bluuebunny/crossref_metadata_2025 huggingface dataset:
Calcification Propensity in Serum and Cardiovascular Outcome in Peripheral Artery Disease
Authors: Bojic Marija , Bielesz Bernhard , Cejka Daniel , Schernthaner Gerit-Holger , Höbaus Clemens
Published: October 2021

Peripheral artery disease (PAD) has been shown to be linked to elevated cardiovascular risk. The novel T50 test quantifies calcification propensity of serum and has been associated with cardiovascular events and mortality in patients with chronic kidney disease (CKD) and in the general population. This study investigated the association of calcification propensity measured by the T50 test in 287 patients with PAD without severe CKD. Major cardiovascular events (MACEs) including nonfatal stroke and nonfatal myocardial infarction and all-cause death (MACE + ) were evaluated after a median follow-up of 4 years and long-term cardiovascular and all-cause mortality after a median follow-up of 8.7 years by Kaplan–Meier and Cox regression analyses. Mean T50 time was 268 ± 63 minutes in the study cohort (age 69 ± 10 years, 32% women, 47% diabetes). Low T50 values that signify high calcification propensity were significantly associated with the occurrence of MACE+ (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.55–0.94). This association sustained multivariate adjustment for cardiovascular risk factors (CVRFs), Fontaine PAD stage, and prevalent media sclerosis (HR: 0.65; CI: 0.47–0.91). Cardiovascular mortality was significantly associated with T50 after multivariate adjustment for CVRF (HR: 0.72; CI 0.53–0.99), but not all-cause mortality (HR: 0.80; CI: 0.64–1.01). In conclusion, calcification propensity associates with MACE+ and cardiovascular mortality in patients with PAD.
Autoimmune Hemolytic Anemia Due to Spondyloenchondrodysplasia with Spastic Paraparesis and Intracranial Calcification due to Mutation in ACP5
Authors: Aylan Gelen Sema , Kara Bülent , Eser Şimsek Isil , Güngör Mesut , Zengin Emine , Sarper Nazan
Published: November 2021

Spondyloenchondrodysplasia (SPENCD) is a rare spondylometaphyseal skeletal dysplasia with characteristic lesions mimicking enchondromatosis and resulting in short stature. A large spectrum of immunologic abnormalities may be seen in SPENCD, including immune deficiencies and autoimmune disorders. SPENCD is caused by loss of tartrate-resistant acid phosphatase activity, due to homozygous mutations in ACP5, playing a role in nonnucleic-acid-related stimulation/regulation of the type I interferon pathway. In this article, we presented a 19-year-old boy with SPENCD, presenting with recurrent autoimmune hemolytic anemia episodes since he was 5 years old. He had short stature, platyspondyly, metaphyseal changes, intracranial calcification, spastic paraparesis, and mild intellectual disability. He also had recurrent pneumonia attacks. The clinical diagnosis of SPENCD was confirmed by sequencing of the ACP5 gene, and a homozygous c.155A > C (p.K52T) variation was found, which was reported before as pathogenic. In conclusion, in early onset chronic autoimmune cytopenias an immune dysregulation may often have a role in the etiology. Associating findings and immunologic functions should be carefully evaluated in such patients in the light of the literature. The present case shows the importance of multisystemic evaluation for the detection of SPENCD that has a monogenic etiology.
Wound Complications with Multiple Wrist Incisions in Distal Radius Reconstruction
Authors: Meaike Joshua J. , Athens Christian , Sgromolo Nicole , Shin Alexander Y. , Rhee Peter C.
Published: October 2021

Background Placement and spacing of skin incisions are important for maintaining soft tissue perfusion and viability, particularly in the setting of local trauma.

Question/Purpose The aim of this article is to determine if multiple skin incisions in the surgical management of distal radius fractures result in an increased risk of postoperative wound complications, particularly in the setting of high-energy mechanisms of injury with substantial initial displacement and associated soft-tissue insult that require multiple incisions for distal radius reconstruction.

Patients and Methods A multicenter, retrospective chart review was performed for all adult patients who underwent open reduction, internal fixation of a closed distal radius fracture with multiple (≥2) hand, and wrist incisions with minimum follow-up of 6 weeks. Primary outcome measures included wound healing complications such as partial or complete skin necrosis, dehiscence, delayed healing, and superficial or deep infections.

Results For 118 wrists, a total of 305 incisions were utilized, averaging 2.6 incisions per patient (range: 2–6) with the flexor carpi radialis and dorsal distal radius approaches occurring in 86 and 78% of cases, respectively. One patient was identified as having a pyogenic granuloma along an incision. However, two patients were identified as having wound concerns, including fracture blisters (n = 1) and wound margin epidermolysis (n = 1) along the incision. There were no cases of skin bridge necrosis, delayed healing, wound dehiscence, or infection.

Conclusions There is no increased risk of wound healing complications with the use of multiple skin incisions (≥2) in the surgical management of distal radius fractures, afforded by the abundant and robust angiosomes around the wrist. Surgeons should have the confidence to utilize the necessary number of skin incisions to effectively reconstruct distal radius fractures.
Sticks and stones might break your bones, but bioengineered environments could regrow them
Authors: Johnson-Groh Mara
Published: November 2021

A review of bone microenvironments summarizes current strategies and applications for bone regeneration.
Fertilization potential of cold-stored Fowler’s toad (
Authors: Arregui Lucia , Kouba Andy J. , Germano Jennifer M. , Barrios Laura , Moore Marian , Kouba Carrie K.
Published: October 2021

