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PubMed2003

Multimodal CME for surgeons and pathologists improves colon cancer staging.

BACKGROUND: Optimal treatment of localized colorectal cancer (CRC) depends on accurate retrieval and assessment of lymph nodes (LN) in the resected specimen. METHODS: Formal CE, informal opinion leadership and reinforcing strategies aimed at pathologists and surgeons to improve LN assessment were implemented. RESULTS: In the pre-intervention period a median of 8 lymph nodes were assessed in making a designation of Stage II CRC (n = 115). Thirty months later (post-intervention period) the median number of LN reported in Stage II CRC increased to 18 (n = 41), p < 0.001. CONCLUSION: A durable improvement in staging was realized through a multipronged change initiative aimed at both surgeons and pathologists.

Aged↗

PubMed2002

A pathologist trying to help endocrinologists to interpret cytopathology reports from thyroid aspirates.

Fine-needle aspiration has become the diagnostic tool of choice in the initial evaluation of thyroid nodules. As a cytopathologist who has been performing fine-needle aspirations for over 25 yr at a university hospital and for the last 3 yr at the largest not-for-profit hospital in the Washington, D.C. area, I have seen increasing demand for this service. However, there is also discontent with the cytopathology reports issued by numerous laboratories. Pathologists have to standardize and simplify their reports so that they will be more meaningful to the referring physician. Endocrinologists should communicate their needs to the pathologists and insist on clear, succinct, and prompt diagnoses.

Biopsy, Needle↗

PubMed2003

Screen-detected adenocarcinoma of the lung. Practical points for surgical pathologists.

Recent technological advances in thoracic radiology and surgery have altered the types of lung specimens handled by cytologists and surgical pathologists. Increasing numbers of individuals with small peripheral adenocarcinomas undergo minimally invasive diagnostic procedures and, in some instances, minimally invasive surgical procedures. The pathologist's role in early lung adenocarcinoma research is central, as clinical and investigational studies depend more than ever on subtle pathologic distinctions. Establishing a diagnosis of malignant neoplasm on samples from fine-needle aspiration, core biopsy, or frozen section is fraught with new considerations, and surgically resected adenocarcinomas must be typed according to the recently revised World Health Organization classification. Familiarity with small glandular proliferations, including the putative precursor lesion atypical adenomatous hyperplasia, will prevent misdiagnoses and untoward impact on tumor staging, therapy, and outcome studies.

Adenocarcinoma↗

PubMed2005

Facilitating communication among speech pathologists treating children with cleft palate.

An interactive web-based system was designed to facilitate communication between nonspecialist speech pathologists who provide therapy for individuals with speech disorders associated with cleft palate or craniofacial anomalies and specialist speech pathologists who provide physiologically based assessments of speech production. The web site includes instructional presentations, streaming video clips of endoscopic examinations, and exchange of information about the nature of therapy as recommended by the specialist and as provided by the nonspecialist. The approach demonstrates use of web-based computer facilities to improve the quality of communication among professionals with the goal of improving the outcomes of speech therapy. Information from the site can also be used in academic training programs as a teaching tool in courses on cleft palate speech.

Child↗

PubMed1990

Speech-language pathologists' opinions on the management of velopharyngeal insufficiency.

A 16-item questionnaire designed to survey opinions on the management of velopharyngeal insufficiency (VPI) was distributed to all members (N = 296) of the American Cleft Palate Association who were speech-language pathologists. Questionnaires were completed by 173 respondents (58.4 percent). There were differences of opinion among speech-language pathologists on various management issues related to VPI, including the value of instrumental assessment of VPI, the importance of oral examination of velopharyngeal function, and the effectiveness of speech therapy in the treatment of VPI. The implications of these findings for clinical training in VPI are discussed.

Adenoidectomy↗

PubMed1992

The role of the surgical pathologist in the examination of the non-palpable breast lesion.

