Data was collected from CLP registry. Results: Most of the referrals were from General Medicine. The most common reason for referral was alcohol use disorders and common diagnoses made by referring physicians were alcohol use disorders, delirium and mood disorders, similar to the psychiatrist’s diagnoses; however, deliberate self harm (DSH), a common diagnosis made by the referring doctor, constituted only 4.2% of psychiatrist’s diagnoses. There was complete diagnostic concordance for 40.9%; perfect agreement was found for DSH and alcohol use disorders, substantial agreement for delirium and moderate agreement for mood disorders. The agreement was low for DSH with comorbid depression, other substance use disorders and organic mental disorders. Conclusion: The diagnostic concordance for common mental health problems is low, according to the present study. CLP needs to extend its educational function towards other specialities and it should be an active component of undergraduate psychiatric training. Keywords: Consultation Liaison Psychiatry, Diagnostic concordance

Purpose To examine the characteristics of polypoidal choroidal vasculopathy using B-scan optical coherence tomography angiography (OCTA), and determine the diagnostic criteria of polypoidal choroidal vasculopathy based on OCTA. Methods This retrospective case series included patients diagnosed with treatment-naive polypoidal choroidal vasculopathy who underwent indocyanine green angiography (ICGA) and swept-source OCTA at baseline. We compared the characteristics of the polyps detected using B-scan OCTA and ICGA. Then, the diagnostic concordance of each polypoidal lesion between ICGA and OCTA was evaluated. Results Among 54 eyes of 52 patients, all 54 eyes showed flow signals indicating polyps on both ICGA and B-scan OCTA. All polyps on B-scan OCTA were detected as round/ring-like flow signals inside pigment epithelial detachments, incomplete round/ring-like flow signals overlaid with round/ring-like OCT structures inside pigment epithelial detachments, or flow signals adjacent to a pigment epithelial detachment notch. Using B-scan OCTA, 94.7% of the polypoidal lesions were detected by an independent evaluator with an overall accuracy of 92.6% for counting the polypoidal lesions per eye relative to ICGA and a Kappa value of 0.82. Conclusion Polyp detection on B-scan OCTA demonstrates high accuracy and is comparable to that obtained on ICGA. B-scan OCTA could replace ICGA for the diagnosis of polypoidal choroidal vasculopathy.

Objective Oral leukoplakia has mixed and differing histopathological features, and it is thus difficult to reach an accurate histological diagnosis of oral leukoplakia based on a local biopsy alone. We recently demonstrated the significance of CD163+ macrophages in oral carcinogenesis. Herein we sought to determine whether CD163+ macrophages in biopsy specimens of oral leukoplakia help identify the overall histological nature of the lesion. Patients and methods Twenty-six patients with tongue leukoplakia who underwent a histological examination by both a preoperative local biopsy and consecutive total excision were enrolled. We evaluated clinicopathological factors and the expression of CD163+ macrophages based on a retrospective comparison of the histological diagnostic concordance between the biopsies and excisions. Results Seventeen patients (diagnostic-agreement group) were diagnosed with squamous intraepithelial lesion based on both the biopsy and the excision. Nine patients (diagnostic-discrepancy group) were diagnosed with invasive cancer by excision, although invasive cancer was not observed in their biopsy specimens. Compared to the diagnostic-agreement group, the diagnostic-discrepancy group had more tongue leukoplakia with non-homogenous or high numbers of intraepithelial CD163+ macrophages. Conclusion The evaluation of intraepithelial CD163+ macrophages in local biopsy specimens from tongue leukoplakia patients is a promising tool for cancer screening.

Polymorphous adenocarcinoma (PAC) shows histologic diversity with streaming and targetoid features whereas cribriform adenocarcinoma of salivary gland (CASG) demonstrates predominantly cribriform and solid patterns with glomeruloid structures and optically clear nuclei. Opinions diverge on whether CASG represents a separate entity or a variant of PAC. We aimed to assess the level of agreement among 25 expert Head and Neck pathologists in classifying these tumors. Digital slides of 48 cases were reviewed and classified as: PAC, CASG, tumors with ≥50% of papillary architecture (PAP), and tumors with indeterminate features (IND). The consensus diagnoses were correlated with a previously reported molecular alteration. The consensus diagnoses were PAC in 18/48, CASG in16/48, PAP in 3/48, and IND in 11/48. There was a fair interobserver agreement in classifying the tumors (κ= 0.370). The full consensus was achieved in 3 (6%) cases, all of which were classified as PAC. A moderate agreement was reached for PAC (κ= 0.504) and PAP (κ= 0.561), and a fair agreement was reached for CASG (κ= 0.390). IND had only slight diagnostic concordance (κ= 0.091). PAC predominantly harbored PRKD1 hotspot mutation, whereas CASG was associated with fusion involving PRKD1, PRKD2, or PRKD3. However, such molecular events were not exclusive as 7% of PAC had fusion and 13% of CASG had mutation. In conclusion, a fair to moderate interobserver agreement can be achieved in classifying PAC and CASG. However, a subset (23%) showed indeterminate features and was difficult to place along the morphologic spectrum of PAC/CASG among expert pathologists. This may explain the controversy in classifying these tumors.

Background Digital pathology has widened pathologists' opportunities to examine both surgical and cytological samples. Recently, portable mobile devices like tablets and smartphones have been tested for application with digital technologies including static, dynamic, and more recently whole slide imaging. This study aimed to review the published literature on the impact of mobile devices on cancer diagnoses in cytology. This analysis focused on their diagnostic potential, technical details, critical issues and pitfalls, and economical aspects. Methods A systematic search was carried out in the electronic databases Embase and PubMed. Studies dealing with the application of mobile devices for diagnosing cancer on cytological specimens were included. The quality of studies was assessed with the QUADAS-2 tool. The main themes addressed were the comparison of manual examination with light microscopy and the use of mobile tools for primary diagnosis. The technical features of different models of smartphones and tablets, software, and adapters were also studied in terms of feasibility and costs-analysis. Results Of 2458 retrieved articles, 18 were included. Concordance with light microscopy was good and diagnostic performance comparable with an expert pathologist's diagnosis. The mobile devices studied differed, sometimes significantly, in terms of speed and cost. The utility was improved by employing specifically designed adapters. Image acquisition and transmission represent the main critical points in almost all studies. Conclusion The use of mobile devices demonstrated promising results regarding the digital evaluation of cytological samples. Widespread adoption even in underserved areas is anticipated following validation studies, technology improvements, and reduction in the costs.

