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We investigate the utility of the ID Now when compared to RT-PCR to triage patients suspected of having COVID-19 presenting to emergency rooms (ERs) and to screen asymptomatic patients presenting for pre-procedural testing. We find it useful when prevalence of COVID-19 is high in symptomatic patents and potentially useful in asymptomatic patients who are likely to be retested if symptoms emerge.

Adenomas or adenocarcinomas located within a colonic diverticulum are considered a rare phenomenon that has been described in the literature. These lesions are technically difficult to manage endoscopically and usually require surgical intervention for removal. There is also an increased risk of perforation upon endoscopic resection owing to the lack of a muscular layer within the diverticulum. We report a case and include a literature review to evaluate different endoscopic techniques and propose the most effective for management of adenomas within a diverticulum. This technique is potentially comprised of employing a combined approach using a suction banding device, an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) , and hyperthemic snare to successfully remove the polyp, ensure tissue retrieval, and reduce risk of iatrogenic colonic perforation.

Context.— The College of American Pathologists periodically surveys laboratories to determine changes in cytopathology practices. We report the results of a 2016 survey concerning thyroid fine-needle aspiration (FNA). Objective.— To provide a cross-sectional survey of thyroid cytology practices in 2016. Design.— In 2016, a survey was sent to 2013 laboratories participating in the College of American Pathologists Non-Gynecologic Cytology Education Program (NGC-A) requesting data from 2015–2016 on several topics relating to thyroid FNA. Results.— A total of 878 laboratories (43.6% of 2013) replied to the survey. Radiologists performed the most thyroid FNA procedures in most laboratories (70%; 529 of 756), followed by endocrinologists (18.7%; 141 of 756), and most of these were performed under ultrasound guidance (92.1%; 699 of 759). A total of 32.6% of respondents (251 of 769) provided feedback on unsatisfactory rates for nonpathology providers who performed FNA. Intraprocedural adequacy assessment was primarily performed by attending pathologists (77.4%; 490 of 633) or cytotechnologists (28.4%; 180 of 633). Most laboratories used the Bethesda System for Reporting Thyroid Cytopathology (89.8%; 701 of 781) and performed molecular testing based on clinician request (68.1%; 184 of 270) rather than FNA diagnosis. Correlation of thyroid excisions with prior cytology results most often occurred retrospectively (38.4%; 283 of 737) and was used for pathologist interpretive quality assurance purposes. Conclusions.— These survey results offer a snapshot of national thyroid FNA cytology practices in 2016 and indicate that standardized cytology terminology is commonly used; pathologists perform most immediate adequacy assessments for thyroid FNA; laboratories use correlation statistics to evaluate pathologists' performance; and molecular tests are increasingly requested for indeterminate interpretations, but reflex molecular testing is rare.

ContextMany production systems employ standardized statistical monitors that measure defect rates and cycle times, as indices of performance quality. Clinical laboratory testing, a system that produces test results, is amenable to such monitoring.ObjectiveTo demonstrate patterns in clinical laboratory testing defect rates and cycle time using 7 College of American Pathologists Q-Tracks program monitors.DesignSubscribers measured monthly rates of outpatient order-entry errors, identification band defects, and specimen rejections; median troponin order-to-report cycle times and rates of STAT test receipt-to-report turnaround time outliers; and critical values reporting event defects, and corrected reports. From these submissions Q-Tracks program staff produced quarterly and annual reports. These charted each subscriber's performance relative to other participating laboratories and aggregate and subgroup performance over time, dividing participants into best and median performers and performers with the most room to improve. Each monitor's patterns of change present percentile distributions of subscribers' performance in relation to monitoring durations and numbers of participating subscribers. Changes over time in defect frequencies and the cycle duration quantify effects on performance of monitor participation.ResultsAll monitors showed significant decreases in defect rates as the 7 monitors ran variously for 6, 6, 7, 11, 12, 13, and 13 years. The most striking decreases occurred among performers who initially had the most room to improve and among subscribers who participated the longest. All 7 monitors registered significant improvement. Participation effects improved between 0.85% and 5.1% per quarter of participation.ConclusionsUsing statistical quality measures, collecting data monthly, and receiving reports quarterly and yearly, subscribers to a comparative monitoring program documented significant decreases in defect rates and shortening of a cycle time for 6 to 13 years in all 7 ongoing clinical laboratory quality monitors.