The specimen excised for the mammographically detected lesion is somewhat unique and requires special consideration by the surgical pathologist. The biopsy, in most instances, contains no grossly visible lesion and is relatively large so that blocking in its entirety is not practical. The pathologist needs to establish that the radiological abnormality is contained in the biopsy and to this end specimen radiography is required. Established prognostic parameters for breast carcinoma, such as tumor size, histological type, grade and hormone receptor status are equally applicable in the non-palpable breast lesion but consideration should also be given to the identification of epithelial proliferations which have increased risk for subsequent carcinoma. In addition, the recognition of ductal carcinoma in situ in the biopsy indicates potential for widespread disease, and lobular carcinoma in situ, a less commonly detected lesion in mammography, is associated with multifocality and disease in the contra-lateral breast. Both lesions are also associated with increased risk of recurrence in the remaining breast tissue. Failure to observe the corresponding quantity of calcium seen in radiographs relates to the fact that calcium may occur, not only as calcium phosphate, but also as calcium oxalate, the latter not being stained by hematoxylin and eosin but readily detected by its birefringent nature in polarized light. Detailed correlation of serial thin slices of the specimen with radiographic features is largely an educational exercise but is the most time-consuming step in the examination of the non-palpable breast lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

Biopsy↗

PubMed2006

Historical perspective and future directions in training of veterinary pathologists with an emphasis on zoo and wildlife species.

This article discusses the history of the field of zoo and wildlife pathology, training opportunities for veterinary students and graduate veterinarians, and current and future job opportunities. The niches occupied by veterinarians in this field and their contributions to animal and human health are also highlighted. The field of zoo and wildlife, or "non-traditional" species, pathology has its roots in comparative anatomy, zoology, wildlife biology, and medical pathology in the mid- to late nineteenth century. The initial emphasis was on comparisons between animal and human diseases or on management of game animals. Veterinarians became increasingly involved during the twentieth century, gradually changing the emphasis to improvement of conservation strategies, captive care, and elucidation of diseases of concern for the animals themselves. Currently there are several zoos and wildlife agencies in the United States employing full-time veterinary pathologists. Private and government diagnostic laboratories, veterinary schools, and other academic institutions in the United States with pathology departments are other employers. The field requires post-DVM training by means of a residency program leading to board certification, graduate school (MS or PhD degrees), or both. Veterinary students can gain valuable experience in the field through externships and, at some schools, through elective courses in the curriculum. Current concerns about ecosystem health, bioterrorism, and the recognition that captive and free-ranging wildlife can serve as sentinel species will increase the demand for veterinary pathologists choosing this very rewarding career path specializing in non-traditional species.

Animals↗

PubMedDate not supplied

Bone tumor radiograph review by pathologists prior to pathologic diagnosis: a receiver operator curve analysis of diagnostic utility.

Radiologic-pathologic correlation has long been considered a prerequisite for the accurate diagnosis of bone lesions. We investigated using receiver-operating characteristic analysis the accuracy of histopathologic diagnoses with and without pathologist review of radiographs. While accuracy of diagnosis did improve when the radiographs were reviewed by the pathologist, this increase did not reach statistical significance (P=0.1311). Potential reasons for this finding including case selection and reviewer expertise are discussed. Based on our study, the review of radiographs did not result in a statistically significant difference in accuracy of the pathologic diagnosis of bone tumors. However, our data suggest that there may be a difference particularly in selected cases and among certain observers.

Bone Neoplasms↗

PubMed1999

Surgical pathology specimens for gross examination only and exempt from submission: a College of American Pathologists Q-Probes study of current policies in 413 institutions.

OBJECTIVE: To survey the scope of current written institutional policies for types of surgical pathology specimens exempt from submission to the laboratory and those that may be examined by gross inspection only. DESIGN AND SETTING: In the first quarter of 1997, a total of 413 voluntary participant institutions enrolled in the College of American Pathologists Q-Probes quality improvement program completed a checklist of 115 proffered specimens. Also included was a questionnaire defining demographic, practice, and reimbursement variables. MAIN OUTCOME MEASURES: The number and types of specimens exempt from submission and submitted for gross examination only based on written institutional policy rather than on unapproved actual practices. RESULTS: Most institutions had a written policy for types of specimens deemed exempt from submission to pathology (87.1 %) and for types of specimens subject to gross examination only (76.6%). There was a wide range of numbers of specimen types with a median number of 17 (range, 2-40) in the exempt category and 29 (range, 6-57) in the category of gross examination only. Significantly higher absolute counts of specimens exempt from submission to pathology were reported by institutions with a greater surgical pathology volume in 1996 and by nonteaching institutions. No aspect of practice was associated with numbers of specimens for gross examination only. CONCLUSIONS: This Q-Probes study creates a multi-institutional reference database of current practices to assist pathologists and clinical staff in the development of written guidelines pertaining to surgical pathology specimen submission exceptions and gross-only examinations.