OBJECTIVES To assess the concordance between lymphoma diagnoses made via tissue biopsy by local pathologists and also to assess the after review of these specimens by more specialized hematopathologists. METHODS A prospective, non-interventional and multicenter study was conducted at seven sites in Mexico from January 2017 to October 2017. Eligible biopsies were sampled from patients with a previous diagnosis of lymphoma on lymph node biopsy or a diagnosis of extranodal lymphoma, with adequate amount and tissue preservation for the review analysis. The biopsy tissues reviewed by local pathologists were also reviewed by hematopathologists participating in the study. The concordance in diagnosis results was classified into three categories: diagnostic agreement, minor discrepancy and major discrepancy. RESULTS Out of 111 samples received, 105 samples met the eligibility criteria and were included for full analysis. The median patient age (range) was 54 (16-94) years. A diagnostic agreement was observed in 23 (21.9%) biopsies, minor discrepancies were observed in 32 (30.5%) biopsies and major discrepancies were observed in 50 (47.6%) biopsies. Diagnostic concordance varied across the seven study sites; the rate of major discrepancies ranged from 0% to 100% and the rate of diagnostic agreement ranged from 0% to 81.8%. Out of the 105 reviewed biopsies, a total of 89 cases were diagnosed as lymphoma by hematopathologists. CONCLUSIONS This study showed that major discrepancies were observed following the review by hematopathologists compared with that of the local pathologist's initial diagnosis in nearly one-half cases. In addition, there was a wide variation in the percentage of diagnostic agreements and discrepancies among different study sites.

PurposeTo investigate the feasibility of a fast liver magnetic resonance imaging (MRI) protocol for lesion detection in adults using 3.0-T MRI.MethodsA fast liver MRI exam protocol was proposed. The protocol included motion-resistant coronal T2-w sequence, axial T2-w fast spin echo sequence with fat suppression, axial in-op phase gradient recalled echo (GRE) T1, axial diffusion weighted imaging (DWI), and axial contrast-enhanced T1 sequences. To evaluate the diagnostic capacity of the proposed protocol, 31 consecutive patients (20 males and 11 females; mean age, 53.2 years) underwent a liver MRI exam with conventional sequences, including the proposed protocol as a subset. Images from the conventional protocol and extracted abbreviated protocol were independently read, and the diagnostic concordance rate was assessed for each patient. The concordance analysis is presented as the proportion of concordant cases between the two protocols.ResultsThe net measurement time of the fast liver MRI protocol without adjustment and waiting time were 4 min and 28 s. In the 31 patients included in this study, 139 suspicious findings were found from both the conventional liver MR protocol and the fast liver MRI protocol. The diagnostic concordance rate was 96.4%.ConclusionsThe fast liver MRI protocol is feasible at 3.0-T, with a shorter exam time and high diagnostic concordance compared to the conventional liver MRI workflow.

Objetivos. Se desean conocer los cambios en el programa de cirugía menor de un centro de salud urbano tras una década desde su implantación, valorando la cobertura, las características de los pacientes y los profesionales implicados, los procedimientos realizados, la concordancia diagnóstica y la eficiencia del mismo. Material y métodos. Se diseña un estudio descriptivo transversal, mediante auditoría de historias y registros clínicos escritos entre los años 2007 y 2017. Se recoge el tipo de procedimiento realizado, la edad del paciente, el profesional que interviene, el envío de muestras a anatomía patológica, así como los diagnósticos clínicos y anatomopatológicos. Se estimará la diferencia del gasto realizado con el ocasionado en caso de derivación al hospital. Se realizará un análisis descriptivo y bivariante según el año de estudio. Resultados. Se valoran 477 actos quirúrgicos (53% en 2017), con edad media del paciente de 49,9 años (±17,9) (superior en 9 años en 2017, p, Our objective is to assess the changes occurred in the minor surgery program of an urban health centre. We designed a cross-sectional descriptive study to perform audits of patients history and clinical records of 2007 and 2017.477 surgical acts were evaluated. Patient mean age is 49,9 years. Percentage of resident doctors and participating nurses is double on 2017, although the main actor is the general practitioner. The right consignment of tissue samples to pathological anatomy is improved in a 16% with a high diagnostic concordance (kappa 0,703). Skin excisions and infiltrations are increased, cryosurgery is decreased. Costs are estimated to be 320% lower to hospital ones. The results of minor surgery carried out in primary-care are comparable to hospitals; however, costs are lower in primary setting. The diversity of interventions and health staff involved, makes necessary a greater incorporation of staff and training hours.

Objectives The aim of this study was to evaluate the diagnostic concordance between the toothbrush and carpet techniques for the detection of Microsporum canis in cats in a field study. Methods Thirty-nine Persian cats from a cattery were used. Fungal culture samples from the haircoat of each cat were collected by stroking the coat with a sterile toothbrush and a 5 × 5 cm-sized sterile carpet square (n = 78 total samples). Specimens were inoculated onto Mycosel Agar and incubated at 25°C for 21 days. Both techniques were compared using the following parameters: number of plates without fungal growth, number of plates with contaminant growth and number of plates positive for dermatophytes. Results The feline population in the study cattery was 39. Thirty (77%) were symptomatic and nine (23%) asymptomatic. The diagnosis was made via carpet and toothbrush methods and 78 cultures were performed. On day 21, M canis was detected in all culture plates. No contaminant molds were observed. Conclusions and relevance The concordance rate between the carpet and toothbrush techniques among the 78 evaluable culture plates was 100%. Both methods are equally effective for collecting material for M canis culture. Additionally, both techniques are inexpensive and easy to perform in feline clinical practice.

Background In Haiti, rural populations lack access to specialized care, such as dermatology, yet dermatological conditions are common causes for primary care (PC) visits. Studies on teledermatology from resource-constrained settings demonstrate promising results. We assessed the feasibility of implementing teledermatology in rural Haiti. Methods Patients with dermatological problems were examined by a PC provider in Haiti. Photos and intake evaluations were reviewed by U.S.-based dermatologists. Results Among 101 patients with dermatological problems, atopic disease and fungal infections were most common. Average diagnostic concordance between Haitian providers and U.S. dermatologists was 68.9%. The average time from intake to "case-closed" was 1.67 days. Discussion Diagnostic concordance and turn-around time were comparable to similar studies, demonstrating that teledermatology is well-suited for rural Haiti and could increase access to specialized care. Conclusion In Haiti and similar settings, telemedicine should be considered a viable option for meeting the health care needs of underserved populations.