Asynchrony of gamete release is problematic in amphibian captive breeding programs but can be overcome by short-term storage of spermatozoa. Hormonally induced sperm from the model species Anaxyrus fowleri were used to determine storage conditions for optimal fertilisation capacity. Sperm motility was measured over time, as a function of storage temperature (4°C or 22°C) and solution osmolality (7–40 mOsm/kg). Sperm at 40 mOsm/kg (spermic urine) stored at 4°C exhibited higher motility compared to 22°C. Also, sperm stored at 40 mOsm/kg retained higher motility compared to sperm stored below 15 mOsm/kg at both temperatures. Under optimal storage conditions (40 mOsm and 4°C) a 30% decrease in sperm motility occurred within 24 h, however, subsequent loss of sperm motility was lower (<10%/day) for days 2–8 thereafter. Sperm samples stored for 1–8 days under optimal conditions were tested for fertilising capacity by conducting in vitro fertilisation trials. Sperm stored for 8 days yielded 48% neurula development, similar to sperm stored for 1 day, which produced 60% neurula development. Overall, sperm stored for up to 8 days at 4°C as spermic urine retained fertilising capacity and thus can be used to circumvent asynchronous gamete release in assisted breeding efforts for amphibians.
Pregnancy prevention and unintended pregnancy across gender identity: a cross-sectional study of college students
Authors: Reynolds Colleen A. , Charlton Brittany M.
Published: November 2021

Using data from the Fall 2015 through Spring 2018 National College Health Assessment, we examined receipt of pregnancy prevention information and unintended pregnancy by gender identity among participants aged 18–25 years who were assigned female at birth (n = 185 658). Non-binary students were more likely than cisgender students to report wanting (adjusted risk ratio [ARR]: 1.12; 95% CI: 1.08–1.16), receiving (ARR: 1.09; 95% CI: 1.04–1.13), and having an unmet need for (ARR: 1.10; 95% CI: 1.02–1.19) pregnancy prevention information from their school. Transmasculine students did not significantly differ from cisgender students for these outcomes. Non-binary and transmasculine students were as likely as cisgender students to have a past-year unintended pregnancy. Non-binary and transmasculine young people are at risk for unintended pregnancy and need access to comprehensive sexual education, reproductive health counseling, and care.
Performance behavior of pocketed journal bearing employing non-newtonian lubricant
Authors: Bhardwaj Vivek
Published: November 2021

This paper reports the improvement in the performance behaviors of non-Newtonian fluid lubricated journal bearings employing a rectangular pocket. Coefficient of friction and load carrying capacity of pocketed and non-pocketed bearings are reported and discussed. In the numerical approach, non-Newtonian behavior of lubricant is simulated employing the power law model. Various cases of bearings having different axial length to diameter ratios [(L/D) in the range 0.5–2.0] are considered. Lubricants of different rheology viz. pseudoplastic, Newtonian and shear thickening were employed for lubricating the bearings. Rheology of lubricant is controlled by varying the power law index n in the range 0.9–1.1. Based on the investigation, it is found that the pocketed bearing yields significantly reduced coefficient of friction and higher load carrying capacity in comparison to the non-pocketed bearing. Also, the performance of pocketed bearing improves with the increase in the power law index. Best performance of the pocketed bearing is observed for the bearing having L/D value of 0.5 at high eccentricity ratio when lubricated with the shear thickening fluid (n=1.1).
Mapping cell-to-cell mitochondria transfer in obesity using high-dimensional spectral flow cytometry
Authors: Borcherding Nicholas , Moley John , Field Rachael , Brestoff Jonathan R
Published: October 2021

Obesity is a metabolic disease that promotes the development of a number of other pathologies. Despite its high disease burden, the underlying pathophysiology of obesity is poorly understood. Emerging research has indicated that adipocytes transfer their mitochondria to macrophages in white adipose tissue as a mechanism of cell-to-cell communication and that this process is impaired in obesity. However, the diversity of intercellular mitochondria transfer axes that occurs in adipose and its regulation in obesity are not known. Here, we utilized 31-color spectral flow cytometry of adipocyte-specific mitochondria reporter (MitoFat) mice to comprehensively analyze intercellular mitochondria transfer from adipocytes to other cell types in white, beige, and brown adipose tissues. Employing manifold machine learning, we generated reference clusters of cells in 5-month (young) and 20-month-old (aged) MitoFat mice fed a normal chow diet (low fat diet). Using the reference clusters and manifold, we then mapped differences in immune cell populations using nearest neighbor search approximations in MitoFat mice fed normal chow, high-fat diet (HFD), high-fat diet with low palmitate (LP-HFD). The degree of mitochondria transfer from adipocytes to each of the various cell clusters was determined for each tissue and for each condition. We observed that adipocytes transfer their mitochondria to a wide range of immune cell populations, most notably macrophages. Although aged mice develop obesity, surprisingly they do not exhibit decreased mitochondria transfer from adipocytes to macrophages in vivo in white, beige, or brown adipose tissue. In contrast, young mice fed a HFD highly enriched in palmitate exhibit obesity and markedly reduced mitochondria transfer from adipocytes to macrophages. The decrease in mitochondria transfer was largely ameliorated by the replacement of palmitate with medium chain fatty acids, suggesting a potential direct dietary mechanism in the alteration of mitochondria transfer. Overall, the 31-color quantification increased granularity, allowing us to quantify differences in immune populations and mitochondria transfer by tissue, age, and diet. Similar machine-learning approaches could be used to investigate both basic biological and clinical questions by effectively reducing dimensions, mitigating batch effect, and enabling comparisons across different tissues, timepoints, or conditions.
Development and Validation of a Liquid Chromatography Mass Spectrometry Method for Simultaneous Measurement of 25-OH D3, epi-25-OH D3, 25-OH D2, Vitamin A, α-Tocopherol, and γ-Tocopherol
Authors: Xiao Yi , Leung Edward
Published: October 2021

Background

Circulatory fat-soluble vitamin levels are commonly measured to identify deficiencies that may lead to rickets, osteomalacia, night blindness, and reversible motor and sensory neuropathies. We developed and validated a rapid and robust LC-MS/MS method that simultaneously measures 25-OH D3, epi-25-OH D3, 25-OH D2, vitamin A, α-tocopherol, and γ-tocopherol for clinical use.