Biopsy↗

PubMed1999

The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions.

OBJECTIVE: To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. DESIGN: Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. SETTING AND PARTICIPANTS: Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. MAIN OUTCOME MEASURES: Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. RESULTS: In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient's death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. CONCLUSION: This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient's death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance.

Autopsy↗

PubMed1999

A method for proficiency testing of small peer groups in the College of American Pathologists Coagulation Surveys.

OBJECTIVE: To develop a grading scheme for the proficiency testing of small peer groups of fewer than 10 members for the prothrombin time (PT) and activated partial thromboplastin time (APTT). METHODS: A modified target value for small peer groups was derived based on the assumption that measurement variability in the PT and APTT is more greatly influenced by variations in reagents than in instruments. Criteria for grading were established by statistical simulation to achieve misclassification errors of less than 5% for both incorrectly passing and failing participants. College of American Pathologists Coagulation Survey data were analyzed to determine the number of additional laboratories graded using the proposed scheme, as well as the failure rates among participants in the small peer groups. RESULTS: The modified target value for small peer groups is a weighted average between the mean of the peer group and the mean of all participants using the same reagent (reagent group). Peer groups with as few as 4 members can be graded provided that specific criteria are satisfied: there must be at least 5 peer groups for the same reagent, at least 3 of these 5 peer groups must have more than 3 members, and the coefficient of variation for the reagent group must be less than 10%. This proposed grading scheme decreased the number of ungraded laboratories by 44% to 46% for the PT and 42% to 55% for the APTT. The percentage of failing grades among participants in the small peer groups ranged from 1.3% to 4.1% for the PT and 1.4% to 7.2% for the APTT. These failure rates were 2.8- to 13.0-fold higher than the failure rates in large peer groups (P < or = .05). CONCLUSIONS: The proposed small peer group grading scheme can improve the effectiveness of College of American Pathologists proficiency testing for the PT and APTT and may also be generally applicable to other test methods and analytes.

Anticoagulants↗

PubMed1999

Patient outcomes and pathology practice: An introduction to the College of American Pathologists Conference XXXIV on Molecular Pathology: Role in Improving Patient Outcome.

This article provides an abbreviated conceptual framework for viewing general issues of outcomes research and management and consideration of the emerging interest in patient-referenced outcomes in medicine and pathology. Specific issues addressed are the reasons for increased interest in outcomes research within the past decade; a review of the current language of outcomes management and research; a critique of the advantages and weaknesses of contemporary outcomes analysis and research methods; a summary of the responses of government, regulatory and accreditation organizations, medical societies, and the College of American Pathologists to the outcomes movement; and, in conclusion, a discussion of opportunities provided through outcomes management for enhanced involvement by pathologists in the care of patients.

Humans↗

PubMed1999

Interobserver variability in subclassification of squamous intraepithelial lesions: Results of the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology.

OBJECTIVE: To determine whether, on a national cytology proficiency test, a competent cytologist can consistently distinguish grades of squamous intraepithelial lesions. DESIGN: Results for low- and high-grade squamous intraepithelial lesion referenced slides from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology for 1996 and 1997 were analyzed including educational, nongraded vs graded validated slides. RESULTS: The discrepant rate between low- and high- grade lesions ranged from 9.8% to 15% for cytotechnologist, pathologist, laboratory, and all responses. There was a statistically significant difference in performance on graded, validated slides vs educational slides with better performance on validated slides. CONCLUSION: This significant interobserver variability in subclassification of squamous lesions should be considered in management guidelines for abnormal Papanicolaou test results and implementation of national cytology proficiency testing.