BACKGROUND Optical flow ratio (OFR) is a novel method for fast computation of fractional flow reserve (FFR) from optical coherence tomography (OCT) images. AIMS We aimed to evaluate the accuracy of OFR in predicting post-percutaneous coronary intervention (PCI) FFR and to evaluate the impact of stent expansion on within-stent OFR pressure drop (In-stent OFR). METHODS Post-PCI OFR was computed in patients with both OCT and FFR interrogation immediately after PCI. Calculation of post-PCI OFR (called simulated residual OFR) from pre-PCI OCT pullbacks after elimination of the stenotic segment by virtual stenting was performed in a subgroup of patients who had pre-PCI OCT images. Stent underexpansion was quantified by the minimum expansion index (MEI) of the stented segment. RESULTS A total of 125 paired comparisons between post-PCI OFR and FFR were obtained in 119 patients, among which simulated residual OFR was obtained in 64 vessels. Mean post-PCI FFR was 0.92 ± 0.05. Post-PCI OFR showed good correlation (r = 0.74, p

This study provides data on the diagnostic concordance between initial and review diagnoses of all breast core biopsy cases at a single tertiary hospital in Western Australia over a 1-year period. A retrospective review of all breast core biopsy cases between January 1 and December 31, 2016, was carried out at PathWest, Fiona Stanley Hospital in Perth, Western Australia. Each biopsy is reported by a single pathologist and then reviewed within 1 week by a panel of intradepartmental subspecialist breast pathologists, who either agree with the original diagnosis, have a minor discordant diagnosis, or a major discordant diagnosis. Records for 2036 core biopsies were available between January 1 and December 31, 2016. Of these, 56.0% (n = 1141) were classified as benign, 34.3% (n = 699) as malignant, 7.2% (n = 147) as indeterminate, 2.3% (n = 46) as nondiagnostic, and 0.1% (n = 3) as suspicious for malignancy. In 99.1% (n = 2018) of cases, there was agreement between initial and review diagnoses. In total, 0.9% (n = 18) were disagreements: 0.49% (n = 10) were major discordant disagreements and 0.39% (n = 8) were minor discordant disagreements. All cases of major discordant disagreements would have resulted in significant changes to clinical management. This study demonstrates that an Australian institution is providing a high-quality pathology service with a low error rate between initial and review diagnoses of breast core biopsies. It reinforces the importance of secondary review of biopsies in a timely fashion for detecting potentially serious misdiagnoses that could lead to inappropriate management.

With the advances in health information technology and the need for increased access to specialized health care, the advent of telemedicine was designed to bring care to individuals at a distance. Telemedicine decreases barriers to health care and brings medical specialists to underserved areas and populations. We have seen a tremendous increase in the need and utilization of telemedicine during the COVID-19 pandemic due to the lockdowns and social distancing efforts. Virtual care continues to be extended to patients to maintain their health care needs when in-person clinic appointments are not feasible or ideal such as seen during a pandemic. Telemedicine is an additional tool that has proven vital to our healthcare system. To provide optimal care, a strong technological infrastructure must be in place. Once in practice, positive outcomes have been noted for patients and healthcare providers as diagnosis, treatment, and appropriate triage can be made virtually and at the patients' convenience. To ensure high-quality care is provided through the Veterans Affairs teledermatology consultation service, we investigated the concordance of teledermatology diagnoses with clinical examination findings through a retrospective chart review covering a one-year time period. Our study found a concordance of 75.3% between the teledermatology diagnoses and the in-person clinical diagnoses. The main limitation we found to virtual examination is the inability to perform total body skin examinations. We found that 60.2% of patients had additional diagnoses when examined in person, with 8.4% of patients having an additional malignant diagnosis. These findings highlight the need for in-person examinations when feasible to ensure that no other diagnoses go undiscovered if not captured on the submitted images for teledermatology consultation. Despite the limitations posed by photographic examination, teledermatology can be used as a reliable method for diagnosis when a conventional in-person examination is not readily available or ideal, such as during a pandemic, and can serve as a powerful triaging tool.

Background: Phyllodes tumours (PT) are rare and distinct breast tumours, which span a morphological continuum. Classification into benign, borderline and malignant categories reflects their biology and clinical behaviour and is essential to guide management. This study aims to assess the diagnostic agreement of PT using the UK National Health Service Breast Screening Programme (NHSBSP) breast pathology external quality assurance (EQA) scheme data. Methods: 26 PTs were identified in the EQA scheme, which were diagnosed by an average of 607 participants/circulation. Data on diagnostic categories were collected, and representative slides were reviewed. The level of concordance between reporting pathologists was assessed. Results: There were 14 benign, 6 borderline and 6 malignant PT. The overall rate of diagnosis agreement was 86% when analysed as benign lesions, borderline PT and malignant lesions, which decreased to 79% when diagnosed as PT (irrespective of grade) and to 63% when the diagnosis was further refined to PT categories (benign, borderline and malignant PTs). The highest agreement rate was observed in malignant PT (86%) and the lowest in borderline PT (42%). Malignant heterologous elements, stromal overgrowth and leaf-like architecture are features associated with higher concordance rates. Lower priority features were stromal expansion, clefting, and multinodularity. Conclusion: The concordance of PT diagnosis, as an entity, is high, but its classification into benign, borderline and malignant has variable agreement levels, with borderline tumours having the lowest concordance rate. More research to refine the diagnostic criteria for categorisation of PT is warranted to improve concordance between pathologists.