Context.—The College of American Pathologists (CAP) developed protocols for reporting pathologic characteristics of breast cancer specimens, including margin status. The Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) published treatment guidelines regarding margins in patients with invasive cancer; and SSO, ASTRO, and the American Society of Clinical Oncology (ASCO) recently published guidelines for patients with ductal carcinoma in situ.Objective.—To assess current practices among pathologists with regard to the processing/reporting of breast specimens, assess compliance with CAP cancer protocols, and assess alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines.Design.—A survey concerning breast specimen processing/reporting was distributed to pathologists enrolled in the CAP Performance Improvement Program in Surgical Pathology.Results.—Ninety-four percent (716 of 764 respondents) and 91% (699 of 769 respondents) define positive margins as “tumor on ink” for invasive cancer and ductal carcinoma in situ, respectively, in compliance with CAP cancer protocols and with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. Of 791 respondents who provided details regarding methods for margin evaluation, 608 (77%) exclusively examine perpendicular margins, facilitating guideline compliance. However, 183 of 791 respondents (23%) examine en face margins in at least a subset of specimens, which may preclude guideline compliance in some cases. When separate cavity (shave) margins are examined, while 517 of 586 respondents (88%) ink these specimens, 69 of 586 (12%) do not, and this may also preclude guideline compliance in some cases.Conclusions.—A substantial proportion of survey participants report margin status for breast cancer specimens in a manner consistent with CAP cancer protocols, and in alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. However, there are opportunities for some laboratories to modify procedures in order to facilitate more complete adherence to guidelines.

Context.—In 2008, the Joint Commission (JC) implemented a standard mandating formal monitoring of physician professional performance as part of the process of granting and maintaining practice privileges.Objective.—To create a pathology-specific management tool to aid pathologists in constructing a professional practice-monitoring program, thereby meeting the JC mandate.Design.—A total of 105 College of American Pathologists (CAP)–defined metrics were created. Metrics were based on the job descriptions of pathologists' duties in the laboratory, and metric development was aided by experience from the Q-Probes and Q-Tracks programs. The program was offered in a Web-based format, allowing secure data entry, customization of metrics, and central data collection for future benchmarking.Results.—The program was live for 3 years, with 347 pathologists subscribed from 61 practices (median, 4 per institution; range, 1–35). Subscribers used 93 of the CAP-defined metrics and created 109 custom metrics. The median number of CAP-defined metrics used per pathologist was 5 (range, 1–43), and the median custom-defined metrics per pathologist was 2 (range, 1–5). Most frequently, 1 to 3 metrics were monitored (42.7%), with 20% each following 4 to 6 metrics, 5 to 9 metrics, or greater than 10 metrics. Anatomic pathology metrics were used more commonly than clinical pathology metrics. Owing to low registration, the program was discontinued in 2016.Conclusions.—Through careful vetting of metrics it was possible to develop a pathologist-specific management tool to address the JC mandate. While this initial product failed, valuable metrics were developed and implementation knowledge was gained that may be used to address new regulatory requirements for emerging value-based payment systems.

We assessed the prevalence of elevated quantitative latex agglutination assay for D-dimer in patients in the emergency department in whom pulmonary embolism (PE) was excluded. D-dimer was normal (

The College of American Pathologists (CAP) conducted a national survey of gynecologic cytology quality assurance (QA) practices. Experts in gynecologic cytology were asked to join 5 working groups that studied the survey data on different aspects of QA. Evaluating the survey data and follow-up questions online, together with a review of pertinent literature, the working groups developed a series of preliminary statements on good laboratory practices in cytology QA. These were presented at a consensus conference and electronic voting occurred.To evaluate a set of QA monitors in gynecologic cytology. Working group 1 evaluated (1) monitoring interpretive rate categories for Papanicolaou tests (Pap tests), (2) concordance of cytotechnologist and pathologist interpretations before sign-out, and (3) turnaround time for Pap tests.The statements are based on a survey of gynecologic cytology QA practice patterns and of opinions from working group members and consensus conference attendees.The outcomes of this process demonstrate the current state of practice patterns in gynecologic cytology QA. Monitoring interpretive rates for all Bethesda System categories is potentially useful, and it is most useful to monitor interpretive rates for cytotechnologists individually and in comparison to the entire laboratory. Laboratories need to determine what level of discrepancy between cytotechnologist and pathologist interpretations of Pap tests is important to track. Laboratories should consider formalizing procedures and policies to adjudicate such discrepant interpretations. Turnaround time should be monitored in gynecologic cytology, but individual laboratories should determine how to measure and use turnaround time internally.

Implementation of proficiency testing for gynecologic cytology was delayed 20 years because of challenges addressing the subjective nature of cytologic interpretation and replicating normal working conditions. Concern remains regarding test scoring, slide validation, test environment, and other issues. How these test results are, or should be, used in quality management has never been explored.To provide information on good laboratory practices for gynecologic cytology proficiency testing based on findings from the College of American Pathologists' survey-based project funded by the Centers for Disease Control and Prevention.An expert working group evaluated results from a Web-based, national laboratory survey plus responses from follow-up questions and findings from the literature. The group created statements on good laboratory practices pertinent to proficiency testing and its role in quality management, which were discussed and voted on at a consensus conference.Two-thirds of laboratories report having an individual with an unsuccessful proficiency testing score. More than 90% did not initiate any remedial action for 1 or 2 unsuccessful tests; 84% of laboratories reported they actively monitored results from proficiency testing, but most laboratories did not initiate any remedial action for cytotechnologists (81.4%; 376 of 462) or pathologists (87.7%; 405 of 462) who passed a proficiency test but who did not score 100%. Proficiency testing pass-fail rates should be monitored globally for the laboratory and for each individual. Proficiency testing slides should be prescreened by cytotechnologists for pathologists who are not primary screeners. Remedial action should not be required for a passed, but imperfect, test. No remedial action is required for an unsuccessful, first proficiency test result before retesting.