Carcinoma, Squamous Cell↗

PubMed2000

Effect of a new international reference preparation for proteins in human serum (certified reference material 470) on results of the College of American Pathologists Surveys for plasma proteins.

OBJECTIVE: To examine the impact of a new international reference preparation for serum proteins on the among-manufacturer variance in the College of American Pathologists Surveys. DATA SOURCE: The results of the Surveys for the years 1993-1998, supplied by the College of American Pathologists. DATA EXTRACTION AND SYNTHESIS: Mean values for manufacturers' assays were compared for each protein in the quality control samples. Results were separated by the reported reference material from which values for calibrators had been transferred. Standard statistical parameters (means, standard deviations, and coefficients of variation) were calculated from the reported means. CONCLUSIONS: Among-manufacturer coefficients of variation have dropped significantly for most serum proteins since the introduction of the new reference material. Possible reasons for continued differences are discussed.

Albumins↗

PubMed2001

Reparative changes and the false-positive/false-negative Papanicolaou test: a study from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology .

CONTEXT: Reparative changes can be a diagnostic challenge on Papanicolaou tests and must be distinguished from epithelial cell abnormalities. Both squamous intraepithelial lesions (SIL) and carcinoma may be underdiagnosed as repair. This study examines laboratory and cytologist performance in the diagnosis of repair. OBJECTIVES: To determine if laboratories and cytologists can consistently distinguish reparative changes from SIL and carcinoma and to document how often SIL and carcinoma are mistaken for repair in a standardized educational slide program. DESIGN: Results for reparative changes, SIL, and carcinoma slides from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology for 1998 were analyzed. Only results from validated referenced slide responses were used. RESULTS: The concordancy rate for reparative-change slides, that is, any response of within normal limits or benign cellular changes, ranged from 91% to 94% for cytotechnologist, pathologist, and laboratory responses. False-negative rates for squamous carcinoma and adenocarcinoma, high-grade SIL, and low-grade SIL ranged from 0.47% to 5.41%; the proportion of false-negative diagnoses of reparative changes ranged from 24% to 62% of all discordant responses. CONCLUSIONS: Of all benign cellular changes and within normal limits categories in the Interlaboratory Comparison Program in Cervicovaginal Cytology, repair most often elicits a false-positive laboratory response. Underdiagnosing epithelial abnormalities as repair is also a source of false-negative Papanicolaou test results.

Cervix Uteri↗

PubMed2002

Routine outpatient laboratory test turnaround times and practice patterns: a College of American Pathologists Q-Probes study.

OBJECTIVES: To determine baseline parameters for routine outpatient test turnaround time (TAT), to identify influential factors, and to study the impact of managed care on this testing. METHOD: Using forms supplied by the College of American Pathologists Q-Probes program, laboratories conducted a self-directed study of routine outpatient TATs over a 4-week period. Data requested included various times of day associated with the collection, laboratory receipt, and result verification of specimens, as well as details on the drawing location and ordering and delivery methods for up to 3 tests, namely, a complete blood cell count (CBC), biochemical profile, or thyrotropin test. For the CBC, an indication was requested if a manual differential was performed. Additionally, practice-related questions were asked, including several about whether the laboratory was associated with a managed care organization (MCO). The main outcome measures included the components of the TAT process and related factors.Participants.-Six hundred nineteen laboratories from those enrolled in the 1997 College of American Pathologists Q-Probes program. RESULTS: Data were submitted by 614 participants, most US hospitals, and represented 30 240 CBCs, 25 683 biochemical profiles, and 14 801 thyrotropins. Collection to verification TATs increased for specimens received later in the day for all analytes, but the magnitude of the increase was greatest for thyrotropin. Collection to laboratory receipt TAT was similar for all analytes, but the time and distribution increased with time of day. Testing time (receipt to verification) was similar for the CBC and biochemical profile, but was greatly increased for thyrotropin. Most participants tested the CBC and the biochemical profile as they arrived, but many delayed testing for thyrotropin. Most (70%) outpatient specimens were collected within the institution; only about 10% came from local physicians' offices. A median 46.7% of hospital testing involved outpatients. Only 10% of laboratories operated under an MCO; these laboratories reported a median of 45% of specimens coming from their MCO. Being associated with an MCO increased TAT for the CBC and biochemical profile. CONCLUSIONS: Outpatient testing comprises about half of all hospital testing, yet systems are not optimized. Preanalytic TAT increases during the day, which indicates increasing delays in the collection and transport stages. Imposition of a test schedule on thyrotropin results in a delay pattern that is very different from the CBC and biochemical profile, which are tested on arrival. A laboratory's association with an MCO had a weak impact on TAT.