Simple Summary Several studies reveal that digital images taken with a smartphone after a visual inspection with acetic acid (VIA) or Lugol’s iodine (VILI) may be useful for detecting cervical intraepithelial neoplasia. Therefore, smartphones could be useful in the early detection of uterine cervical lesions and an alternative to colposcopy in countries with limited health resources. In this systematic review, we found that the VIA using a smartphone seems to be more sensitive than the VIA, VILI, or VIA/VILI examinations with the naked eye. Therefore, it can improve diagnostic accuracy for the detection of uterine cervical lesions. Abstract Little is known regarding the usefulness of the smartphone in the detection of uterine cervical lesions or uterine cervical cancer. Therefore, we evaluated the usefulness of the smartphone in the detection of uterine cervical lesions and measured its diagnostic accuracy by comparing its findings with histological findings. We conducted a systematic review to identify studies on the usefulness of the smartphone in detecting uterine cervical lesions indexed in SCOPUS, MEDLINE/PubMed, Cochrane, OVID, Web of Science, and SciELO until November 2020. The risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 16 studies that evaluated the usefulness of the smartphone in the detection of uterine cervical lesions based on the images clicked after visual inspection with acetic acid (VIA), Lugol’s iodine (VILI), or VIA/VILI combination were included in the study. Five studies estimated diagnostic sensitivity and specificity, nine described diagnostic concordance, and five described the usefulness of mobile technology. Among the five first studies, the sensitivity ranged between 66.7% (95% confidence interval (CI); 30.0–90.3%) and 94.1% (95% CI; 81.6–98.3%), and the specificity ranged between 24.0% (95% CI; 9.0–45.0%) and 85.7% (95% CI; 76.7–91.6%). The risk of bias was low (20%), and the applicability was high. In conclusion, the smartphone images clicked after a VIA were found to be more sensitive than those following the VILI method or the VIA/VILI combination and naked-eye techniques in detecting uterine cervical lesions. Thus, a smartphone may be useful in the detection of uterine cervical lesions; however, its sensitivity and specificity are still limited.

Summary Next Generation Sequencing (NGS) is increasingly used in diagnostic centers for the assessment of genomic alterations to select patients for precision oncology. The Italian Society of Anatomic Pathology and Diagnostic Cytopathology (SIAPEC) through the Molecular Pathology and Predictive Medicine Study Group (PMMP) has been following the progressive development of centers that have adopted NGS technology in diagnostics over time. In July 2017, a study network on massive parallel sequencing was activated in Italy and recognized as the NGS SIAPeC National Network by the SIAPeC Scientific Society Board. Since then, activities have been implemented within the network that provide for alignment of laboratories through diagnostic concordance analysis and monitoring of centers adhering to the Network. Recently, considering the growing need for extended genomic analyses, the PMMP distributed a national survey to assess activities related to the use of genomic diagnostics in oncology within the NGS SIAPEC National Network. Thirty centers participated in the survey. Eighty percent of the centers are laboratories within Pathology Departments. The distribution of laboratories in the country, the diagnostic laboratory/population ratio, the staff dedicated, the type and number of sequencing and mechatronics platforms available, the genomic panels utilized, and the type and number of diagnostic tests carried out in the last year in each center, are reported. The centers were also asked whether they participated in a multidisciplinary Molecular Tumor Board (MTB) for management of patients. Thirty percent of the centers had a MTB that was ratified by regional decree. The professionals most frequently involved in the core team of the MTB are the pathologist, oncologist, molecular biologist, geneticist, pharmacologist, and bioinformatician. The data from this survey indicate that NGS diagnostics in Italy is still heterogeneous in terms of geographical distribution and the characteristics of laboratories and diagnostic test performed. The implementation of activities that favors harmonization, the logistics and the convergence of biological material in reference centers for molecular analyses is a priority for the development of a functional laboratory network.

Random upper arm circumference (RUAC) is frequently used for malnutrition screening among children aged 6–59 months. However, inadequate evidence exists regarding its agreement with mid upper arm circumference (MUAC). This study examined diagnostic concordance between RUAC and standard MUAC measurements and tested RUAC’s ability for screening malnutrition among children aged 6–59 months. A cross-sectional study was conducted from April 30 to May 30/2015 in Ethiopia. Data were taken from a sample of 819 children aged 6–59 months with a simple random sampling technique. The data were analyzed using SPSS version 22 software. The kappa agreement level, sensitivity, and specificity were calculated. The receiver operating curve was prepared to determine the optimal cutoff RUAC for the sensitivity and specificity. With National Center for Health Statistics (NCHS) cutoff (12 cm), the performance of RUAC measurements in terms of sensitivity was low (44%). The kappa agreement level between the two measurements was 0.551 ( p value < 0.001). With the new WHO cutoff (12.5 cm), however, RUAC was improved in validity (sensitivity 81%), specificity 96.9%, and kappa agreement level (K = 0.807; p < 0.001 ).

Purpose. To examine choroidal neovascularization (CNV) characteristics in patients with exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV), using swept-source optical coherence tomography angiography (SS-OCTA), and investigate agreement with OCT B-scan, fundus fluorescein angiography (FFA), and indocyanine green angiography (ICGA) by two different examiners. Methods. This is a retrospective multicentric study that involved patients with a history of AMD and PCV. Examiner A, who had access to OCTA, B-scan OCT, FFA, and ICGA imaging, had to differentiate between AMD and PCV, study the activity of AMD using Coscas’ criteria (active vs. quiescent), and categorize PCV subtypes, while examiner B had only access to OCTA. Then, the diagnostic concordance was assessed between both examiners. Results. A total of 27 patients (11 females (40.7%) and 16 males (59.3%), P = 0.231 ) were included in the analysis. Among those, 13 patients presented with neovascular AMD and 14 patients with PCV. There were 92.3% of correct answers regarding appropriate diagnosis and lesion characterization among AMD patients, against 61.5% of correct answers among PCV patients. The overall interrater reliability agreement between examiners, using Cohen’s kappa coefficient ( κ ) was 0.70 (0.5082-0.8916). Disagreement was found with one active AMD misdiagnosed as inactive AMD, three inactive PCV misdiagnosed as inactive AMD, and one inactive PCV misdiagnosed as active AMD. Conclusion. SS-OCTA alone remains limited in some specific phenotypes of PCV, which suggests the ongoing role of B-scan OCT associated with FFA and ICGA in the diagnosis of these conditions.

Summary Histological interpretation of testicular biopsies in the investigation of infertility in men with azoospermia requires adequate tissue fixation to preserve the nuclear and cytoplasmic detail, as well as the architectural organisation of germ cells in different phases of maturation within seminiferous tubules. The aim of the study was to assess the histomorphological quality of testicular biopsies using Davidson's fluid (DF) as fixative and compare it to standard 10% neutral buffered formalin. Concurrent testicular biopsies from the same testis from patients undergoing microsurgical testicular sperm exploration (m-TESE) were separately fixed in DF and formalin and processed for histological examination. Histological parameters including sloughing of cells, cytoplasmic shrinkage of seminiferous tubular cells, nuclear chromatin detail, cytoplasmic graininess and overall clarity of morphological detail were graded on a scale of 0–4 (0, none; 1, minimal; 2, slight; 3, moderate; 4, marked). The effect of DF on biopsy diagnoses was assessed by comparison with corresponding formalin fixed biopsy diagnoses. Eighty-seven testicular biopsies from 27 patients were examined. DF fixation resulted in significantly less luminal sloughing of cells (1.59±1.34 vs 3.44±0.83, p≤0.00001), less cytoplasmic shrinkage of seminiferous tubular cells (1.58±1.11 vs 3.11±1.07, p≤0.00001), better nuclear chromatin detail (3.06±0.91 vs 1.92±0.48, p≤0.00001), less cytoplasmic graininess (2.11±0.96 vs 2.86±0.87, p=0.0014) and better overall clarity of morphological detail than formalin fixation (3.14±0.69 vs 2.14±0.58, p≤0.00001). The diagnostic concordance between DF fixed and formalin fixed biopsies was 90.8%. This study supports the use of DF as a superior alternative fixative to formalin for histological assessment of testicular biopsies.

