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PubMed1977

The role of the pathologist in environmental medicine and public health.

The present paper summarizes the role of the morbid anatomist and clinical pathologist in environmental carcinogenesis. It points out that in the past he has contributed considerably to the identification of rare tumors and their etiology. He has an important role to play in the future in providing more accurate data on which epidemiology studies can be developed. The view is also expressed that it is highly important that modern pathologists have an understanding of toxicologic and pharmacologic techniques and their potential application to biologic material in order that they may be in a position to correlate and develop multidisciplinary approaches to the identification of environmental hazards. Some of these approaches are illustrated and their potential developments outlined.

Animals↗

PubMed1993

Performance characteristics of fibrinogen assays. Results of the College of American Pathologists Proficiency Testing Program 1988-1991.

Plasma fibrinogen concentration appears to be an important risk factor for the development of atherosclerotic cardiovascular disease of a similar magnitude to cholesterol. The quality control of plasma fibrinogen assays has taken on new importance as a consequence of this potential role as an atherosclerotic risk factor. This article reviews the performance characteristics of 40,000 fibrinogen assays comprising the College of American Pathologists Proficiency Testing Program from 1988 through 1991. Instrument and reagent variables both play roles in the poor interlaboratory reproducibility documented by this study. The absence of either a national or international standard for plasma fibrinogen assays has been a major source of reagent variability. The validation and calibration of the College of American Pathologists lyophilized plasma reference preparation for fibrinogen determination is also reported in this study. The availability of this validated reference plasma should markedly improve interlaboratory reproducibility.

Analysis of Variance↗

PubMed1996

Bedside glucose monitoring. Comparison of performance as studied by the College of American Pathologists Q-Probes program.

OBJECTIVE: To measure changes in practice characteristics and accuracy of bedside glucose monitoring between studies performed in 1991 and 1994. DESIGN: Participants in a 1991 and a 1994 bedside glucose monitoring study of the College of American Pathologists Q-Probes program were compared using data collected by a questionnaire for 15 quality variables and data from paired specimens for accuracy. Accuracy goals of bedside testing were those defined by the American Diabetes Association as within 10% of the laboratory value. Accuracy was estimated using a daily paired comparison of patient specimens for 30 days, one bedside glucose instrument, and individuals who commonly performed these measurements. SETTING: Institutions subscribing to the College of American Pathologists' voluntary quality improvement program, Q-Probes. PARTICIPANTS: In 1991 and 1994, 605 and 544 institutions collected data about performance characteristics, whereas 171 and 242 institutions participated in the accuracy components, respectively. MAIN OUTCOME MEASURE: Changes in accuracy between 1991 and 1994. RESULTS: When compared, improvement occurred for 12 of 15 quality variables. However, no significant changes were found for the percentage of values within stated accuracy goals. CONCLUSIONS: Although the process of bedside glucose testing improved between the 1991 and 1994 studies, the testing accuracy remained unchanged.

Blood Chemical Analysis↗

PubMed1996

Quality assurance of autopsy permit form information, timeliness of performance, and issuance of preliminary report. A College of American Pathologists Q-Probes study of 5434 autopsies from 452 institutions.

OBJECTIVE: To develop a multi-institutional reference database of autopsy practices and performance for quality improvement purposes. DESIGN: In 1992, participants in the Q-Probes quality improvement program of the College of American Pathologists each prospectively evaluated consecutive autopsies performed over a 6-month period, up to a maximum of 20 autopsies per institution. SETTING: Hospital-based autopsies, excluding forensic cases and stillborn infants. PARTICIPANTS: Four hundred forty-nine North American institutions and three Australian laboratories. MAIN OUTCOME MEASURES: Completeness of information contained on autopsy permit forms, timeliness of autopsy performance between patients' deaths and autopsy prosections, and turnaround time of preliminary autopsy reports. RESULTS: In the aggregate database of 5434 autopsy cases, 7 of 11 selected data items were consistently present on autopsy permit forms in 80% of the participating institutions. The median percentage of autopsies in which permission was given for an unrestricted (complete) autopsy was 71%. The following median time intervals were obtained: time of the patient's death to time the autopsy permission was received, 5 hours, 23 minutes; time the autopsy permission was received to time the prosection was started, 3 hours, 30 minutes; and time of the patient's death to time the prosection was started, 14 hours, 52 minutes. Differences were observed in some time intervals when the participating institutions were grouped by reported demographic characteristics. Preliminary reports were completed in 2 days or less in 80.9% of the autopsies. CONCLUSIONS: Through this multi-institutional study, we have documented a consistent core of autopsy permit form information requested and a wide range of time intervals elapsed between the patients' deaths and autopsy performance. We have also established that the majority of participating institutions meet the College of American Pathologists' laboratory accreditation standard of providing a documented preliminary report of the gross pathologic diagnoses submitted to the attending physicians and institutional record within 2 working days following autopsy completion.