Context.—The manual microscopic examination (MME) of the urine sediment is an imprecise and labor-intensive procedure. Many laboratories have developed rules from clinical parameters or urinalysis results to limit the number of these examinations. Objective.—To determine the rate of urinalysis specimens on which an MME of the urine sediment was performed, document how various rules influence this rate, and determine whether any new information was learned from the MME. Design.—Participants selected 10 random urinalysis tests received during each traditional shift and determined if an MME was performed until a total of 50 urinalysis tests with an MME were reviewed. Participants recorded the rules that elicited an MME and any new information learned from such an examination. Results.—The MME rate for the median institution was 62.5%. An MME of urine was most frequently done for an abnormal urinalysis result and often resulted in new information being learned, irrespective of the rule that elicited the MME. The median institution learned new information as a result of the manual examination 66% of the time. The use of an automated microscopic analyzer was associated with fewer manual examinations (P = .005), whereas the ability of a clinician to order a manual examination was associated with more manual examinations (P = .004). Conclusions.—The use of an automated microscopic analyzer may decrease the number of MMEs. An MME when triggered by an abnormal macroscopic appearance of urine, a physician request, or virtually any positive urinalysis result often resulted in new information.

The production and interpretation of a haematoxylin-eosin stained slide from a patient specimen is a complex, multi-step process. An error within any of the steps may cause patient harm. The steps in this process can be divided into the pre-analytic, analytic and post-analytic phases. This paper will review benchmarking and published error rates, where available, across all three phases. Practical, evidence-based, methods to reduce errors in all three phases will be discussed with emphasis placed upon the benefits and limits of benchmarking and six-sigma. The concept of striving for zero defects through lean production methods and the Toyota Production System will be discussed as it applies to all three phases of surgical pathology.

Background Angiosarcoma is a rare high-grade neoplasm that frequently involves the skin and subcutaneous tissue. Rarely, angiosarcoma can occur in the gastrointestinal tract where it frequently exhibits multicentric epithelioid morphology. Design We report a case of multicentric epithelioid angiosarcoma (EAS) of the small intestine in a 73-year-old male patient who presented with weakness and melena, and was found to have bleeding lesions in the small intestine on upper gastrointestinal endoscopy. In addition to this case, we extensively reviewed the clinical and pathological features of previously reported cases of angiosarcoma of the small intestine in the English literature since 1970. Results Our patient presented with rare and aggressive EAS of the small intestine. Despite surgical resection of the lesions, the patient continued to worsen and developed rapidly progressive metastatic disease. He died within 4 months of the diagnosis. Conclusions Angiosarcoma, especially of the deep tissues and the gastrointestinal tract, is very aggressive and rapidly metastatic. The survival rate in these patients is extremely poor, and most patients die within 6 months to 1 year of the diagnosis. Treatment usually involves surgical resection of the bleeding lesions and frequent blood transfusions for symptom alleviation.

Anaplastic large cell lymphoma (ALCL) is an aggressive neoplasm of T- or null cell phenotype and is recognized as a distinct clinicopathologic subtype of non-Hodgkin lymphoma (NHL) in the revised World Health Organization (WHO) classification of hematopoietic neoplasms. It is rarely associated with leukemic phase. Most cases with leukemic involvement are the small cell variant of ALCL. These cases often lack the pleomorphism seen in the common variant of ALCL and may be misdiagnosed. We report a series of three patients who presented with leukemic phase ALCL. The patients included an 11-year-old boy, a 29-year-old man, and a 59-year-old woman. The clinical and pathologic features of these cases are reviewed. The patients in our case series with leukemic phase ALCL exhibited rare clinical features. The patients presented with massive extranodal disease involving cerebrospinal fluid (CSF), liver, spleen, lungs, and bone marrow. CSF involvement was documented morphologically as well as by flow cytometry in two patients. Two of the patients had small cell variant and the third patient had common type ALCL. The neoplastic cells in all three patients were ALK positive; however these patients died within months of diagnosis. Leukemic phase ALCL is rare, and behaves in an aggressive manner. Some, but not all, cases in the literature presenting with peripheral blood involvement had small cell variant ALCL, as seen in two of our cases. The leukemic phase of ALCL should be considered when a T-cell leukemia with unusual morphologic features is encountered.