QuestionWhat is the level of diagnostic concordance between physicians and physiotherapists for patients consulting in an emergency department (ED) with musculoskeletal disorders (MSKDs)?DesignSecondary analysis of data obtained through a pragmatic randomized controlled trial, physiotherapist (PT) and emergency physicians (EPs) unblinded, per-protocol analysis.Participants78 participants aged 18 to 80 years presenting with a minor MSKD were recruited and data from the 40 participants randomized in the intervention group were used (mean age 36.6 yrs (SD: 17.3, IQR: 22.0; 46.8); women: 55%).Outcome measuresDiagnostic concordance was established using the International Classification of Diseases 11 (ICD-11) and examined between EP and PT using raw agreement and Gwet’s first-order agreement coefficient (AC1).ResultsForty participants were recruited and 36 were assessed by the PT and EP (36.8 ± 18.2 years old; 55.6% women). Overall raw agreement was 86.1% and an almost perfect diagnostic concordance was observed between PT and EP (Gwet’s AC1: 0.84, 95% CI: 0.69 – 0.98). The most common reason for disagreement was suspected bone fracture or contusion in comparison with ligament or meniscus disorder.ConclusionResults from this study indicate that overall diagnostic concordance between PT and EP in the ED for patients consulting with MSKDs is almost perfect. These results tend to support the safety of such models of care. However, more studies are needed to confirm these results as the EP wasn’t always independent and the classification used was imprecise.Registration#NCT04009369

Background In Chile, there is little access to Dermatology outpatient consultations in the public health care system, which has favored the development of tele dermatology (TD). Aim To assess satisfaction levels of primary care providers with a TD channel via the social networking app WhatsApp® and the concordance between the diagnosis of general practitioners and dermatologists at Pontificia Universidad Catolica de Chile. Material and methods An electronic survey was answered by the general practitioners who participate in the TD channel. In 417 cases, the diagnostic concordance between general practitioners and specialists was assessed. Results The survey was answered by 84 practitioners. General satisfaction levels with the platform were over 95%. Satisfaction levels with the response speed and the management suggested by the specialist were over 90%. Over 80% of the practitioners read the consultation sent by dermatologists and considered that their dermatological knowledge improved. Diagnostic concordance between practitioners and specialists was 41%. Conclusions TD via a WhatsApp® group linked to a university is a low cost and easy to implement intervention, generating high levels of satisfaction among general practitioners.

Aims En-bloc transurethral resection (TUR) of bladder tumour (ERBT) is designed to provide more accurate pathological diagnosis of specimens than conventional TUR of bladder tumour (cTURBT). Some studies have reported that T1 bladder cancer substage could be a prognostic factor in assessing tumour progression, but such substaging has not been widely adopted because of problems with pathological diagnosis using cTURBT specimens. The aim of this study was to evaluate the possible advantages of en-bloc TUR specimens in T1 substaging following assessment by a panel of 10 pathologists. Methods and results We assessed the substages in 123 patients (cTURBT, n = 91; ERBT, n = 32) who were diagnosed with pT1 bladder cancer. We randomly selected 10 ERBT specimens and 10 cTURBT specimens with cancer invasion areas equivalent to those of their corresponding ERBT specimens. Ten pathologists performed pT1 substaging for pT1a/b/c and pT1m/e in 20 patients (cTURBT, n = 10; ERBT, n = 10). We evaluated diagnostic times and rates of diagnostic concordance among these pathologists, comparing cTURBT and ERBT. The median diagnostic times per slide were 87.7 s [interquartile range (IQR) 71.9-109.2 s) for cTURBT and 54.7 s (IQR 46.0-59.6 s) for ERBT (P = 0.009). The rate of diagnostic concordance was significantly better for ERBT specimens. For pT1a/b/c, the median concordance rates were 50% for cTURBT and 80% for ERBT (P = 0.02); for pT1m/e, the median concordance rates were 70% for cTURBT and 90% for ERBT (P = 0.05). For pT1a/b/c, the average κ-values between the pathologist and the standard diagnosis were 0.04 for cTURBT and 0.47 for ERBT. Conclusions The use of ERBT specimens shortened the diagnostic time and minimised interobserver variability for T1 substaging compared with the use of cTURBT specimens.

Bone marrow examination entails study of aspirate smears, touch imprints and trephine biopsy. Bone marrow aspirate smears can be prepared by the squash (crush) or wedge method. Both techniques have their own advantages and disadvantages. There is paucity of studies that have compared these smear types. This study was conducted over a period of one year. Two hundred and five bone marrow aspirates were included. Both squash and wedge smears were made. Blinded slide review was done. Bone marrow cellularity, megakaryocyte number, myeloid to erythroid (M:E) ratio, morphology and final diagnosis on each smear type was compared. Chi square test, t-test and Kappa were applied to study the agreement between the wedge and squash smears. Among the 205 patients studied, squash smears showed significant over estimation of cellularity and megakaryocyte number (p 0.05) in the M:E ratio and morphological scores. Most patients (188/205 [91.7%]) showed complete diagnostic concordance while 17 (8.3%) patients had discrepancy in diagnosis between the squash and wedge smears. In 8 (3.9%) of these, major discrepancies were seen while 9 (4.4%) patients had minor discrepancies. Bone marrow cellularity and megakaryocyte numbers were underestimated in wedge smears with no differences in M:E ratio or morphology. Acceptable agreement for diagnosis was seen for patients with most disorders. Major diagnostic discrepancies were seen in patients with lesions known to have focal distribution—lymphoma, myeloma and tuberculosis (granulomas). Both squash and wedge smears should be studied for bone marrow examination.