Autopsy↗

PubMed1996

Surgical pathology specimen identification and accessioning: A College of American Pathologists Q-Probes Study of 1 004 115 cases from 417 institutions.

OBJECTIVE: To examine and suggest improvements for deficiencies occurring in the specimen identification and accessioning process in the surgical pathology laboratory. DESIGN: Using the College of American Pathologists' and the Joint Commission for Accreditation of Healthcare Organizations' requirements as the standard, each laboratory was asked to prospectively document deficiencies in specimen identification and accessioning for 4 months, or until a maximum of 4000 cases or 400 deficiencies were accrued. PARTICIPANTS: Four hundred seventeen laboratories in the College of American Pathologists' voluntary quality improvement program, Q-Probes, participated in this study. RESULTS: Identification and accessioning deficiencies were found in 60 042 (6%) out of a total 1 004 115 cases accessioned (median deficiency rate of 3.4%). Errors related to specimen identification accounted for 9.6% of these deficiencies, discrepant or missing information items were present in 77%, and 3.6% involved specimen handling. The most common deficiency was "no clinical history or diagnosis present on the requisition slip," which represented 40% of all deficiencies. Deficiencies were most often detected by the person assigned to accessioning duties or by histology personnel. In 66% of cases, no action was taken to remedy the deficiency, but this varied dramatically according to the specific type of deficiency. An action was taken to remedy deficiencies in 69% of cases involving specimen identification errors, in 58% of specimen handling errors, and in 27% of cases with discrepant or missing information. Peer group stratifiers were associated with a lower deficiency rate. Laboratories with lower numbers (<15 000) of accessioned cases and laboratories with a formal written plan for the detection of errors in accessioning and specimen identification reported lower rates of deficiencies. Factors that correlated with a higher rate of deficiencies included submitting the specimen container and requisition slip in a unique secondary container (P<.005) and labeling the specimen container with only a patient's name or unique patient identification number (as opposed to both identifiers). CONCLUSIONS: The majority of deficiencies occurring in surgical pathology specimen identification and accessioning are related to missing or inaccurate clinical information. Deficiencies are detected in multiple locations, including areas not typically thought of as quality check points, such as transcription. A variable amount of effort occurs to rectify deficiencies; this effort is largely dependent on the type of deficiency involved. Finally, laboratories with a formal error detection plan had fewer deficiencies.

Humans↗

PubMed1996

Cervical biopsy-cytology correlation. A College of American Pathologists Q-Probes study of 22 439 correlations in 348 laboratories.

OBJECTIVE: To study the diagnostic correlation between cervical cytology specimens and corresponding surgical biopsies. DESIGN AND SETTING: College of American Pathologists Q-Probes laboratory quality improvement study in 348 laboratories. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive predictive value of cervicovaginal cytology diagnosis. RESULTS: Statistical analysis of 22 439 paired cervicovaginal cytology--cervical biopsy specimens reveals a sensitivity of 89.4%, specificity of 64.8%, and predictive value of a positive cytology of 88.9%. The majority of discrepancies were attributed to cytology or biopsy sampling errors. Routinely providing the patient's recent cervical cytology report to the surgical pathologist at the time the biopsy was examined resulted in improved sensitivity. Correlations for cytology specimens obtained at the time of biopsy revealed lower sensitivity and higher specificity than for those obtained at a time prior to the biopsy. CONCLUSIONS: We have defined current statistical expectations for cervical cytology-biopsy correlation, reasons for noncorrelation, and have provided recommendations for quality improvement.