Context.—Blood culture contamination extends hospital stays and increases the cost of care. Objectives.—To measure blood culture contamination rates in a large number of institutions over time and to elucidate practice patterns and demographic factors associated with sustained reduction in contamination rates. Design.—Longitudinal cohort study of 356 clinical laboratories that provided quarterly data about blood culture results, using a uniform definition of contamination. Mixed linear model analysis of the 1999 through 2003 data set. Results.—Blood culture contamination was significantly higher in institutions that used nonlaboratory personnel to collect blood (P = .03) and significantly lower in facilities that used a dedicated phlebotomy team (P < .001). Higher volume of blood collection was significantly associated with lower contamination rates (P < .001). Continued participation in the Q-Tracks monitoring program was associated with significant and progressive reduction in contamination rates. By the fifth year of participation, the median institution had reduced its blood culture contamination rate by 0.67% (P < .001). Conclusions.—Institutions that use decentralized patient-centered personnel rather than dedicated phlebotomy teams to collect blood cultures experience significantly higher contamination rates. Long-term monitoring of contamination is associated with sustained improvement in performance.

Waldenström macroglobulinemia (WM) and its associated hyperviscosity syndrome (HVS) are generally caused by lymphoplasmacytoid lymphoma or other small B-cell lymphoproliferative disorders. WM associated with extranodal marginal zone B-cell-mucosa-associated lymphoid tissue lymphoma (EMZL/MALT-type) has not been emphasized. We describe 4 men and 2 women (age, 40-79 years) with clinical and laboratory manifestations of WM and EMZL/MALT-type involving one or more sites: lung, pericardium/pleura, ocular adnexa, nasopharynx, minor salivary gland, glossopharyngeal fold, skin, and stomach. The following immunophenotypic patterns were observed: CD20+, 6; CD43+, 3; kappa light chain restriction, 5; and lambda light chain restriction, 1. All were negative for CD5, CD10, and cyclin D1 expression. A clonal paraproteinemia was present in each (IgM kappa, 4; IgM lambda, 1; biclonal IgM kappa/IgA kappa, 1). All 4 patients tested had elevated plasma viscosity; clinical HVS occurred in 3, and 2 required emergency plasmapheresis. These findings suggest that EMZL/MALT-type can cause WM and that the laboratory evaluation of EMZL/MALT-type should include serum protein electrophoresis/immunofixation, and plasma viscosity measurements and urine immunofixation in select cases. EMZL/MALT-type should be considered in the differential diagnosis in patients with clinicopathologic features of WM.

A 74-year-old male with a long-standing history of chronic lymphocytic leukemia presented with dyspepsia. Upper endoscopy showed a subtle bluish 3–5-mm discoloration in the esophageal mucosa at approximately 20 cm from the incisors (Fig. 1). Biopsies demonstrated melanoma in situ and focal invasion into the superficial sub-mucosa, associated with melanosis, and consistent with primary esophageal melanoma (PMME, Fig. 2a, b). The cells stained positive for S-100 and MART-1a, which confirmed PMME. In an attempt to stage and treat the lesion, endoscopic mucosal resection (EMR) was done using the band and snare method. Pathology revealed an extensive in situ melanoma and a small cluster of invasive melanoma at one margin of excision within the sub-mucosa. A repeat EGD and biopsy demonstrated residual melanoma in situ at the margins of the resection. Repeat EMR was discussed; however, the patient wished to proceed with a transhiatal esophagectomy with cervical esophagogastric anastomosis. The surgical specimen revealed a 4.0×2.5-cm area of black–brown mucosal discoloration, located 1.5 cm form the proximal margin of resection. Microscopic sections showed extensive residual intramucosal melanoma involving the discolored area, the proximal cervical margin and random sections of mucosa away from the discolored area (Fig. 3a, b). Thirty weeks after the surgery, the patient is clinically stable except for cervical dysphagia for which he is treated with dilatations.

Small lymphocytic lymphoma (SLL), mantle cell lymphoma (MCL), and SLL plasmacytoid (SLLP) are malignant neoplasms of small B cells that may have overlapping cytologic features. Entities such as SLL with irregular nuclear contours may pose additional diagnostic difficulties. We investigated the utility of flow cytometric analysis and immunohistochemistry studies in distinguishing these disorders from each other. We reviewed 29 lymphomas and classified them as SLL (13 cases), MCL (8 cases), and SLLP (8 cases) based on histology and expression of cytoplasmic immunoglobulin light chain. Paraffin section immunohistochemistry was performed for CD5, CD20, CD23, CD43, CD45RA, CD45RO, and kappa and lambda light chains. Flow cytometric analysis was carried out by 2-color direct immunofluorescence for CD5, CD11c, CD19, CD20, CD22, CD23, FMC7, and kappa and lambda light chains. By immunohistochemistry, we found that the expression of CD23 in SLL discriminates between SLL and MCL and that the expression of CD23 and CD43 in SLL discriminates between SLL and SLLP. By flow cytometric analysis, we found that CD11c+ and dim fluorescence intensity of slg and dim fluorescence intensity of FMC7 in SLL distinguish SLL from MCL, and the expression of CD5+, CD23+ and dim fluorescence intensity of FMC7 in SLL distinguishes SLL from SLLP. We found no immunophenotypic difference between SLL and SLL with irregular nuclear contours.