Objectives: Telemedicine allows for the remote delivery of patient care and has been found to have a wide range of uses in otolaryngology. In order to achieve best practices in telemedicine, a platform must be effective and both patients and providers must be satisfied with the use of technology. As telemedicine becomes more widely used in otolaryngology clinics, particularly in the face of the current COVID-19 pandemic, it is important to assess its applicability in this field. The goal of this study was to evaluate existing literature on telemedicine and assess overall image quality, diagnostic concordance, and patient and provider satisfaction with telemedicine technologies. Methods: A systematic review was conducted on PubMed and MEDLINE according to the PRISMA 2009 guidelines for articles from 1982 to 2019 relating to telemedicine in otolaryngology. English language studies with primary or secondary endpoints pertaining to image quality, diagnostic concordance, or patient or provider satisfaction were included. Descriptive studies, editorials, and literature reviews were excluded. Results: A total of 32 studies were included in our review. Studies assessing imaging quality and diagnostic concordance reported adequate results but with some heterogeneity. Patient and provider satisfaction were consistently high. Conclusions: The literature supports telemedicine delivery of otorhinolaryngologic care as having achieved high rates of patient and provider satisfaction with adequate image quality and heterogeneity in diagnostic concordance. Variability in diagnostic accuracy was reported, but appears improved given proper clinical context. More standardized studies are needed specific to telemedicine in the field of otolaryngology.

The aim of this study was to investigate the diagnostic yield of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) for detecting thoracic aortic graft infection (AGI) in comparison to expert consensus MAGIC criteria. Patients suspected clinically of having thoracic-AGI were prospectively recruited. Consensus MAGIC criteria for AGI were compared to findings on FDG PET imaging. MAGIC criteria were verified against clinical/surgical, radiological, and microbiological/laboratory predefined major and minor parameters. FDG images were interpreted using a semiquantitative visual grading score (VGS, abnormal ≥ 3), focal uptake and quantitative maximum standard FDG uptake value (SUVmax, abnormal ≥ 7.3), and target-to-background FDG ratio (TBRmax, abnormal ≥ 4.2). Of 35 patients suspected of having thoracic-AGI, MAGIC diagnostic criteria were positive for AGI in 25 patients (71%) and negative in 10 (29%). FDG PET imaging was abnormal in 27 patients (77%). Abnormal and normal FDG imaging findings were concordant with MAGIC criteria in 31 patients (88.6%). In 4 patients, FDG imaging results were discordant with MAGIC criteria. By ROC analysis, optimal FDG cut-off values for detecting AGI by MAGIC were ≥ 3 for VGS, ≥ 7.3 for SUVmax and ≥ 4.2 for TBRmax, with concordance with MAGIC criteria in 88.6%, 85.7%, and 88.6% of patients, respectively. Two or more FDG imaging parameters (VGS, focal uptake, SUVmax, and TBRmax) yielded highest diagnostic concordance of 91.4%. VGS inverse odds ratio for AGI was 7.14. In 4 of 6 selective patients who had repeat FDG PET imaging during antibiotic treatment, quantitative FDG imaging values improved over time with associated improvement of laboratory markers of inflammation. FDG PET/CT imaging, using (semi-)quantitative imaging parameters, showed high concordance with expert consensus MAGIC criteria for AGI. These data suggest a potential complementary role of quantitative FDG/CT imaging, not only to detect AGI, but also to monitor response to antibiotic treatment.

The usefulness of PET/MRI in head and neck malignancy has not been fully elucidated. The purpose of our study was to evaluate the diagnostic accuracy and confidence of PET/MRI in comparison with PET or MRI alone. This study included 73 consecutive patients who underwent [18F] FDG PET/MRI in head and neck under the suspicion of malignancy. A neuroradiologist and a nuclear medicine specialist reviewed MRI and PET images, respectively and independently, followed by a consensus review of PET/MRI one month later. For 134 lesions, accuracy and confidence were compared among PET, MRI, and PET/MRI. For lesion base, PET/MRI had a sensitivity of 85.7%, a specificity of 89.1%, a PPV of 89.6%, a negative predictive value of 85.1%, and an accuracy of 87.3%. AUCs of PET/MRI per lesion (0.926) and per patient (0.934) for diagnosing malignancy were higher than PET (0.847 and 0.747, respectively) or MRI (0.836 and 0.798, respectively) alone (P

Background: Teledermoscopy (TDS) improves diagnostic accuracy and decreases the number of unnecessary consultations. Objectives: To determine the diagnostic concordance in tertiary (dermatologist-to-experts) TDS with histopathology/follow-up–based diagnosis. Methods: A descriptive retrospective cohort study including 290 requests. Results: Perfect diagnostic concordance was found in 202 (69.7%) cases and partial agreement in 29 (10%). Disagreement was found in 59 (20.3%) cases. Perfect concordance on the benign/malignant nature of the lesion was found in 227 (78.3%) cases and disagreement in 63 (21.7%). In onychology, diagnostic concordance was perfect in 43 (76.8%) cases, partial in 7 (12.5%), and there was disagreement in 6 (10.7%). Final concordance on the benign/malignant nature of the lesion was perfect in 48 (85.7%) and there was disagreement in 8 (14.3%) nail cases. For pediatric requests, diagnostic concordance was perfect in 29 (65.9%) cases, partial in 5 (11.4%), and there was disagreement in 10 (22.7%). Final concordance on the benign/malignant nature of the lesion was observed in 34 (77.3%) cases, disagreement in 10 (22.7%). Conclusions: This study confirms that tertiary TDS improves diagnostic accuracy of pigmented skin lesions. Moreover, it shows encouraging results in unusual conditions such as ungual and pediatric skin tumors. The main limitation was the retrospective nature and the “real-life” setting of our study that could have created a selection bias toward inclusion of the most difficult cases.

