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Biomedical subjects

Raouf E Nakhleh

Publications and source records attributed to Raouf E Nakhleh.

8 recordsLinked to original sources

Clinicopathologic findings and outcomes of liver transplantation using grafts from donors with unrecognized and unusual diseases.

Despite certain strict criteria for suitable organ donors, some unrecognized and unusual diseases have been transmitted through liver transplantation to recipients. In the current series, we review our experience with 14 patients who underwent liver transplantation using donor grafts with unusual pathology, including amyloidosis (6), schistosomiasis (3), iron overload (2), and alpha-1 antitrypsin deficiency (3). One of 6 patients who received grafts with amyloidosis developed vasculitis associated with the presence of arterial amyloid. With proper management, patients with donor schistosomiasis, iron overload and alpha-1 antitrypsin deficiency appear to have outcomes comparable to liver transplantation using grafts without these findings. In conclusion, long-term follow-up is necessary to confirm these findings and understand the impact of using these grafts.

Adult↗

Error reduction in surgical pathology.

CONTEXT: Because of its complex nature, surgical pathology practice is inherently error prone. Currently, there is pressure to reduce errors in medicine, including pathology. OBJECTIVE: To review factors that contribute to errors and to discuss error-reduction strategies. DESIGN: Literature review. RESULTS: Multiple factors contribute to errors in medicine, including variable input, complexity, inconsistency, tight coupling, human intervention, time constraints, and a hierarchical culture. Strategies that may reduce errors include reducing reliance on memory, improving information access, error-proofing processes, decreasing reliance on vigilance, standardizing tasks and language, reducing the number of handoffs, simplifying processes, adjusting work schedules and environment, providing adequate training, and placing the correct people in the correct jobs. CONCLUSIONS: Surgical pathology is a complex system with ample opportunity for error. Significant error reduction is unlikely to occur without a sustained comprehensive program of quality control and quality assurance. Incremental adoption of information technology and automation along with improved training in patient safety and quality management can help reduce errors.

Diagnostic Errors↗

Gallbladder lymphangioma: a case report and review of the literature.

Lymphangiomas are benign neoplasms usually occurring in childhood and located in the head and neck. Intraabdominal lymphangiomas account for less than 5% of cases. The involvement of the gallbladder is rare. We report a case of a 29-year-old woman who presented with right upper quadrant pain that had persisted for 6 months. Imaging with ultrasound and magnetic resonance imaging (MRI) revealed a multiseptated lesion surrounding the gallbladder. The patient underwent an exploratory laporatomy, and the mass was resected en bloc with the gallbladder. Histological evaluation of the cystic mass revealed findings consistent with lymphangioma. The prognosis is generally good after complete surgical excision, as was the case for our patient.

Adult↗

Patient safety in anatomic pathology: measuring discrepancy frequencies and causes.

CONTEXT: Anatomic pathology discrepancy frequencies have not been rigorously studied. OBJECTIVE: To determine the frequency of anatomic pathology discrepancies and the causes of these discrepancies. DESIGN: Participants in the College of American Pathologists Q-Probes program self-reported the number of anatomic pathology discrepancies in their laboratories by prospectively performing secondary review (post-sign-out) of 100 surgical pathology or cytology specimens. Reasons for the secondary review included conferences, external review, internal quality assurance policy, and physician request. PARTICIPANTS: Seventy-four laboratories self-reported data. MAIN OUTCOME MEASURES: Frequency of anatomic pathology discrepancy; type of discrepancy (ie, change in margin status, change in diagnosis, change in patient information, or typographic error); effect of discrepancy on patient outcome (ie, no harm, near miss, or harm); and clarity of report. RESULTS: The mean and median laboratory discrepancy frequencies were 6.7% and 5.1%, respectively. Forty-eight percent of all discrepancies were due to a change within the same category of interpretation (eg, 1 tumor type was changed to another tumor type). Twenty-one percent of all discrepancies were due to a change across categories of interpretation (eg, a benign diagnosis was changed to a malignant diagnosis). Although the majority of discrepancies had no effect on patient care, 5.3% had a moderate or marked effect on patient care.Conclusions.-This study establishes a mean multi-institutional discrepancy frequency (related to secondary review) of 6.7%.

Humans↗

Portal donor-specific blood transfusion and mycophenolate mofetil allow steroid avoidance and tacrolimus dose reduction with sustained levels of chimerism in a pig model of intestinal transplantation.

BACKGROUND: In a pig model of intestinal transplantation, we previously showed that hepatic conditioning through portal donor-specific blood transfusion (pDSBT), high-dose tacrolimus (TAC), and steroids prevented rejection and increased survival Our current study tests a protocol of pDSBT, short-term mycophenolate mofetil (MMF), and low-dose TAC to eliminate the use of steroids, reduce TAC dosage, and increase the level of chimerism in the peripheral blood. MATERIALS AND METHODS: Four groups of outbred, mixed lymphocyte culture (MLC)-reactive pigs underwent bowel transplants and pDSBT. Immunosuppression (group 1, high-dose TAC and steroids; group 2, low-dose TAC and MMF; group 3, low-dose TAC, MMF, and aminoguanidine; group 4, low-dose TAC, MMF, and arginine) was discontinued after 28 days. RNA was extracted from intestinal graft and native liver biopsies for cytokine measurements. Chimerism levels were determined using a Q-PCR analysis. RESULTS: Pig survival and death rates due to rejection did not significantly differ between the four groups. Chimerism levels determined by Q-PCR analysis were not different until day 28. After discontinuation of immunosuppression, we noted a trend (P = 0.15) toward higher mean chimerism levels on day 60 for groups 2, 3, and 4 (9%) vs. group 1 (0.5%). Tissue cytokine and serum nitrate levels did not significantly differ between the four groups. Attempts to modify nitric oxide synthase activity offered no added benefit. CONCLUSIONS: The combination of pDSBT, MMF, and low-dose TAC (vs. high-dose TAC and steroids) allowed sustained levels of mixed chimerism to develop after discontinuation of immunosuppression.