Method

100 µL of serum was mixed with isotope-labeled internal standard and extracted using a 96-well supported-liquid extraction plate with 1.5 mL of hexanes/isopropanol (90/10) (v/v). Dried eluate was reconstituted with 100 µL of methanol/water (90/10) (v/v) and analyzed by LC-MS/MS with a 10-minute gradient. Accuracy was assessed using NIST Standard Reference Materials SRM972a and SRM968f, patient comparison analysis with a LC-MS/MS method at a reference lab, and spike-recovery studies using patient sera and vitamin D-depleted serum. Analytical measurement range (AMR) was determined by spiking 6 analytes into vitamin D-depleted serum to give 7 specimens at varying concentrations. The lower limit of the measuring interval (LLMI) was assessed using 6 pooled specimens with varying low concentrations of each analyte over 20 days. Precision (repeatability and reproducibility) was assessed using quality control materials. Interference studies were performed using pooled patient specimens spiked with varying concentrations of hemoglobin, bilirubin, or intralipid. Matrix effect was assessed by post-column infusion and by matrix dilution with saline.

Results

The method was linear covering physiological concentrations with r2 > 0.99. Repeatability and reproducibility were <15% CV at all QC levels. LLMI for 25-OH D3, epi-25-OH D3, 25-OH D2, vitamin A, α-tocopherol, and γ-tocopherol were 4 ng/mL (15% CV), 4 ng/mL (15% CV), 4 ng/mL (18% CV), 1 µg/dL (20% CV), 0.2 µg/mL (20% CV), and 0.2 µg/mL (8% CV). Recoveries for NIST Standard Reference Materials were between 92 - 111% and between 81 - 122% for spike-recovery studies. Passing-Bablok analyses for vitamin D total, vitamin A, and α-tocopherol demonstrated slopes between 1.04 and 1.11 and r2 between 0.94 and 0.96. Minimal matrix effect was observed.

Conclusions

We have developed and validated a comprehensive and rapid LC-MS/MS method for the simultaneous measurement of 25-OH D3, epi-25-OH D3, 25-OH D2, vitamin A, α-tocopherol, and γ-tocopherol for clinical use.
Identifying unnecessary duplicate genetic testing in a large medical center
Authors: Lee Edward , Goldstein D Yitzchak , Naeem Rizwan
Published: October 2021

Introduction

Genetic testing has become ubiquitous in clinical medicine and plays an important role in making diagnoses and guiding treatment plans. Indiscriminate use of these tests can cause duplicate testing, which is typically not indicated because results from repeated constitutional molecular genetic testing should not change over time. Thus, duplicate genetic testing often represents inappropriate test utilization that can contribute an unnecessary burden on the laboratory and health care system.

Objective

The purpose of our study is to determine the incidence of duplicate testing of in-house genetic testing offered at a large medical center, which includes cystic fibrosis, factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase (MTHFR) C677T, and MTHFR A1298C, and to develop a tool to identify and block duplicate testing.

Methods

We retrospectively analyzed internal laboratory databases of all cystic fibrosis (n = 36164), factor V Leiden (n = 3264), prothrombin G20210A (n = 2890), MTHFR C667T (n = 1451), and MTHFR A1293C (n = 1290) testing performed at the molecular pathology laboratory at a large medical center from either January 2010 or January 2014 to July 2019. We analyzed and cleaned the databases with the R programming language, and we developed a prototype web-based app to proactively identify duplicate test requests with the Shiny R package.

Results

From January 2010 to July 2019, 3535 (9.8%) of the 36164 cystic fibrosis tests performed were duplicate tests for 3257 unique patients. Of these duplicate cystic fibrosis tests, 2997 were repeated once in the same patient, 244 were repeated twice in the same patient, 14 were repeated three times in the same patient, and 2 were repeated four times in the same patient. From January 2014 to July 2019, 99 (3.0%) of the 3264 factor V Leiden tests, 86 (3.0%) of the 2890 prothrombin G20210A tests, 49 (3.4%) of the 1451 MTHFR C667T, and 46 (3.6%) of the 1290 MTHFR A1298C tests performed were duplicate tests.

We developed a proof-of-concept Shiny web-browser app that provides a user-friendly interface to determine if a patient has been previously tested in the molecular pathology lab. This app operates locally on a laboratory computer and uses spreadsheets automatically exported from the electronic medical record. These features allow for the app to be deployed quickly without needing to be integrated into the electronic medical record.