We retrospectively studied the usefulness of intraoperative cytology (IOC) and frozen section (FS) in the rapid diagnosis of 68 thyroid lesions. In 14 cases of papillary thyroid carcinoma, IOC correctly diagnosed 13 cases, while FS correctly diagnosed 11 cases. There was no significant difference in sensitivities, and both methods had similar specificities. In 21 cases of colloid nodule, IOC was slightly more sensitive than FS; IOC correctly diagnosed 16 cases, while FS correctly diagnosed 15 cases. However, the specificity of IOC was only 71%, but was 98% for FS. Of 17 follicular adenomas, FS diagnosed 16 as follicular neoplasms and misdiagnosed only 1 as a colloid nodule. By contrast, IOC misdiagnosed 9 follicular adenomas as colloid nodules, most of which were macrofollicular variants with abundant colloid. Of 11 follicular carcinomas, FS diagnosed all as follicular neoplasms, while IOC misdiagnosed 3 as colloid nodules. While IOC is not as accurate as FS in the diagnosis of colloid nodules and follicular neoplasms, it is highly sensitive and specific in the diagnoses of papillary carcinoma and performance of the technique is rapid and easy. In an intraoperative setting, IOC is a useful adjunct to FS in screening thyroid nodules for the presence of papillary carcinoma.

Context.—Gynecologic cytopathology is a heavily regulated field, with Clinical Laboratory Improvement Amendments of 1988 mandating the collection of many quality metrics. There is a lack of consensus regarding methods to collect, monitor, and benchmark these data and how these data should be used in a quality assurance program. Furthermore, the introduction of human papilloma virus testing and proficiency testing has provided more data to monitor.Objective.—To determine good laboratory practices in quality assurance of gynecologic cytopathology.Data Sources.—Data were collected through a written survey consisting of 98 questions submitted to 1245 Clinical Laboratory Improvement Amendments–licensed or Department of Defense laboratories. There were 541 usable responses. Additional input was sought through a Web posting of results and questions on the College of American Pathologists Web site. Four senior authors who authored the survey and 28 cytopathologists and cytotechnologists were assigned to 5 working groups to analyze data and present statements on good laboratory practices in gynecologic cytopathology at the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference. Ninety-eight attendees at the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference discussed and voted on good laboratory practice statements to obtain consensus.Conclusions.—This paper describes the rationale, background, process, and strengths and limitations of a series of papers that summarize good laboratory practice statements in quality assurance in gynecologic cytopathology.

Context.—There are many long-standing quality monitors for cytopathology laboratories and their cytotechnologists and pathologists. Many of these monitors are based on tradition and empirical good intentions. There is no established standard as to how results of these monitors should be used in a quality assurance program.Objective.—To review practices that are typically part of a general quality program in cytopathology laboratories and to provide statements regarding good laboratory practices that laboratories may find useful in a quality assurance program in their own setting.Data Sources.—An expert working group evaluated results from a national laboratory survey, responses from follow-up questions posted on a Web site, and findings from the literature. The group created statements on good laboratory practices related to general quality practices and quality assurance in gynecologic cytopathology. These were discussed and voted on at a consensus conference.Conclusions.—Laboratories follow many metrics. Most laboratories facilitate comparison of individual metrics against the laboratory's metrics: 81.1% for cytotechnologists and 59.6% for pathologists. The majority of laboratories facilitate comparison of individual cytotechnologist metrics with other cytotechnologists, but less frequently metrics from pathologists with other individuals. The most common methods to recognize variance in performance in individuals were by identifying outliers from the data or by user-defined action limits. The most common method to address variance was an attempt to identify the cause of the variance and conduct a focused review. Quality metrics should be monitored for the laboratory as a whole and in selected cases for both individual pathologists and cytotechnologists. Results should be shared with individuals, and newly hired primary screeners should be monitored. Reviewing selected cases is a useful quality tool. Low-volume methodologies, such as conventional Papanicolaou tests, should have additional oversight.

Context.—To avoid errors many surgical pathology services mandate review of a case by a second pathologist before reports are released (signed out). Objective.—To study the extent and characteristics of such review. Design.—Participants retrospectively examined up to 400 cases to identify a maximum of 30 cases reviewed by at least one additional pathologist before sign-out. For each case, participants documented the organ system, primary disease type, number of additional pathologists consulted, and the reason for case review. The main outcome measure was the fraction of surgical pathology cases that underwent second pathologist review before sign-out. Results.—From 45 laboratories, examination of 18 032 surgical pathology cases yielded 1183 (6.6%) cases that had been reviewed before sign-out. The median laboratory reviewed 8.2% of cases. Three-fifths of reviews focused on 4 organ systems: gastrointestinal (20.5%), breast (16.0%), skin (12.7%), and female genital tract (10.0%). Malignant neoplasm far exceeded all other categories of disease in reviewed cases (45.3%). Cases were reviewed by one additional pathologist 78% of the time. Two dominant reasons for case review emerged: difficult diagnosis (46.2%) and audit required by departmental policy (43.0%). Most laboratories (71%) had departmental policies regarding review of cases. These laboratories reviewed cases about 33% more often than laboratories without policies (9.6% versus 6.5%). Conclusions.—Review of selected surgical pathology cases before sign-out is widely accepted with 71% of participant laboratories following policies to this effect. About 1 case in 15 (6.6%) were reviewed with the median laboratory of participants reviewing about 1 in 12 (8.2%).

