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Because the inclusion of the speech-language pathologist in a burn management team is not widely practiced, we discuss our successes as members of a burn team. We also review speech-language evaluation and treatment strategies and present two patients with head and neck burns who gained from our intervention.
Patients with ulcerative colitis are at an increased risk of developing dysplasia and carcinoma. The histologic recognition of dysplasia arising in this setting, particularly when patients have active colitis, can be challenging. However, even if it is clear that the patient has dysplasia, further challenges include the distinction of low-grade dysplasia from high-grade dysplasia and the distinction of an inflammatory bowel disease-related dysplastic lesion from a sporadic adenoma. This review article will summarize some of these issues from the gastrointestinal pathologist's perspective.
The aims of this study were twofold: (1) to test the ability of parents and teachers to discriminate the speech of children with repaired cleft palate from that of their unaffected peers and (2) to compare these lay assessments of speech acceptability with the critical perceptual assessments of expert clinicians. The subjects for this study were 20 children of school age (age range, 8 to 12 years) who were drawn from a large population (n = 1282) of patients. All subjects had been referred for palatoplasty to the same tertiary cleft center between 1978 and 1991. There were 16 matched controls. The listening team included parents of subjects (n = 32) and teachers of age-matched school children (n = 12). Randomized master audiotape recordings of the study group were presented in blinded fashion to both groups of the adult raters, who were inexperienced in the evaluation of patients with speech dysfunction. An experienced panel of three extramural speech pathologists evaluated the same recordings. In all parameters rated, both parents and teachers showed a consistent tendency to give the subject children more negative ratings than the control children. Expert raters were sensitive to differences in resonance and intelligibility in the control and cleft palate groups. Results of this study differ from similar previous research, indicating that naive peer raters (similar-age children) were insensitive to speech differences in the cleft palate and control groups.
In this paper, we review the histological features of coeliac disease and propose a standardized report scheme based on the Marsh classification. Furthermore, terms used by pathologists are defined. The most important histological differential diagnoses are given, as well as a definition of the different clinical forms of coeliac disease such as symptomatic, silent, latent, potential, treated and refractory coeliac disease.
The diagnosis of Barrett's oesophagus has traditionally relied on the identification of a 3-cm segment of endoscopically abnormal epithelium (columnar) in the distal oesophagus. More recently, the presence of intestinal metaplasia has become essential. The importance of the definition relates to the identification of the risk of cancer development. These factors are discussed in the context of the rising incidence of adenocarcinoma, and the relative contributions of endoscopists and pathologists in determining likely progression are explored. We also discuss the advances in endoscopic technology that may aid the endoscopist in predicting malignant progression.
Ideally, the bone marrow core biopsy should be reviewed with knowledge of the clinical history, complete blood count, and findings in the peripheral blood and bone marrow aspirate smears. However, for a variety of reasons, the pathologist may receive the core biopsy and aspirate clot section without all of this information. Although this approach is not optimal, a great deal of valuable information can be generated from these specimens. Over the past 20 years, there has been considerable progress in the fields of flow cytometric analysis, immunohistochemistry, and molecular diagnostic studies that can be performed on smears or extracted DNA from paraffin embedded tissue. These modalities have augmented and refined diagnostic criteria formerly ascertained by light microscopy, cytochemistry, and cytogenetics. This is particularly true of some myeloid and lymphoreticular neoplasms where a collaborative and multidisciplinary approach to the diagnosis has become necessary. Despite this growing complexity and dependence on newer methodologies, the traditional role of histopathology in evaluating the bone marrow biopsy remains as important as it has been in the past. In this review, we focus on contemporary practices and expectations for interpreting bone marrow biopsies and clot sections.
Oral developmental, reactive, benign neoplastic and malignant neoplastic conditions, many odontogenic in origin, may not be seen routinely by the general surgical pathologist and therefore may present a diagnostic dilemma. This article describes odontogenic and nonodontogenic conditions with little or no destructive potential along with the more aggressive conditions that resemble them clinically and histologically. The importance of clinical and radiographic correlation as an adjunct to tissue diagnosis is highlighted. Additionally, a brief summary of odontogenesis is presented with attention given to odontogenic embryologic remnants and the developmental and pathologic processes that may arise from them.
For many years the paradigm of coronary atherosclerosis, set by pathologists, was the far-advanced lesion containing extensive atheromatosis with calcifications. From the point of view of understanding atherogenesis, however, it is much more rewarding to study the coronary artery in patients without clinical evidence of obstructive coronary artery disease. In fact, the normal coronary artery is most revealing in showing discrete intimal changes, which consist of a splitting of the internal elastic lamina accompanied by a proliferation of vascular smooth muscle cells. This process eventually results in the formation of the musculo-elastic layer. In time the cellular and muscular appearance of this layer gradually transforms into a more densely packed fibrous texture. It is of interest, from a point of view of atherogenesis, that the early atherosclerotic lesions often display the histologic features of the musculo-elastic layer at the base of the plaque. Hence, these observations support the concept that the basic lesion in coronary atherosclerosis is a proliferation of vascular smooth muscle cells, most likely as a response to injury. To this extent a dysfunction of the endothelial cell barrier may by crucial. The observations also indicate that the mechanisms involved in atherogenesis also may alter vascular tone and hence, may contribute to a "spastic state" of the coronary arteries. A classification of angina pectoris, on the basis of pathogenesis into organic and spastic may thus prove to be simplistic.