Conclusions

The results of this study indicate that unnecessary duplicate testing represents a small but significant proportion of genetic testing performed by the molecular pathology laboratory. Duplicate testing occurred more frequently with cystic fibrosis testing, which reflects its high volume at the medical center. Deployment of web-based apps using Shiny can provide straightforward and efficient tools for reducing duplicate tests.
Evaluating the reference range of a new high-sensitivity troponin assay using retrospective review of laboratory data
Authors: Reinhart Alexandria , Mathias Patrick , Hoofnagle Andrew
Published: October 2021

Rapid diagnosis of myocardial infarction (MI) in the emergency department (ED) is critical for proper patient management and optimal patient outcomes. High-sensitivity plasma troponin assays may help identify cardiac injury sooner by having better analytical sensitivity. When our institution first adopted the Beckman-Coulter high-sensitivity troponin I assay (hsTnI), cardiologists were hesitant to use the upper reference limit (URL) provided by the manufacturer (< 0.0136 ng/mL for female patients, < 0.0198 ng/mL for male patients), due to concerns regarding assay specificity at the URL. To help transition to the new high-sensitivity assay and its potential benefits, we began using the new hsTnI assay, but maintained the URL of the previous automated immunoassay, which was based on the 99th percentile of a healthy population (< 0.04 ng/mL = negative; 0.04 - 0.4 ng/mL = suspected MI, above the 99th percentile; > 0.4 ng/mL = likely MI). The purpose of the current study was to assess the suitability of the manufacturer’s URL for the new hsTnI assay for our health system’s patient population. To do this, we extracted patient encounter ICD-10 diagnosis codes, diagnosis-related groups (DRGs), and hsTnI results from our institution’s enterprise data warehouse and the laboratory information system for patients seen between Jan 2, 2020 and Aug 31, 2020. We included all patients who presented to the ED and received hsTnI testing. Each patient encounter was subsequently categorized as having MI or no-MI, based on diagnosis codes and DRGs. The first troponin test for each encounter was selected for analysis. The URL recommended by the manufacturer identified 92% and 100% of female and male patients with MI, respectively. Furthermore, 5.1% of 1947 female patients without MI and 9.9% of 1976 male patients without MI were above the manufacturer’s URL (female = 0.0136 ng/mL; male = 0.0198 mg/mL) but below 0.04 ng/mL. These results are lower than the false-positive rate of 12% observed in a separate study cited by the assay manufacturer. These data suggest that the manufacturer’s range is applicable to our patient population.
Why get tested? Linking Intentions for Seeking SARS-CoV-2 Testing with RT-PCR Results and Cycle Threshold Values at Community Testing Sites
Authors: Laitman Andrew , Greninger Alex , Mathias Patrick , Hoffman Noah
Published: October 2021

During the SARS-CoV-2 pandemic, community-based testing sites have provided free COVID testing to millions of people who would have otherwise faced substantial barriers. In one metropolitan area, over 700,000 tests were performed from September 2020 through February 2021. To make appointments online, people not only provided basic demographic information such as age, gender, and address but also free-text reasons for seeking testing. We sought to examine how reason for testing, coded as free text, in combination with other collected demographic information, correlated with rates of SARS-CoV-2 positivity and measures of infectiousness such as the Real-Time Polymerase Chain Reaction (RT-PCR) Cycle Threshold (Ct) value. Data from the scheduling software used to coordinate the on site testing workflow was extracted and linked to SARS-CoV-2 PCR assay metadata stored in a laboratory data warehouse, including Ct values. We categorized individual text responses into 3 separate categories: symptomatic, exposed but asymptomatic, and asymptomatic without exposure. Symptomatic individuals were identified based on the presence of common keywords and phrases like “symptom”, “fever”, “cough”, and “sore throat.” Similarly, exposed individuals were identified by keywords such as “exposed”, “exposure”, and “roommate.” All others were categorized as asymptomatic. We found that symptomatic individuals had the highest frequency of testing positive at 11.6% (21,150/181,868). Exposed individuals and asymptomatic individuals had lower rates of detection with frequencies of 7.4% (10,266/138,721) and 4.9% (8,987/185,026) respectively. Repeat testing represented 29.9% of the results and positivity rates were calculated using the first result for each individual. In addition, among those who tested positive, symptomatic individuals exhibited the lowest average Ct values, while those who are asymptomatic exhibit the highest average Ct values. Among those who self-reported duration of symptoms, recent onset of symptoms was strongly correlated with lower Ct values. Across more than 700,000 results, self-reported symptomatic people, based on free text responses, have a higher likelihood of testing positive for SARS-CoV-2. People who claim a more recent onset of symptoms are more likely to exhibit higher concentrations of viral RNA.
Comparative Evaluation of Three Serologic Assays for the Identification of SARS-CoV-2 Antibodies
Authors: Hogan Keenan , Klippel Dave , Plapp Fred , Liesman Rachael
Published: October 2021

Serologic assays for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies continue to be developed and approved rapidly with limited external validation. Accurate diagnostics are an essential component of pandemic management and public health. Residual serum samples (N=113) from patients who were evaluated for SARS-CoV-2 infection status by polymerase chain reaction (PCR) were retrospectively tested in parallel across three automated SARS-CoV-2 serologic assays: Liaison SARS-CoV-2 S1/S2 IgG, Elecsys anti-SARS-CoV-2 total antibody, and Access SARS-CoV-2 IgG. Testing of 51 PCR-positive and 62 PCR-negative patients demonstrated qualitative inter-test agreement of 96% overall, 100% in PCR-negative patients, 88% in early positive samples (0-13 days post positive PCR), and 100% in convalescent samples (14+ days post positive PCR). Calculated kappa values for paired inter-test agreement ranged 0.93-0.96. Compared to PCR, overall percent positive agreement ranged from 82-86% (100% for convalescent samples) and percent negative agreement was 100% for each assay. This study demonstrates high diagnostic accuracy and inter-test agreement for three automated SARS-CoV-2 serologic assays. External validation of serologic assays is critical to ensure diagnostic accuracy and appropriate utilization of critical resources.
A rare autopsy case of pentalogy of Cantrell with tetralogy of Fallot and olfactory bulb agenesis
Authors: Akinsanya A O , Inman A
Published: October 2021

Introduction/Objective

Pentalogy of Cantrell is an uncommon congenital disorder characterized by sternal, diaphragmatic, pericardial, intracardiac and supraumbilical abdominal or chest wall defects. It is usually associated with other abnormalities and thus poses a therapeutic challenge, with a high mortality rate despite early diagnosis.