Biopsy↗

PubMed1996

Is there still a need for the general surgical pathologist?

As the work of surgical pathologists becomes increasingly complex and specialized, we must ask whether there is still a need for the generalist. The answer to this question depends on a variety of factors within a given laboratory, including laboratory setting (service versus academic), specimen volume and composition, and level of staffing. The major advantages to maintaining staff expertise in general surgical pathology include flexibility of scheduling and improvement in the overall quality of diagnostic work. However, academic teaching departments inevitably require a higher level of subspecialization to accommodate research and teaching obligations. The advantages and limitations of maintaining staff expertise in general surgical pathology are discussed in light of the system that has evolved in the author's own hospital-based laboratory, in which expertise in general surgical pathology is required of all staff pathologists in addition to the development of expertise in one or more subspecialty areas. Current trends toward managed care will demand that most of us maintain our general skills. Failure to do so may lead to consolidation of services and elimination of jobs.

Humans↗

PubMed1996

[The role of the pathologist in the diagnosis and monitoring of Wilson's disease].

Wilson's disease (WD) is an inherited disorder of copper metabolism, characterized by copper accumulation in different organs. The clinical presentation of WD is variable: juvenile cirrhosis, with or without neurological symptoms, fulminant hepatitis, acute intravascular hemolysis or late onset with neurological or psychiatric symptoms. The histological picture, the histochemical stains and the ultrastructural findings of the liver are variable in WD. The recent cloning of the WD gene and the report of several mutations (at least 25) of the WD gene suggest the hypothesis that the clinical and pathological variability of this disease is related to a genetic polymorphism. These data may explain why the diagnosis of WD is often extremely difficult for the pathologist, since histochemical stains for copper may be highly variable or negative, despite increased levels of tissue copper concentrations. The most important pathological data are: 1) the evaluation of liver architecture, relevant in the staging of liver disease in three stages; 2) histochemistry for copper, which is variable and needs the use of multiple methods: Timm's method is probably the most useful one, since it shows copper deposits even in the first stage of WD, when liver changes are often reversible; 3) the determination of copper concentration may be crucial in WD diagnosis; copper levels exceeding 250 ug/g of dry tissue are considered diagnostic for the disease; 4) transmission electron microscopy shows, mainly in youngsters, mitochondrial changes considered typical of WD; the ultrastructural picture may be diagnostic for WD in cases with not specific histology and negative histochemical stains; 5) scanning electron microscopy after osmic maceration may be a new useful tool in the study of this liver disease: this technique may give both panoramic and high-power enlargements and allows the localization in the acinar zones of the intracellular hepatocytic changes. Finally, only the optimal approach to liver biopsy, obtaining the highest number of histological, histochemical, quantitative and ultrastructural data, may allow the pathologist to an early diagnosis of WD.

Biopsy, Needle↗

PubMed1977

[Locally and regionally limited breast cancer from the pathologist's view point].

The role of the pathologist in breast cancer is discussed from the practical viewpoint. For primary diagnosis surgical biopsy is preferred. Of prognostic significance are the size of the tumor and the number of regional lymph nodes affected. The different histological patterns have little prognostic bearing, with the exception of some rare special types such as medullary or mucinous carcinomas. Histological and/or cytological "grading" is too time-consuming for practical purposes. The pathologist is confronted with new problems by non-palpable "minimal breast cancer" detected by mass screening methods. The solution to these problems requires close interdisiplinary cooperation. In In the broad field of cystic diseases of the breast there is a need for a better histological definition of what constitutes a true premalignant lesion. Finally, the problems of multicentric and bilateral breast cancers are mentioned.

Breast Diseases↗

PubMed1997

The impact of homicide trials on the forensic pathologist's time--the Fulton County experience.

Subpoenas received for criminal trials related to homicides in Fulton County (Atlanta) Georgia were tracked in a computer database for an 18 month period in order to determine the proportion of forensic pathologist worktime required for testimony in homicide cases. The number of subpoenas received annually amounted to 64% of the average number of homicides occurring annually. Testimony was required in about 33% of cases in which a subpoena was received, and, therefore, the number of testimony appearances per year was about 21% of the average annual number of homicides. Assuming a 40 hour work week for 52 weeks per year and an average of 3 hours of time preparing for, traveling to, and testifying in court, the time required of the forensic pathologist to testify in homicide trials amounted to about 2% of a full-time-equivalent. Although the time required for testimony in homicide cases may vary among jurisdictions because of the nature of its homicides, distance and travel time to court, and other factors, the data presented here may be used to estimate the impact of homicide trial court time on forensic pathology practice.