The results of the diagnostic accuracy of breast fine needle aspiration specimens taken by the pathologist in a joint surgical clinic are compared with those taken by a surgeon. In the joint clinic the complete sensitivity rose by 15% and the number of missed malignancies fell by half.
An improved method of analysing interobserver variation in histopathological studies is described and illustrated, by use of data from a congruence survey of malignant melanoma. The method provides, between any number of pathologists, an assessment of overall agreement and of agreement on each individual category of a classification system. Adjustment for differences in chance agreement due to varying numbers of categories or an altered composition of cases is included in the analysis. A generalization of the procedure designed to measure the strength of associations between different categories is formulated and explained with the use of an example.
Inter-observer variation between six pathologists in their application of histological classifications during a survey of cutaneous malignant melanoma was analysed using kappa statistics. The highest levels of adjusted agreement were attained for tumour thickness and the presence of ulceration; intermediate levels were achieved on cross-sectional profile, level of invasion, histogenetic type, solar elastosis and the presence of an associated benign melanocytic lesion; agreement on other histological features of melanoma tended to be relatively poor. The problems experienced in the interpretation of these classifications are discussed and suggestions for their improvement are offered.
Perce, a promising young trainee pathologist, correctly recognizes a biopsy of a benign pseudosarcoma but his diagnosis is overruled by the less well read Head of Pathology. Acting under instructions from his Chief, Perce knowingly and without protest 'signs out' this benign condition as a sarcoma. The surgeon accepts the diagnosis without question and performs radical surgery, which is complicated by postoperative haemorrhage from which the patient dies. The Coroner orders a review of the slides and the misdiagnosis is discovered. Perce's defense that he did as he was told is rejected; he is forced to quit pathology and becomes an administrator. This unfortunate tale, which is related in verse, is intended to stress the importance of such benign but uncommon pseudosarcomas as nodular fasciitis, proliferative myositis, myositis ossificans, postoperative spindle cell nodule, pseudosarcoma of the bladder and juxta-articular myxoma. The poem also implies that surgeons should not carry out radical surgery based on an uncommon pathological diagnosis without checking on the adequacy of consultation and informed review of the sections.
The spectrum of histopathologic changes in four cases of chronic recurrent multifocal osteomyelitis encountered in our orthopedic outpatient clinic in the past 3 years was studied in conjunction with clinical and radiologic findings. All presented with pain with or without swelling in the affected region. Radiographically, the appearance of the lesions varied from a mixed picture of bone lysis and sclerosis with expansion to sclerosis alone to bone collapse. Bone scintigraphy demonstrated asymptomatic and separate foci of activity in all cases. Prior to biopsy, the clinical and radiologic differential diagnoses included Ewing's sarcoma, metastatic neuroblastoma, hematolymphoid malignancy, Langerhans cell histiocytosis and chronic infection, notably tuberculosis. The spectrum of histopathologic changes ranged from acute (acute inflammatory infiltration, active bone resorption and necrosis, reactive bone formation) to subacute (predominantly lymphocytic and plasma cell infiltration) to chronic inflammation (fibroblastic organization and bony sclerosis). Histologic changes correlated poorly with clinical features, but relatively well with radiologic findings. Lesional excision was performed in one case, cortical saucerization in another, while the final two cases received supportive treatment. All remained well 18-21 months post-therapy. Chronic recurrent multifocal osteomyelitis is a great clinical and radiologic mimic, which merits recognition by the pathologist. Awareness of the spectrum of histologic features encountered enables a correct diagnosis to be made in the appropriate clinical setting. The patient can thus be reassured of a favorable prognosis.
OBJECTIVE: To elucidate the effectiveness of the collaboration of a dentist and speech-language pathologist (SLP) in the rehabilitation of a stroke patient with dysarthria. DESIGN: A clinical case report treated in the rehabilitation hospital and dental surgery. SUBJECT: A 71-year-old Japanese man who was admitted to the rehabilitation hospital for speech rehabilitation 2 years and 5 months after a stroke. METHODS: Provision of prosthesis (palatal lift prosthesis + palatal augmentation prosthesis) for improving velopharyngeal incompetence (VPI) and articulation by dentist, and speech behavioural management by SLP including self-monitoring and bio-feedback training using the See-Scape. RESULTS: Speech behavioural management proved useful for promoting improvement in speech intelligibility to a functionally sufficient level after improving VPI by prosthesis. CONCLUSION: The collaborative efforts of the dentist and SLP in the rehabilitation of post-stroke patients with velopharyngeal incompetence should be encouraged.