Methods/Case Report

This is an autopsy case of a 1 day old, former 37-week-old male infant with a prenatal diagnosis of incomplete pentalogy of Cantrell including omphalocele, ectopia cordis, pleural effusions, cardiac anomalies and polyhydramnios who was delivered via elective cesarean section. Maternal history included tobacco use during pregnancy, multiple psychiatric disorders, and a family history of an unbalanced translocation. The infant required intubation, ventilation, and chest tube insertion at birth due to respiratory distress. He also developed pneumoperitoneum which had to be decompressed. Within 24 hours the infant passed, despite advanced care. On autopsy, external examination showed central and peripheral cyanosis and a large omphalocele containing the heart, parts of the liver and intestines. Initial internal examination revealed a hypoplastic left lung, anterior diaphragmatic defect and absence of the pericardium. Organ dissection post-fixation showed an overriding aorta, pulmonic stenosis, subaortic valve ventricular septal defect and right ventricular hypertrophy, all components of tetralogy of Fallot. On brain examination, the olfactory groove and bulb were both absent. Examination of the placenta and 3 vessel cord revealed no abnormalities. Chromosomal microarray analysis on cord blood was normal.

Conclusion

The spectrum of defects seen in this disease complex has been postulated to be due to failure of differentiation or migration of mesenchymal structures during embryonic development but ultimately, this entity is not well understood. Identifying various disease associations through autopsies can help to establish possible etiologies, and options for therapeutic interventions or screening.
Postmortem Findings in Patients with COVID19 Using Multiple Organ Core Needle Biopsies
Authors: Harb Z F , Mueller J , Khan A , Ravikumar N , Tidswell M
Published: October 2021

Introduction/Objective

The coronavirus disease 2019 (COVID19) pandemic had caused more than 500,000 deaths in the United States. Although it mainly manifests with respiratory symptoms, postmortem examination reveals that it is more of a systemic disease affecting mutliple body organs.

Methods/Case Report

Postmortem needle core biopsies from multiple organs were obtained from 9 patients who died at our institution in the months of April and May of 2020 due to a confirmed SARS-CoV-2 infection by RT-PCR testing of nasopharyngeal swabs. The core biopsies from body organs included lungs (8), liver (7), kidneys (5), heart (2), spleen (2), and brain (2). Histopathological examination was performed in conjunction with a set of special and immunohistochemical stains. Electron microscopy examination was also done in 4 cases.

Results (if a Case Study enter NA)

The cohort consisted of 6 males and 3 females with a mean age of 70.4 years (range: 68–79). The majority had comorbidities (8/9) and presented with respiratory symptoms (9/9). The most significant postmortem findings were mainly in the lungs, including alveolar hemorrhage, hyaline membranes, fibrin thrombi, intraalveolar macrophages, type-2 pneumocyte hyperplasia, and interstitial myofibroblast reaction and collagen deposition. Immunohistochemical stains showed predominance of T-lymphocytes with a mixture of CD4 and CD8 positive cells. Examination of liver showed minimal to marked microvesicular and macrovesicular steatosis and centrilobular congestion and necrosis. Tissue from kidneys revealed mild to severe acute tubular injury. Microglial activation and Alzheimer type-II astrocytosis were noted in brain, and mild white pulp depletion was seen in the spleen. Electron microscopy showed the presence of foreign bodies suspicious for viral particles ranging in size from 52.6 to 97.9 nm in 2/4 cases.

Conclusion

Our findings based on postmortem core needle biopsies confirm the observation that most severely affected patients have significant pulmonary pathology. However, other organs show findings that may lead to a better understanding of this disease. Postmortem examination will continue to be an invaluable tool for studying the pathologic manifestations of COVID-19.
To evaluate if ultrasound gel or water-based media affects ER/PR staining patterns on breast core biopsy specimens
Authors: Chng J K , Mihir G , Lee Y , Tan C , Mansor S
Published: October 2021

Introduction/Objective

IHC staining for biomarkers ER, PR and HER-2 (CerB2) forms an essential component of breast cancer management and prognostication. Staining for these biomarkers is dependent on optimal fixation of the specimen in formalin. Scoring systems employed for ER and PR grade the intensity of the nuclear staining along with the percentage of the cells stained. This study aims to determine if ultrasound gel used during core biopsy as opposed to water affects immunohistochemical staining of biomarkers ER and PR in breast cancer specimens, following an observation that ultrasound gel assisted core biopsies may affect ER/PR nuclear staining scores through excess cytoplasmic staining.

Methods/Case Report

We included a total of 50 cases of invasive breast carcinoma diagnosed on core biopsy from KK Women’s and Children’s Hospital from February 2019 to July 2020. These included 25 cases with gel and 25 cases with water applied to the breast prior to the procedure. All biopsies were optimally fixed in formalin as per recommended latest ASCO/CAP guidelines. The control group included 25 resection cases of invasive breast carcinoma which had neither gel nor water and had been optimally fixed in formalin. Cytoplasmic staining for ER and PR was graded as being present or absent and was compared against the excision specimens (control group) to determine if using the gel was significant in producing cytoplasmic staining. The data was analyzed on SPSS using multiple logistic regression.

Results (if a Case Study enter NA)

Using the gel appeared to be statistically significant in producing cytoplasmic staining for ER (p=0.042) as opposed to using water (p=0.274). For PR staining, both gel-based (p=0.250) and water-based media (p=0.286) were not statistically significant in causing cytoplasmic staining.