Ambulatory Care↗

PubMed2002

Detection of bcl-2/J(H) translocation by polymerase chain reaction: a summary of the experience of the Molecular Oncology Survey of the College of American Pathologist.

CONTEXT: The t(14;18)(q32;;t6q21) translocation, found in about 85% of follicular lymphomas, brings the bcl-2 gene on 18q21 under control of the immunoglobulin heavy-chain gene transcriptional regulatory elements on 14q32. Detection of this translocation in a clinical sample suspected of containing lymphoma can assist the pathologist in diagnosis and classification of lymphoma. Polymerase chain reaction is a technology that is frequently used to detect the t(14;18)(q32;q21) translocation (bcl-2/J(H)). This article reviews the utility of polymerase chain reaction testing for bcl-2/J(H) detection and summarizes the experience of participants in the Molecular Oncology Proficiency Survey of the College of American Pathologists from 1997 through 2000. OBJECTIVE: To describe current practice and encourage improvement of bcl-2/J(H) testing in clinical laboratories. DESIGN: Retrospective analysis of Molecular Oncology Proficiency Survey data. PARTICIPANTS: Laboratory participants in the College of American Pathology Molecular Oncology Proficiency Survey. RESULTS: Twenty-four well-characterized specimens were sent to participants, of which 6 contained bcl-2/J(H) major breakpoint region translocations. Eight hundred nineteen major breakpoint region and 323 minor cluster region determinations were performed, with an overall correct response rate of 91% and 94%, respectively. No significant difference in correct response could be found for frozen versus paraffin-embedded tissues. Many laboratories did not know their assay sensitivity. CONCLUSION: Overall performance was good; however, there was great variability in the methods reported and lack of knowledge of the limits of detection was common. Continued participation in external quality control programs, such as the Molecular Oncology Survey; dissemination of information that impacts on test performance; and technical recommendations from the molecular diagnostics community are critical for improved testing for bcl-2/J(H).

Chromosomes, Human, Pair 14↗

PubMed2005

Cytologic features of squamous cell carcinoma in conventional smears: comparison of cases that performed poorly with those that performed well in the College of American Pathologists Interlaboratory Comparison Program in cervicovaginal cytology.

CONTEXT: Characteristic cytologic features have been identified that distinguish cases that are always identified from those that are sometimes missed in the College of American Pathologists Gynecologic Cytology Program for a variety of different lesions and preparations. OBJECTIVE: To compare the cytologic features of cases of squamous cell carcinoma in conventional smears that perform poorly and well. DESIGN: The cytologic features of 8 conventional smear cases of squamous cell carcinoma that performed poorly in the College of American Pathologists Interlaboratory Comparison Program were compared with 17 cases that performed extremely well. RESULTS: A total of 2387 individual interpretations were recorded. Of the 86 incorrect responses, 6.2% were for repair, and 0.8% were for Trichomonas. Cases that performed well were significantly more likely to have greater than 1000 dysplastic cells (16/17 vs 4/8, P = .02) and be keratinized (13/17 vs 1/8, P = .007). Obscuring inflammation and cell size were not significant. CONCLUSION: Conventional smears with a diagnosis of squamous cell carcinoma that were always identified were significantly more likely to have greater than 1000 cells and be keratinized than cases that performed poorly.

Carcinoma, Squamous Cell↗