Coroners and Medical Examiners↗

PubMed1997

The pathologist's workstation.

To leverage the time and expertise of the pathologist, a comprehensive workstation is a useful tool. Because the practice of pathology is so diverse, however, there is no one standard for what constitutes a workstation. The author reviews the several elements and components which must be included (access to your LIS, word processing, electronic mail, Web browser, literature search), and also reviewed are the many more which may be included, depending on the specialized needs of the practitioner (statistical analysis, ROC curves, image analysis, voice synthesis). It is, however, up to the pathologist to determine which of these components are required and to assemble them in as seamless a manner as possible.

Computers↗

PubMed1997

Changes in emergency department turnaround time performance from 1990 to 1993. A comparison of two College of American Pathologists Q-probes studies.

OBJECTIVE: To compare the results of a 1990 College of American Pathologists Q-Probes Emergency Department (ED) turnaround time (TAT) study with a similar study done in 1993 and to identify factors associated with TAT improvement. DESIGN: Participants gathered data over a 4-week period on the various times of day associated with the ordering, specimen-collection, laboratory-receipt, and result-reporting stages of stat tests for potassium and hemoglobin levels, using a mail-in questionnaire that also included practice parameter questions. PARTICIPANTS: Laboratories enrolled in the 1990 College of American Pathologists Q-Probes study on ED TAT and laboratories enrolled in the 1993 program ED TAT study. MAIN OUTCOME MEASURES: Components associated with shorter ED TAT and, for those participating in both the 1990 and 1993 studies, comparison with previous results. RESULTS: Six hundred fifteen hospital laboratories returned data on up to 43,521 hemoglobin and 41,989 potassium specimens. Half of these laboratories collected and reported 90% of their ED potassium results in 53 minutes or less, compared to 61 minutes or less in 1990, and reduced the corresponding median collection-to-reporting TAT for 90% of hemoglobin results from 46 minutes or less to 39 minutes or less. The fastest 10% of laboratories showed interlaboratory median order-to-report TATs of 36 and 50 minutes for potassium and hemoglobin tests, respectively. Comparisons of TATs from 277 laboratories with 1990 and 1993 data were possible. Components found to contribute statistically to improvement of ED TAT between 1990 and 1993 were laboratory control of specimen handling, rapid transport time, and monitoring. Active monitoring was particularly important when the laboratory did not control the specimen-handling process. CONCLUSIONS: Laboratories improved their control of ED TAT from 1990 to 1993 and reduced the number of TAT events exceeding 70 minutes. Internally set TAT goals, however, were not met most of the time.

Diagnostic Tests, Routine↗

PubMed1997

The implantable cardioverter-defibrillator. A potential hazard for autopsy pathologists.

The implantable cardioverter-defibrillator (ICD) is an implantable electronic device that has been proven to be safe and effective in treating various malignant tachyarrhythmias in susceptible individuals. As the use of ICDs becomes more widespread, more individuals with the implanted devices will be encountered at autopsy. Manipulation of an activated ICD can result in electrical shock. To avoid injury, pathologists must be properly prepared to deal with bodies containing activated ICDs. These devices can also provide valuable information that may be helpful in determining the cause and mechanism of death. Herein, we present information regarding the appropriate guidelines and safeguards for pathologists confronted with an activated ICD.

Accidents, Occupational↗

PubMed1998

Implantable cardioverter-defibrillators and the pathologist: comment and cautionary notes.

This paper briefly reviews the components of, the clinical uses of, the techniques to place, and the complications related to implantable cardioverter-defibrillators (ICDs). Information useful in the specific identification of ICDs is presented. A series of recommendations for the autopsy examination or postmortem explantation of ICDs by the pathologist is given. Because of the serious risk of injury to the pathologist possible with postmortem discharges of ICDs which have not been deactivated, and because of the risk of device explosion if the ICD is incinerated, a number of cautionary notes are provided. A brief case with occurrence of accidental postmortem discharge of an active ICD is also presented.