Conclusion

The preliminary findings of this small retrospective case-control study gives an insight that gel-based media may have a role in causing cytoplasmic staining for oestrogen receptor in breast cancer biopsy specimens which may interfere with accurate scoring and impact results of external quality assurance schemes to which laboratories subscribe to. However the study is limited by the small sample size and exclusion of any other pre- analytical factors like needle bore or number of cores taken which may have had an impact on the staining.
Analytical and Clinical Performance Evaluation of ARK Fentanyl II Assay on Beckman Coulter AU System
Authors: Larsen N , Smothers C , Martin D , Moore A , Lima J , Cao L
Published: October 2021

Introduction/Objective

Drugs of abuse, specifically opioids, have been in recent years an important focus in both medicine and media due to the ‘opioid epidemic’ and large numbers of overdose deaths. Synthetic opioids such as fentanyl have contributed to this epidemic. The CDC reports that of roughly 50,000 opioid overdose deaths in 2019, nearly 73% were due to synthetic opioids. The objective of this study is to assess the analytical and clinical performance of the Fentanyl II Assay by ARK Diagnostics, Inc.

Methods/Case Report

Fentanyl was qualitatively determined by the ARK Fentanyl II Assay, a homogenous enzyme immunoassay based on competition between drug in the specimen and drug labeled with recombinant glucose-6- phosphate dehydrogenase (rG6PDH) for antibody binding sites. The presence of drug in urine increases enzyme activity, which converts nicotinamide adenine dinucleotide (NAD) to NADH in the presence of glucose-6-phosphate, resulting in an absorbance change measured by spectrophotometry. The evaluation was performed following CLSI guidelines. The analytical performance was evaluated for accuracy and precision.

Results (if a Case Study enter NA)

To evaluate the accuracy, twelve positive and eight negative specimens were tested by the ARK immunoassay performed on two Beckman Coulter instruments (AU480 and AU680) and by LC- MS/MS. The results from both instruments showed 100% agreement with the results from LC-MS/MS. On instrument AU480, the within-run CVs were 18.0% at the level of 22.510 ng/mL and 0.8% at the level of 552.628 ng/mL. The between-run CVs were 8.8% at the level of 68.928 ng/mL and 3.7% at the level of 158.947 ng/mL. On instrument AU680, the within-run CVs were 273.4% at the level of 1.052 ng/mL and 0.8% at the level of 523.788 ng/mL. The between-run CVs were 7.8% at the level of 53.779 ng/mL and 3.1% at the level of 145.263 ng/mL. In May 2021, 2,075 fentanyl assays were run at UAB. Of those, 476 returned a positive result with a positive rate of 22.9%, and 1,599 were negative with a negative rate of 77.1%. One positive result was confirmed by LC-MS/MS as negative for fentanyl but positive for norfentanyl, a metabolite of fentanyl. The clinical specificity was 99.9% and sensitivity was 100%.

Conclusion

In Conclusion, the ARK fentanyl Assay II on Beckman Coulter AU system has good accuracy, sensitivity and specificity. The precision at medium and high levels are good. However, the precision at low level needs to be improved.
Difference in hemoglobin %A2 between homozygous hemoglobin A and hemoglobin S-trait patients as measured by capillary electrophoresis
Authors: Tucker C M , Stickle D
Published: October 2021

Introduction/Objective

Quantitation by high-performance liquid chromatography (HPLC) of hemoglobin %A2 is often not used in evaluation for thalassemia of hemoglobin S-trait patients, due to analytical interference from glycated hemoglobin S1d to increase %A2. In contrast, an increase in %A2 for S-trait when measured by capillary electrophoresis (CE) has been reported, without known analytical interference. This observation has not been re- evaluated in modern versions of CE, however. For validation exercises associated with startup of CE at our institution, we compared distributions of %A2 among A patients and S-trait patients using Sebia “Capillarys® 2” CE.

Methods/Case Report

%A2 is provided in two Sebia “Capillarys® 2” methods: analysis of A1c (method 1, M1) and analysis of hemoglobin variants (method 2, M2). To minimize effect of potential preselection for thalassemia among M2 samples, we first evaluated distributions of %A2 for A and S-trait among M1 samples. We then evaluated correlation of A2 measurements between M1 and M2. Statistical analyses were conducted using R programming.

Results (if a Case Study enter NA)

Using M1, %A2 for S-trait patients (2.61±0.31%, n=116) was higher than for A patients (2.11±0.27%, n=108) (p<0.001), with difference=0.42-0.57 %A2 (95% confidence interval, CI). %A2 by M1 was consistently less than %A2 by M2, for both A and S-trait (p>0.25): for A, M1/M2=0.89±0.05 (n=35); for S-trait, M1/M2=0.88±0.05 (n=32). Decreased %A2 by M1 compared to M2 may in part be due to separation in M1 of a glycated form of A2. Using M2, %A2 for S-trait patients (3.05±0.29%, n=32) was higher than for A patients (2.41±0.29%, n=35) (p<0.001), with difference=0.50-0.76 %A2 (CI). M2 results were consistent with M1 data when combined with the observed M1/M2 ratios.