Background Bing-Neel syndrome is an extremely rare neurologic complication of Waldenstrom macroglobulinemia (WM) that was first described in 1936. It is associated with central nervous system infiltration by neoplastic lymphoplasmacytoid and plasma cells with or without cerebrospinal fluid (CSF) hyperglobulinemia. Case Report We report a case of a 69-year-old white man with a 10-year history of WM. He was diagnosed with Bing-Neel syndrome based on magnetic resonance imaging and pathology studies of CSF. In addition, a comprehensive review of the reported cases of Bing-Neel syndrome in the up-to-date English-language literature was performed. Results Our patient underwent successful treatment with cranial radiation and intrathecal chemotherapy. He has been in clinical and pathologic remission for 3 years following the completion of his treatment. Based on our literature review, we also summarize and discuss clinical manifestations, diagnosis, and treatment options for Bing-Neel syndrome. Conclusion Bing-Neel syndrome is a rare and potentially treatable complication of WM. Patients with a history of WM presenting with neurologic symptoms should be evaluated for possible Bing-Neel syndrome. Cranial radiation therapy alone or in combination with intrathecal chemotherapy is more likely to achieve sustainable remission than intrathecal chemotherapy alone.

Introduction There are several types of small bowel pathology that can lead to small bowel obstruction or intussusception. The etiology causing small bowel obstruction varies by age. Benign disease is the typical cause in children and adolescents while malignant or adhesive disease is far more common in older patients. Although cases of adult intussusception caused by benign processes are rare, there are reports of inflammatory fibroid polyps causing adult intussusception of the terminal ileum published in the literature. Case presentation We present the case of a 70-year-old man with a multiple year history of intermittent episodes of bowel obstruction who was found to have a giant ileal inflammatory fibroid polyp causing intermittent small bowel obstruction. The patient underwent operative intervention and has now been symptom-free for three years. Conclusion Small bowel lesions include both malignant and benign etiologies. The malignant etiologies include adenocarcinoma, carcinoid or lymphoma while benign lesions are typically lipomas, inflammatory polyps or adenomas. Inflammatory fibroid polyps are rare, benign lesions that can occur anywhere within the gastrointestinal tract. They are typically an incidental finding, but on rare occasions have been presented as the source of intussusception or obstruction.

While anadromous salmonids reproduce in fresh water, most harvests occur at sea. Effective genetic management requires knowledge of the stock (source population) composition of the harvest. This is accomplished with genetic stock identification (GSI), which compares the genotypes of harvested fish with those of freshwater stocks, assuming that all candidate stocks are identified and that their allele frequencies are known exactly. We develop methods that: (1) allow for sampling error in allele frequencies of candidate stocks, and (2) evaluate the possibility of unsampled contributing stocks. Composition analysis for chinook salmon (Oncorhynchus tshawytscha) collected for the Bonneville Dam egg bank program in 1980 and 1981 shows that about 10% of both harvests were from the Deschutes River and about 90% from the Hanford Reach area. Contributions from lower Columbia and Snake River stocks or from unidentified sources were limited.

Context.—The use of Papanicolaou (Pap) test cytologic-histologic correlation in quality improvement activities is not well studied. Objective.—To determine if continuous monitoring of correlation data improves performance. Design.—Participants in the College of American Pathologists Q-Tracks program (213 laboratories) self-reported the number of Pap test–histologic biopsy correlation discrepancies every quarter for up to 8 years. A mixed linear model determined if the length of participation in the Q-Tracks program was associated with improved performance. Main outcome measures were predictive value of a positive Pap test, Pap test sensitivity, sampling sensitivity, and proportion of positive histologic diagnoses following a Pap test diagnosis of atypical squamous cells or atypical glandular cells. Results.—Institutions evaluated 287 570 paired Pap test– histologic correlation specimens and found 98 424 (34.2%) true-positive Pap test correlations, 19 006 (6.6%) false-positive Pap test correlations, and 6575 (2.3%) false-negative Pap test correlations. The mean predictive value of a positive Pap test, sensitivity, screening and interpretive sensitivity, sampling sensitivity, and proportion of positive histologic diagnoses following a Pap test diagnosis of atypical squamous or glandular cells were 83.6%, 93.7%, 99.2%, 94.2%, 60.3%, and 38.8%, respectively. Longer participation was significantly associated with a higher predictive value of a positive Pap test (P = .01), higher Pap test sensitivity (P = .002), higher Pap test sampling sensitivity (P = .03), and higher proportion of positive histologic diagnoses for a Pap test diagnosis of atypical squamous cells (P < .001). Conclusions.—Long-term monitoring of cytologic-histologic correlation is associated with improvement in cytologic-histologic correlation performance.