Accidents, Occupational↗

PubMed1976

Nonmediated use of MEDLINE and TOXLINE by pathologists and pharmacists.

Pathologists and pharmacists have used terminals in their departmental areas successfully to perform searches on MEDLINE and TOXLINE, during the period from fall 1974 through August 1975; MEDLINE has been used more than TOXLINE. In the Department of Pathology at the University of Maryland Health Sciences Center, the annual rate of combined mediated and nonmediated use of MEDLINE increased from 142 search sessions to 432, over half of the identified use being by three individuals. About half of the total potential users from each group tried MEDLINE or TOXLINE at least once. Nine pathologists and seven pharmacists used MEDLINE five or more times. Five of the individuals in each group were "intensive" users, who concentrated more than half of their sessions within two months. Vocabulary experience and systems problems are touched on. Most individuals learned to use the systems from one another or in individual sessions with the authors, although a twenty-five page "minimanual" has also been used by a limited group.

Information Systems↗

PubMed1997

Attitudes of a group of South African speech-language pathologists towards stutterers and stuttering therapy.

The present study aimed to examine the attitudes of a group of South African speech-language pathologists towards stuttering and stuttering therapy. Further aims were to investigate whether a stereotype of stutterers was found among these speech-language pathologists, and to determine whether there was any relationship between the attitudes held about stutterers, and the therapists' training and experience. A random probability sample of respondents was selected from the population of speech therapists registered with the Interim Medical and Dental Council of South Africa (I.M.D.C.S.A.). A self-administered mailed questionnaire was employed to realise the aims of the study. The main result of this investigation indicated that almost 50% of the sample of qualified clinicians surveyed, viewed stutterers as a group characterised by specific personality traits and psychological problems. This belief held true irrespective of the number of years of experience working in the field, the time of graduation, the frequency of treating stutterers, or the training emphasis. Implications of these results are considered with respect to student training, continuing education of qualified practitioners and future research.

Adult↗

PubMed1998

Extension of useful reagent shelf life beyond manufacturers' recommendations. Cell Markers Committee of the College of American Pathologists.

OBJECTIVE: The College of American Pathologists Cell Markers Committee designed a study to evaluate the use of immunohistochemistry primary antibodies beyond manufacturers' recommended dates. METHODS: Pathologists were asked to save aliquots of primary antibodies during mid-1997 so that by spring 1998 the reagents would be "outdated" according to manufacturers' recommendations. Three tumors were immunostained both in mid-1997 and early 1998 (using outdated reagents in 1998). Two hundred twenty-one laboratories participated. PATIENT SAMPLES: Immunostained materials consisted of an angiomyolipoma immunostained for muscle-specific actin and HMB-45, a melanoma immunostained for S100 protein and HMB-45, and a large cell lymphoma immunostained for common leukocyte antigen and HMB-45. Blocks from the same tumor were used in each instance. MAIN OUTCOME MEASURE: We compared the immunostaining results as a percentage of laboratories indicating a positive or negative immunohistochemical result between the 1997 and 1998 time points. RESULTS: Only minor differences were identified for the 221 reporting laboratories in 1998 as compared with those in 1997. CONCLUSIONS: The data suggest review of the Health Care Financing Administration's ruling on extending the useful reagent shelf life beyond manufacturers recommendations. Similar studies using more inherently quantitative methodology are suggested.

Antibodies↗

PubMed1998

Practice guideline for forensic pathology. Members of the Forensic Pathology Committee, College of American Pathologists.

The guideline for forensic pathology was prepared by the Forensic Pathology Committee of the College of American Pathologists. The definitional criteria for forensic pathology included in this guideline have been approved both by the House of Delegates and the Board of Governors of the College of American Pathologists. The guideline presents an overview of forensic pathology and an approach to the forensic autopsy and medicolegal death investigation. Emphasis is placed on the role of forensic pathology in maintaining public health, welfare, and safety. The guideline is intended to serve as an educational tool, and its use should be determined by the individual circumstances and settings of specific cases.

Autopsy↗