In the College of American Pathologists (CAP) rubella survey program, 45% of laboratories rely on the latex agglutination (LA) card assay for detecting rubella immunoglobulin G (IgG) antibodies. By using CAP survey data over a 3-year period, we compared LA results with hemagglutination inhibition (HI) and enzyme immunoassay (EIA) results. EIA indices were used to classify results into three categories: nonimmune, EIA index of 0.300 or less; borderline, EIA index of 0.300 to 0.619; and immune, EIA index of 1.700 or greater. There was 91% or more agreement between LA, HI, and EIA for categories i and iii. In category ii, the response from LA users varied, depending on the level of antibody present in the survey samples; at an EIA index of 0.346, 81% reported nonimmune status, whereas at an EIA index of 0.619, 48% reported nonimmune status. Less than 10% indicated borderline status. In testing of samples in the same category, approximately 40%, using the HI method, reported titers of less than 1:8 (nonimmune status). Among EIA users, 97 to 99% regarded the specimens as nonimmune. On analysis of specimens in the borderline category, the LA test showed a pattern of sensitivity and specificity comparable to that reported with the HI technique, whereas the EIA method showed a greater degree of precision. The LA card assay provides a rapid screening test in which LA is read macroscopically, and the procedure differs considerably from the fully quantitative HI and EIA methods.(ABSTRACT TRUNCATED AT 250 WORDS)
Participants in the College of American Pathologists' Mycobacteriology E proficiency testing survey in 1993 were asked to complete a questionnaire addressing mycobacterial test methods, test volume, and frequency of detection of drug-resistant Mycobacterium tuberculosis (MTB). A similar questionnaire had been distributed in 1992. The population responding to the 1993 questionnaire changed, because of a shift of small hospitals to the limited Mycobacteriology E1 survey, and the format of some questions was altered, so a direct comparison of 1992 and 1993 responses was not always possible. Among participants who answered the questions in both years, there was a significant increase in the use of the fluorochrome stain (57% in 1992, 61% in 1993), BACTEC TB for culture (34% in 1992, 38% in 1993) and susceptibility testing (51% in 1992, 61% in 1993), and DNA probes for identification (30% in 1992, 51% in 1993). The percentage of participants who processed respiratory specimens at least seven times per week increased from 9% in 1992 to 13% in 1993, and the percentage processing five times per week increased from 68 to 72%. The percentage of respondents who reported an identification of MTB within 21 days of specimen receipts and susceptibility test results within 28 days in 1992 and 1993 increased from 30 to 41% and from 12 to 19%, respectively. In regard to resistant MTB, 177 institutions in 1991 and 291 in 1992 reported resistance to isoniazid, and 114 in 1991 and 187 in 1992 reported resistance to both isoniazid and rifampin. Laboratorians are to be applauded for using the more rapid mycobacterial testing methods; however, given that tuberculosis remains a problem, this trend must continue.
In 1991, we reported that 55% of laboratories participating in the Wisconsin Proficiency Testing Program could not accurately identify serum samples from Lyme disease patients containing antibody against Borrelia burgdorferi. The purpose of this study was to determine whether the accuracy of Lyme disease test results reported by approximately 500 participants in the Wisconsin State Laboratory of Hygiene/College of American Pathologists Lyme Disease Survey had improved. From 1992 through 1994, 50 serum samples were sent to participants of the survey. Each laboratory received 28 serum samples from individuals with Lyme disease according to the case definition of the Centers for Disease Control and Prevention and 22 serum samples from healthy individuals. Unfortunately, the serodiagnosis of Lyme disease by participants had not improved. The specificity of the Lyme disease assays steadily decreased from approximately 95% to approximately 81% during the 3-year period of the survey. False-positive test results approached 55% with some of the serum samples from healthy donors. A serum sample containing antibody against Treponema pallidum was reported as positive by 70% of the participants. In addition, the sensitivity fluctuated between 93 and 75%, depending upon the conjugate used by the laboratories. These results suggest that stronger criteria must be applied for approving and continuing to approve commercially available kits for the serodiagnosis of Lyme disease.
Pathologists all over the world increasingly encounter prosthetic cardiac devices. A good evaluation of these devices is a valuable source of information, which can contribute to patient care and the appreciation and understanding of the pathobiology involved in the changes occurring between the host and the implanted prosthetic device. This article summarises the considerations underlying the analysis of prosthetic devices (particularly prosthetic heart valves), including the identification of the devices, the major morphological features of the devices, their modes of failure, and some technical details about evaluation and pitfalls.