Context.—Papanicolaou (Pap) tests are often diagnosed as atypical squamous cells of undetermined significance (ASC-US). Human papillomavirus (HPV) DNA testing has been proposed as a quality metric for this diagnosis. Objective.—To measure the frequency of HPV positivity in Pap tests diagnosed as ASC-US and to examine laboratory variables that are associated with institutional deviation from the mean percent of HPV positivity. Design.—As part of a College of American Pathologist Q-Probes program, 68 participating laboratories retrospectively identified approximately 50 consecutive ASC-US Pap tests that had HPV testing results. Results.—The mean percentage of HPV positivity for ASC-US was 43.74% among institutions surveyed, but it had a broad distribution, with an SD of 17.77%. Associations were found for lower difference of the institutional mean from the surveyed interinstitutional mean percentage of positive HPV with (1) higher numbers of Pap tests in the past year that had HPV testing, (2) in-house HPV testing, and (3) teaching hospitals. All 3 factors correlated with a larger volume of Pap tests per institution. An association was found between patient age and the probability of a positive HPV result, indicating a dependence upon prevalence of HPV. Conclusions.—Larger volumes of Pap tests may offer an opportunity to gain greater comfort in interpreting Pap tests. While there is significant variability in interinstitutional HPV-positive rates in ASC-US Pap tests, monitoring the HPV-positive rate in ASC-US Pap tests is a valuable broad measure of quality. Performance beyond 2 SDs of the mean should prompt reassessment of diagnostic criteria used in the evaluation of Pap tests and/or investigation of the prevalence of HPV positivity in the population from which the Pap tests are obtained.

Context.—The effectiveness of the long-term monitoring of errors detected by frozen section–permanent section correlation is unknown. Objective.—To determine factors important in laboratory improvement in frozen section–permanent section discordant and deferral rates by participation in a multi-institutional continuous quality improvement program. Design.—Participants in the College of American Pathologists Q-Tracks program self-reported the number of anatomic pathology frozen–permanent section discordant and deferred cases in their laboratories by prospectively performing secondary review of intraoperative consultations. Laboratories participated in the program for 1 to 5 years and reported their data every quarter. We calculated mean and median discordant and deferred case frequencies and used mixed linear modeling to determine if length of participation in the program was associated with improved performance. Participants.—One hundred seventy-four laboratories self-reported data. Main Outcome Measures.—Mean frozen–permanent section discordant and deferred diagnostic frequencies and changes in these frequencies over time were measured. Results.—The mean and median frozen–permanent section discordant frequencies were 1.36% and 0.70%, respectively. The mean and median deferred diagnostic frequencies were 2.35% and 1.20%, respectively. Longer participation in the Q-Tracks program was significantly associated (P = .04) with lower discordant frequencies; 4- or 5-year participation showed a decrease in discordant frequency of 0.99%, whereas 1-year participation showed a decrease in discordant frequency of 0.84%. Longer participation in the Q-Tracks monitor was associated with lower microscopic sampling frequencies for discordant diagnoses (P = .04). Increased length of participation in the Q-Tracks program was significantly associated (P = .04) with lower deferred diagnostic frequencies. Conclusions.—Long-term monitoring of frozen–permanent section correlation is associated with sustained improvement in performance.

Stromal tumors of the abdominal colon, the least common of all gastrointestinal stromal tumors, have not been well characterized. They have often been lumped with stromal tumors of the anorectum in order to achieve significant numbers for analysis, yet there are no data to prove that stromal tumors from these two sites are the same. In this study, we evaluated 20 colonic stromal tumors to identify clinical, morphologic, and immunophenotypic features that were useful in discriminating between those that had metastasized or caused death from those that had not metastasized or caused death. We found that colonic stromal tumors are morphologically heterogeneous, and the malignant ones are clinically aggressive. They often have metastases at presentation, and cause death in a short time. An infiltrative growth pattern in the muscularis propria, invasion of the mucosa, and high mitotic counts correlated significantly both with metastases and with death from tumor. We also found that dense cellularity correlated significantly with metastases, but not with death, and that coagulative necrosis correlated with death, but not with metastases.

OBJECTIVE: The objective of this study was to describe the mammographic appearance with pathologic correlation of metaplastic carcinoma of the breast. CONCLUSION: Metaplastic carcinomas of the breast are masses with mammographic characteristics of low suspicion because of their histologic appearance. Metaplastic carcinoma should be included in the differential assessment of predominately circumscribed, noncalcified masses revealed on mammography. One salient feature that may distinguish metaplastic carcinomas is the occurrence of a circumscribed portion with a spiculated portion, which is seen in carcinomas that have a significant mixture of metaplastic and invasive carcinoma growth patterns.