Conclusion

Results suggest a physiological increase in %A2 in S-trait patients compared to A patients, not likely to be attributable to thalassemia. The average increase is ~0.6 %A2 for hemoglobin variant analysis by CE.
The Diagnostic Predictive Value of Aspartate Aminotransferase/Platelet Ratio Index (APRI) in Assessing the Disease Severity of Filipino Dengue Patients in Pampanga, Philippines: A Multicenter Study
Authors: Serrano S S , Yambao D C , Sarile C M , Torres P B , Tranquilino A M , Umali M T , Umipig J C , Sison R G , Nieto X A
Published: October 2021

Introduction/Objective

Lack of good predictive biomarkers tied with its widely varying clinical manifestation make DENV infection a major public health concern especially in developing countries like the Philippines. Liver involvement is found to be a common manifestation among severe dengue patients hence enzymes such as aspartate aminotransferase (AST) is used in determining dengue severity. This study aims to evaluate the predictive value of AST/platelet ratio index (APRI) in assessing disease severity among Filipino dengue patients upon admission.

Methods/Case Report

Clinical data of 16 dengue patients from two hospitals in Pampanga were analyzed retrospectively. Results for NS1 antigen test, CBC, and AST along with signs and symptoms of patients upon admission were reviewed. ANCOVA was used to compare AST and APRI between the groups while ROC regression and Youden’s index were utilized in identifying severe dengue using AST and APRI.

Results (if a Case Study enter NA)

Among the 16 patients, 10 were male and 6 were females with a mean age of 17.9 years (range, 6 to 34). There was no evidence that AST (p=0.223) significantly differed between severe and non- severe dengue, with a mean of 131.0±24.5 and 78.5±24.5, respectively. Calculated APRI scores (p=0.604) did not show significant difference between SD and NSD, with a mean of 3.8± 4.1 and 3.7±4.1, respectively. The obtained AST cutoff for SD was 119 U/L; while the APRI cutoff for SD is 4.03. However, considering the age of patients as covariate, both AST [AUC = 0.55 (95% CI: 0.15 to 0.86)] and APRI [AUC = 0.69 (95% CI: 0.27 to 1.00)] was not able to differentiate patients with SD and NSD.

Conclusion

The parameters AST and APRI were not able to differentiate and predict severity between SD and NSD. A larger cohort with a more specific age group, and collection of samples throughout the course of illness are needed to further substantiate the results.
Cytomorphologic findings of SMARCA4-deficient thoracic sarcoma/carcinoma: Report of two cases
Authors: Abu-Salah A K , Segura S , Cramer H M
Published: October 2021

Introduction/Objective

SMARCA4-deficient thoracic sarcoma/carcinoma is a highly aggressive neoplasm characterized by SMARCA4 (chromatin remodeling complex) deficiency. It affects mostly smokers (85%) with a broad age range of presentation (mean age: 50 years). Most patients present with advanced disease and extensive involvement of thoracic structures. The cytomorphologic features of this entity have not been fully described.

Methods/Case Report

A 59-year-old female, former smoker, with a prior history of lung adenocarcinoma, presented with a new 2.8 cm right infrahilar nodule concerning for recurrence. The second patient, a 54-year-old male who is a smoker, presented with an 8.0 cm right perihilar mass extending into the right lung and mediastinum with encasement of the right main pulmonary artery. Cytologically, the smears from both aspirates were comprised of single cells and loosely cohesive clusters of ovoid to spindle cells with scant to moderate cytoplasm, stippled chromatin, and focally prominent nucleoli. Numerous mitotic figures were appreciated. Necrosis was present within the smear background. The cell block sections showed tumor cells arranged in glandular and focal papillary architecture with a myxoid background. In one case, intermediate to large-sized cells with focal cytoplasmic clearing and patchy extracellular metachromatic material were also noted. Rhabdoid morphology was not appreciated. Immunohistochemically, the tumor cells were at least focally positive for vimentin, TLE-1, SALL4, CK AE1/AE3 and TTF-1, while being negative for CK7, CK20, Napsin-A, SOX-10, p40 and neuroendocrine markers. Both tumors showed SMARCA4 (BRG1) loss of expression.

Results (if a Case Study enter NA)

N/A

Conclusion

While the cytomorphologic findings of SMARCA4-deficient thoracic sarcomas/carcinomas are not specific, the FNA diagnosis should be considered for any poorly differentiated neoplasm involving the lungs or mediastinum which should prompt an appropriate immunocytochemical work-up that includes SMARCA4/BRG1 assessment
Effusion tumor cell (ETC) detection from cytology samples following long-term storage
Authors: Libert D , Allard G , Zhu Y , Lowe A C
Published: October 2021

Introduction/Objective

Circulating tumor cells (CTCs) are shed from solid tumors into blood. The RareCyte CTC system involves multiplexed fluorescence whole-slide imaging of blood for antibody-based identification of EpCAM/cytokeratin-positive and CD45-negative CTCs. We have previously established an assay to detect carcinoma effusion tumor cells (ETCs) from remnant pleural fluid samples employing RareCyte, providing a potential avenue for tumor cell detection from any cytology sample. To facilitate this, our aim is to evaluate slide storage conditions. We hypothesize that long-term storage of pleural fluid ThinPrep slides at -20°C prior to RareCyte analysis will yield similar ETC numbers and characteristics to freshly-prepared slides.

Methods/Case Report

ETCs were identified and counted via RareCyte according to our previously established criteria (EpCAM mean fluorescence intensity (MFI) > 100 arbitrary unit (a.u.), CD45 MFI < 100 a.u., and cellular morphology). We analyzed 7 paired fresh-stored pleural fluid samples. Stored samples were maintained at -20°C for 154 or 385 days. ETCs counts between the fresh and stored conditions were compared using a Wilcoxon signed-rank test. Marker intensities from the 35 EpCAM-brightest cells across one paired fresh-stored sample were compared using a two-tailed independent t-test. The cutoff for significance is p<0.05.