Animals↗

Customer satisfaction in anatomic pathology. A College of American Pathologists Q-Probes study of 3065 physician surveys from 94 laboratories.

CONTEXT: Measurement of physicians' and patients' satisfaction with laboratory services has recently become a requirement of health care accreditation agencies in the United States. To our knowledge, this is the first customer satisfaction survey of anatomic pathology services to provide a standardized tool and benchmarks for subsequent measures of satisfaction. OBJECTIVE: This Q-Probes study assessed physician satisfaction with anatomic pathology laboratory services and sought to determine characteristics that correlate with a high level of physician satisfaction. DESIGN: In January 2001, each laboratory used standardized survey forms to assess physician customer satisfaction with 10 specific elements of service in anatomic pathology and an overall satisfaction rating based on a scale of rankings from a 5 for excellent to a 1 for poor. Data from up to 50 surveys returned per laboratory were compiled and analyzed by the College of American Pathologists. A general questionnaire collected information about types of services offered and each laboratory's quality assurance initiatives to determine characteristics that correlate with a high level of physician satisfaction. SETTING: Hospital-based laboratories in the United States (95.8%), as well as others from Canada and Australia. PARTICIPANTS: Ninety-four voluntary subscriber laboratories in the College of American Pathologists Q-Probes quality improvement program participated in this survey. Roughly 70% of respondents were from hospitals with occupied bedsizes of 300 or less, 65% were private nonprofit institutions, just over half were located in cities, one third were teaching hospitals, and 19% had pathology residency training programs. MAIN OUTCOME MEASURES: Overall physician satisfaction with anatomic pathology and 10 selected aspects of the laboratory service (professional interaction, diagnostic accuracy, pathologist responsiveness to problems, pathologist accessibility for frozen section, tumor board presentations, courtesy of secretarial and technical staff, communication of relevant information, teaching conferences and courses, notification of significant abnormal results, and timeliness of reporting). RESULTS: The database of 3065 physician surveys was derived from 94 laboratories. An average of 32.6 surveys (median 30) was returned per institution, with a range of 5 to 50 surveys per institution. The mean response rate was 35.6% (median 32.5%). The median (50th percentile) laboratory had an overall median satisfaction score of 4.4. The lowest satisfaction scores that were obtained all related to poor communication, which included timeliness of reporting, communication of relevant information, and notification of significant abnormal results. Statistically significant associations of customer satisfaction with certain institutional characteristics and laboratory performance improvement activities were identified. CONCLUSIONS: The importance of this satisfaction survey lies not in its requirement as an exercise for accrediting agencies but in understanding the needs of the customer (in this case the physician) to direct performance improvement in the delivery of quality anatomic pathology laboratory services.

Consumer Behavior↗

Surgical pathology extradepartmental consultation practices.

OBJECTIVES: To document the practice parameters and case characteristics associated with personal (expert) consultations. We also examine the value, level of participant (customer) satisfaction, turnaround time, and rate of personal consultations. DESIGN: We asked participants in the College of American Pathologists' Q-Probes program to document cases sent for consultation during 4 months or up to 20 cases. They documented patient and specimen characteristics, the turnaround times, and the participants' levels of satisfaction with the consultation experience. PARTICIPANTS: One hundred eighty laboratories/surgical pathology practices. One hundred seventy-two (95.6%) were from the United States; the remainder were located in Canada and Australia. MAIN OUTCOME MEASURES: Rate and turnaround time of consultations and participant level of satisfaction. RESULTS: A total of 2746 consultation cases were examined for an aggregate consultation rate of 0.5% (median, 0.7%). Institutions with a higher occupied bed size and a greater number of surgical pathology cases both had lower consultation rates (P < or =.05). The median turnaround time (defined as the interval from the date on which the case was sent to the date on which the diagnosis was received) was 6 days. Twenty-nine percent and 68% of cases had a turnaround time within 3 and 7 days, respectively. Fifty-two percent of cases were sent to nationally known experts, and 32% were sent to local experts. Skin (18.0%), hematolymphoid (11.6%), and breast (9.6%) specimens were most commonly sent for consultation. In 70.5% of cases, the consultant confirmed the referring pathologist's original diagnosis, but in 15.9% of cases, the consultant also added significant information. Satisfaction rates were higher with faster turnaround times and verbal reporting. Satisfaction rates were lower for cases in which the patient or the clinician requested the consultation and in which the consultant's diagnosis was ambiguous. CONCLUSIONS: This study establishes a multi-institutional consultation rate of 0.5%, defines the nature of surgical pathology consultations, and demonstrates that satisfaction with consultations is associated with a faster turnaround time and receipt of additional, clinically meaningful information.

Female↗