Stromal tumors of the anorectum are a rare group of mesenchymal tumors that often have a protracted clinical course. We sought to determine which clinical, morphologic, and immunophenotypic features correlated with an adverse outcome in 22 patients with anorectal stromal tumors. An adverse outcome, defined as either tumor recurrence or metastasis, occurred in nine patients. Seven patients had metastases, two of whom also had local recurrences. Four of these patients also died from their disease. One patient had one local recurrence, and one patient had two local recurrences; neither of these patients had metastases. Recurrences were found as long as 103 months and metastases as late as 117 months after initial presentation. However, for patients without an adverse outcome, maximum follow-up was only 84 months. Thus both recurrence and metastasis may not appear until several years after treatment, indicating that a long-term follow-up period, probably longer than available for many tumors without an adverse outcome in this study, is needed before a patient can be considered to be cured. Tumor size greater than five centimeters correlated with an adverse outcome. However, given the protracted course of these tumors and the relatively limited follow-up available, other features such as location within the muscularis propria, mitotic activity, necrosis, and pleomorphism that did not significantly correlate with an adverse outcome may become significant with longer follow-up periods. We also found that on the basis of morphologic appearance and whether tumors were confined to the submucosa or located within the muscularis propria, anorectal stromal tumors could be divided into three groups, and that the behavior of anorectal stromal tumors may also depend upon their phenotype. The largest group of 17 tumors was located within the muscularis propria, mitotically active, and composed of densely cellular spindle-shaped cells. A second group of two tumors was also located within the muscularis propria and was composed of spindle-shaped cells, but lacked dense cellularity and mitotic activity. The third group was composed of three submucosal, polypoid tumors.

PURPOSE: Preclinical studies show a significant increase in the ratio of the radiosensitizer bromodeoxyuridine (BUdR) in tumors versus the intestinal mucosa during the drug elimination period, compared with the ratio during drug infusion. We constructed a phase I study in patients with locally advanced cervix cancer, using alternating cycles of BUdR and radiation therapy (RT). PATIENTS AND METHODS: Eighteen patients with stage IIB to IVA cervix cancer participated. A treatment cycle consisted of a 4-day BUdR infusion followed by a week of pelvic RT, 15 Gy twice daily in 1.5-Gy fractions. After three cycles, additional BUdR was infused, followed by brachytherapy. The fraction of thymidine replaced by BUdR and the fraction of cells incorporating BUdR were determined in rectal mucosa and tumor biopsies at the end of the first BUdR infusion (day 5), at the middle of the first RT week (day 10), and at the time of brachytherapy. RESULTS: Dose-limiting toxicity was observed in one of 16 patients receiving 1,000 mg/m2/d × 4 days and inboth patients receiving 1,333 mg/m2/d × 4 days each cycle. After a median follow-up of 39 months, 12 patients (66%) were free of pelvic disease and nine (50%) were alive and disease free. The ratio of tumor to rectum BUdR incorporation averaged 1.5 to 1.8 and did not differ significantly between day 5 and day 10. A trend toward reduced ratio was observed at brachytherapy. Drug-containing cells in rectal biopsies migrated from the crypts to the mucosal surface. CONCLUSION: In this schedule, 1,000 mg/m2/d is the maximum-tolerated dose of BUdR. BUdR incorporation levels in tumors were consistent with clinically significant radiosensitization. The migration of BUdR-containing rectal mucosa cells from the crypts to the surface at the time of RT suggests that this regimen may offer a relative sparing of the mucosa from radiosensitization.

The comparative analysis of DNA molecules is a useful means for phylogenetic reconstruction, because different types of genetic elements yield resolution at different levels of taxonomic divergence. A single individual is usually characterized for each operational taxonomic unit (OTU), based on the premise that within-OTU variation can be safely ignored. Whereas that premise is expedient, it may not be generally valid. Sometimes variation within OTUs can affect the analysis. We develop a formal analytic treatment of variation in phylogenetic output as a consequence of intraspecific variation. Using restriction site data from the mitochondria of three species of cyprinid fishes to illustrate, we show that genetic variation within taxa impacts on tree topology

Background Bupropion is approved for the treatment of mood disorders and as an adjuvant medication for smoking cessation. Bupropion is generally well tolerated and considered safe. Two randomized controlled trials of bupropion therapy for smoking cessation did not report any hepatic adverse events. However, there are three reports of severe but non-fatal bupropion hepatotoxicity published in the literature. Case Presentation We present the case of a 55-year old man who presented with jaundice and severe hepatic injury approximately 6 months after starting bupropion for smoking cessation. Laboratory evaluation demonstrated a mixed picture of hepatocellular injury and cholestasis. Liver biopsy demonstrated findings consistent with severe hepatotoxic injury due to drug induced liver injury. Laboratory testing was also notable for positive autoimmune markers. The patient initially had clinical improvement with steroid therapy but eventually died of infectious complications. Conclusion This report represents the first fatal report of bupropion related hepatotoxicity and the second case of bupropion related liver injury demonstrating autoimmune features. The common use of this medication for multiple indications makes it important for physicians to consider this medication as an etiologic agent in patients with otherwise unexplained hepatocellular jaundice.