Introduction The rate of malignancy (ROM) in thyroid fine needle aspirations (FNA) classified under "atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), including Hurthle cell type (HLUS)" category of The Bethesda system for reporting thyroid cytopathology (TBSRTC) in literature is highly variable. The 2018 TBSRTC was updated to note a preferred categorization of AUS cases into subcategories. This study evaluates the impact of AUS subclassification on rates of neoplasia (RON), rates of malignancy (ROM), and cytopathologist (CP) concordance. Methods 93 thyroid FNAs previously diagnosed as FLUS or HLUS from January 1, 2013 to December 31, 2014 with subsequent surgical resection were identified. Four CPs reclassified these cases using TBSRTC AUS subcategories of follicular cells with architectural and/or cytologic atypia, predominantly Hurthle cells, and atypical lymphocytes. RON and ROM were calculated for each diagnostic subcategory for each CP. Results The original RON and ROM for FLUS cases were 31.4% and 15.1% and were 77.8% and 22.2% for HLUS cases. 10.8% of cases showed diagnostic concordance amongst the four CPs. The most frequently utilized subcategory was architectural atypia. RON ranges for architectural atypia, cytologic atypia, architectural and cytologic atypia, and predominantly Hurthle cells were 28.1% to 35.7%, 0% to 33.3%, 35.3% to 66.7%, and 57.1% to 87.5%. The range of ROM was 13.9% to 16.7%, 0% to 33%, 0% to 42.9%, and 0% to 25%, respectively. Conclusion RON for AUS predominantly Hurthle cells subcategory was higher than previously reported, which may indicate use for tailored patient management pathways. AUS subclassification can result in significant interobserver variability. Therefore, institutions may consider consensus/quality control sessions to optimize diagnostic concordance.

Background: While elevations in fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) are both recognized by the American Diabetes Association (ADA) as diagnostic of hyperglycemia, previous comparisons of these tests have demonstrated discordant individual classifications and population estimates. This may be due to additional postprandial glycemia reflected by HbA1c and, in African-descent populations, to non-glycemic factors that contribute to higher HbA1c at any given level of glycemia. We hypothesized that glycemic classifications based on FPG or HbA1c would differ in a Black South African population and investigated factors associated with discordance. Methods: 889 Black adults with previously undiagnosed diabetes, aged 40-79 years, from the population-based Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort were included. Concordance between ADA FPG (normoglycemia [NG] Results: Median age was 55 years (IQR 49-62) and 49.3% of the sample was male. Median glucose was 86.4 mg/dl and median HbA1c was 5.4%. Pre-DM, as defined by HbA1c, was present in 204 participants (22.9%), while FPG-defined pre-DM was present in 122 (13.7%). DM defined by HbA1c was present in 146 (16.4%), while FPG-defined DM was present in 36 (4.0%). Concordance between the two tests was poor (kappa statistic 0.18; 95%CI 0.13-0.24). Self-reported history of tuberculosis (OR 1.90, p=0.026) and higher HbA1c (OR 4.70, p Conclusion: FPG and HbA1c exhibit poor concordance in classifying hyperglycemia in this Black South African population, with HbA1c-based definitions identifying higher prevalences of pre-DM and DM. Further work is needed to confirm whether these discrepancies are due solely to elevations in postprandial glucose. In the interim, clinicians should consider confirming elevated HbA1c concentrations with oral glucose tolerance testing, particularly in those with a history of tuberculosis, prior to making a diagnosis of DM in this population.

Introduction Universal newborn hearing screening proved to be an effective measure to screen out hearing-disability infants at a younger age, from which testified the existence of middle ear fluid or effusion was one major source of referred screening result. Some reports had verified the comparative advantage of using the 1000-Hz probe tone for tympanometry in infants, while little was known about the accordance to imaging manifestations, especially the findings of Magnetic Resonance Imaging (MRI). Objective To investigate the diagnostic consistency between 226 Hz-, 1000 Hz- probe tone tympanometry and MRI in infants after hearing screening. Method 226 Hz and 1000 Hz probe-tone tympanometry were tested followed by MRI in 58 infants. According to MRI results, patients were divided into Group 1 with abnormal middle ears with fluid, Group 2 with normal middle ears. Tympanometry included tympanograms, volume of ear cannal (Vec, mL), compliance of peak (Y, mmho), the width at the pressure of ±50dapa (TW, daPa), the pressure of the peak (TPP, daPa). The data were analyzed by statistic software SPSS19.0. Results In group 2, 92.41% were negative tympanograms(n = 73), 7.59% was positive tympanograms(n = 6) at 1000 Hz; while 91.14% was negative tympanograms (n = 72), 8.86% was positive tympanograms (n = 7) at 226 Hz. In group 1, 80.00% were positive tympanograms(n = 28), 20.00% was negative tympanograms (n = 7) at 1000 Hz; while 80.00% was negative tympanograms (n = 28), 20.00% was positive tympanograms (n = 7) at 226 Hz. McNemar test demonstrated that there was no significant difference between 1000 Hz and MRI diagnosis (P = 1.000), while significant difference between 226 Hz and MRI test (P = 0.001). Diagnostic concordance rate between 1000 Hz tympanometry and MRI (Kappa = 0.730, p = 0.000) was significantly higher than 226 Hz tympanometry (Kappa = 0.134, p = 0.095). Normal data of 1000 Hz tympanometry showed Vec was 0.71 ± 0.28ml, Y was 0.82 ± 0.49mmho, TW was 124.60 ± 27.68dapa, and TPP was 11.83 ± 73.73dapa. Conclusion 1000 Hz tympanometry significantly had a better diagnostic agreement with MRI than 226 Hz. Clinically, 1000 Hz but not 226 Hz tympanometry is recommended to diagnose otitis middle ear fluid in infants.

AIM To establish a role for modified ultrafast magnetic resonance imaging (MRI) of the brain in clinical paediatric patients based on clinically acceptable image quality and diagnostic accuracy. MATERIALS AND METHODS A prospective study was conducted with institutional review board approval on an ultrafast MRI brain protocol consisting of sagittal T1-weighted, axial T2-weighted, axial fluid-attenuated inversion recovery (FLAIR), axial diffusion-weighted imaging (DWI), and axial T2∗-weighted sequences. Preliminary investigations revealed that the default ultrafast T2-weighted sequence was prone to pulsation artefacts. A modified ultrafast T2-weighted sequence was therefore developed to replace the default ultrafast T2-weighted sequence. Thirty-five patients with clinical indication for neuroimaging underwent ultrafast MRI, modified ultrafast T2-weighted sequence and standard MRI at 3 T. Image quality of ultrafast MRI sequences were graded as clinically “diagnostic” or “non-diagnostic” and compared against the corresponding standard MRI sequences as the reference standard. The modified ultrafast T2-weighted sequence surpassed the default ultrafast T2-weighted sequence in image quality. The ultrafast MRI protocol was therefore replaced with the modified ultrafast T2-weighted sequence creating a modified ultrafast MRI protocol. The clinical reports of modified ultrafast MRI were compared against standard MRI for diagnostic concordance, categorised further as “normal”, “clinically significant”, or “clinically minor” abnormalities. RESULTS Ultrafast T1-weighted, FLAIR, and DWI sequences had comparable image quality to standard MRI sequences. The ultrafast T2∗-weighted sequence had significantly higher non-diagnostic images (42.9%) compared to the standard MRI sequence (2.9%). The default ultrafast T2-weighted sequence had significantly higher non-diagnostic images compared to the modified ultrafast T2-weighted sequence and standard T2-weighted sequence (82.9%, 5.7%, 8.6%, respectively). There was 100% concordance for normal and clinically significant abnormalities and 23% discordance for clinically minor abnormalities. Modified ultrafast MRI takes 5 minutes 41 seconds compared to standard MRI time of 14 minutes 57 seconds. CONCLUSION The modified ultrafast MRI protocol for brain imaging demonstrates clinically acceptable image quality in four out of five sequences and has high accuracy in diagnosing normal and clinically significant abnormalities when compared against the standard MRI protocol for brain imaging. It could potentially benefit a select group of paediatric patients who require neuroimaging.

Introduction There is an emerging need for telecytology in Colombia as the demand for cytopathology has increased. However, due to economic and technological constraints telecytology services are limited. Our aim was to evaluate the diagnostic feasibility of using whole slide imaging with and without Z-stacking for telecytology in Colombia, South America. Methods Archival glass slides from 17 fine needle aspiration smears were digitized employing whole slide imaging (WSI) (Nanozoomer 2.0 HT, Hamamatsu) in one Z-plane at 40x, and panoramic digital imaging (Panoptiq system, ViewsIQ) combining low-magnification digital maps with embedded 40x Z-stacks of representative regions of interest. Fourteen Colombian pathologists reviewed both sets of digital images. Diagnostic concordance, time to diagnosis, image quality (scale 1-10), usefulness of Z-stacking, and technical difficulties were recorded. Results Image quality scored by pathologists was on average 8.3 for WSI and 8.7 for panoramic images with Z-stacks (P = .03). However, diagnostic concordance was not impacted by image quality ranking. In the majority of cases (72.4%) pathologists deemed Z-stacking to be diagnostically helpful. Technical issues related to Z-stack video performance constituted only a minor proportion of technical problems reported. Slow downloads and crashing of files while viewing were mostly experienced with larger WSI files. Conclusion This study demonstrated that international telecytology for diagnostic purposes is feasible. Panoramic images had to be acquired manually, but were of suitable diagnostic quality and generated smaller image files associated with fewer technical errors. Z-stacking proved to be useful in the majority of cases and is thus recommended for telecytology.

To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients.Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients.After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohen's κ of 0.745 [95% CI, 0.385-1.0; P.01]) in the diagnosis of shock when compared to experienced intensivists.Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.

Objectives BNP and NT-proBNP are viewed as comparable in their ability to diagnose and monitor HF in clinical guidelines. However, no recent large-scale study has directly established diagnostic concordance between BNP and NT-proBNP. This study sought to assess diagnostic concordance of BNP and NT-proBNP for ruling in and ruling out heart failure (HF). Methods Simultaneous BNP and NT-proBNP testing was performed on 2729 patient samples with routinely ordered BNP testing. Hospital location, age, sex, creatinine, BNP and NT-proBNP were also recorded. Recommended cutoffs for BNP and NT-proBNP for ruling in and out HF were used for assessing diagnostic concordance and correlation. Results In the ED setting, concordance between BNP and NT-proBNP was 0.695 (95% CI, 0.668–0.723) by weighted kappa using the recommended cutoffs for the acute setting. In non-ED patients, the concordance was 0.642 (95% CI, 0.580–0.705) using non-acute setting cutoffs. In the ED setting, patients with eGFR 60 mL/min/1.73m2 (0.707, 95% CI 0.669–0.744). Patients with an eGFR 60 mL/min/1.73m2 (17.0 vs. 4.7, P Conclusion The current cutoffs for diagnosing HF for NT-proBNP and BNP have relatively low diagnostic concordance and correlation, particularly among patients with chronic kidney disease.

Objectives: We developed a simple and effective rinsing technique of needle biopsies to produce cell suspensions for flow cytometry and evaluated if the rinsing technique is comparable to the conventional tissue cell suspension technique. Methods: We retrieved 93 needle core biopsy cases employing the rinsing technique (RT) for flow cytometry and 25 needle biopsy cases using tissue cell suspension (TCS) for flow cytometry. Results: The diagnostic concordance between the flow cytometry results and the morphologic diagnoses of both groups was compared. The diagnostic concordance was comparable in the RT group (92.6%) to the TCS group (71.4%). Furthermore, the diagnostic concordance in the RT group was associated with number of isolated cells. The diagnostic accuracy increased significantly when the cell number was above 30,000 in the RT group. Conclusions: The rinsing technique for flow cytometry not only maximizes the tissue utilization, but also is a simple and effective method to obtain cell suspension as compared to traditional cell suspension technique. This article is protected by copyright. All rights reserved.

Angina pectoris merupakan gejala klinis Sindrom Koroner Akut (SKA) yang mengarah pada penyakit jantung koroner. Sindromkoroner akut terdiri dari Unstable Angina dan Infark Miokard Akut (IMA). Kadar Troponin I (TnI) dapat mendukung penegakkandiagnosis IMA di pasien angina pectoris. Beberapa metode pemeriksaan TnI semakin berkembang diantaranya TnI high sensitive (TnI hs)dan TnI next-generation (TnI ng). Tujuan penelitian ini adalah menganalisis kesesuaian diagnostik antara kadar TnI ng yang diperiksamenggunakan metode Fluorescent Enzyme Transfer Latex (FETL) [Alere Triage MeterPro®] dan TnI hs dengan metode ChemiluminescentImmunoassay (CLEIA) [Mitsubishi PathFast®] di pasien angina pectoris. Penelitian dilaksanakan di RSUD Dr.Soetomo Surabaya masawaktu Maret-Juli 2016 dengan rancangan penelitian potong lintang. Sebanyak 82 subjek penelitian dengan gejala angina pectorisdiperiksakan kadar Troponin-I menggunakan kedua metode. Subjek penelitian sebanyak 44% didiagnosis SKA, dan 56% non SKA. Nilaikesesuaian koefisien kappa antara TnI ng dan TnI hs di pasien angina pectoris adalah 0,738 (p