Results (if a Case Study enter NA)

The median (25%, 75%) number of cells detected in the 7 fresh and stored samples was 36 (14, 129) and 13 (5, 22), respectively, and was not significantly different (p=0.08). Although the MFIs for DAPI nuclear staining (p=0.12) and CD45 (p=0.82) were not significantly different between the fresh and stored 35 EpCAM-brightest cells, cytokeratin (p=0.02) and EpCAM (p<0.00001) MFIs were significantly less in stored samples.

Conclusion

Detecting ETCs is possible after long-term storage at -20°C despite a significant decrease in EpCAM and cytokeratin MFIs in stored samples. In this small sample, paired ETC counts were not significantly different. These preliminary results provide a foundation for larger studies to define storage conditions.
Pleural Metastasis of High-Grade Endometrial Stromal Sarcoma With YWHAE Gene (17p13.3) Rearrangement, A Rare Case Report
Authors: Re A C , Enrique M , Ren S
Published: October 2021

Introduction/Objective

Endometrial stromal sarcoma (ESS), a rare malignant neoplasm of endometrial stroma, accounts for less than 1% of all uterine tumors. High grade ESS (HGESS) is aggressive and commonly relapses even after surgical and neoadjuvant therapy. Abdominal and pelvic regions are common sites of metastasis, however, distant metastases to the liver, lung, vertebrae, and brain have been reported.

Methods/Case Report

We encountered a 49-year-old female who presented with shortness of breath, found to have a left pleural effusion and multiple pleural masses. She initially presented three years ago with heavy irregular menses and left pelvic pain for one year. D&C revealed prominent small spindle cells for which a stromal nodule and low-grade or malignant process was probable. CT scan showed an enlarged uterus. Hysterectomy with bilateral salpingo- oophorectomy, bilateral pelvic and para-aortic lymph node dissection, and partial omentectomy were performed. The uterus revealed an intramural 7 cm mass with a serpiginous growth pattern and lymphovascular invasion. Tumor cells were plump to spindled with areas of high cellularity, rounded nuclei, increased atypia and mitosis. Atypical areas were positive for cyclin D1, focally positive for CD10, and negative for ER, PR, SMA, desmin, AE1/3 and CAM5.2. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement of JAZF1 or PHF1 gene regions. Findings supported the diagnosis of HGESS. The patient received post-operative chemotherapy. Biopsy of the current pleural lesion revealed a nonspecific malignant spindle cell neoplasm positive for BCL1, CD56, CD117, CD99, TLE1 and INI1, while negative for AE1/3, CAM5.2, EMA, ER, PR, CK5/6, calretinin, SMA, desmin and S100. The CD10 stain was inconclusive. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement involving JAZF1 or PHF1 gene regions. No rearrangement of the SS18 gene region was observed and synovial sarcoma was excluded. Overall findings support the diagnosis of metastatic HGESS.

Results (if a Case Study enter NA)

NA

Conclusion

HGESS, a rare tumor with a nonspecific immunostain profile, has the ability to metastasize to rare body sites, such as the pleura in our case. Display of spindle cell morphology is a nonspecific finding that raises broad differential diagnoses. In women, with or without a history of uterine neoplasm, HGESS is a clinically worthwhile diagnosis to be mindful of.
Choriocarcinoma Presenting as a Metastatic Pancreatic Mass: a Cytopathologic Diagnostic Challenge
Authors: Al-Attar M M , Zou T , Fischer A H , Cosar E F
Published: October 2021

Introduction/Objective

Choriocarcinoma is a malignant tumor of trophoblasts, with gestational choriocarcinoma as the most common type. It commonly presents with vaginal bleeding and uterine mass; occasionally, hemorrhage due to metastatic disease to the lung, liver, brain, and gastrointestinal tract may be the first presentation. We describe an unusual case of metastatic gestational choriocarcinoma presenting as a pancreatic head mass mimicking a pancreatic neuroendocrine tumor (PanNET). The concern for choriocarcinoma was raised by fine-needle aspiration (FNA) cytology.

Methods/Case Report

A 32-year-old woman, 16 months status-post caesarian delivery of healthy twins, presented with progressive right upper quadrant and epigastric pain, nausea, and marked elevation of Beta-hCG, lipase, ALT, and AST levels. Abdominal CT revealed a hypoenhancing 2.6 cm pancreatic head mass and multiple liver nodules, suggestive of PanNET with liver metastasis. Endoscopic ultrasound and FNA of the pancreatic mass revealed a poorly differentiated tumor composed of bizarre large malignant cells with marked cytologic atypia, focal spindle cell change, and rare multinucleated cells. By immunohistochemistry, the tumor cells were positive for pancytokeratin, CAM5.2, and CD56 (focally), while negative for synaptophysin, chromogranin, inhibin, P63 and P40. While pancreatic adenocarcinoma and PanNET couldn’t be completely ruled out, metastatic choriocarcinoma was also considered; however, inconclusive immunostaining warranted a tissue biopsy. Follow-up liver biopsy and FNA showed that tumor cells were positive for Beta-hCG and negative for SALL4, placenta lactogen, HepPar1, and TTF1 immunostains, compatible with choriocarcinoma. Molecular analysis using short tandem repeat supported a gestational origin of the tumor. The patient underwent chemotherapy with marked improvement in her status and beta-hCG levels.

Results (if a Case Study enter NA)

NA

Conclusion

Although highly aggressive, gestational choriocarcinomas show good treatment response, necessitating accurate diagnosis in cases of an atypical presentation. Choriocarcinoma presenting as metastatic pancreatic mass is extremely rare and poses a diagnostic cytopathologic and radiologic challenge that requires comprehensive correlation with clinical and laboratory data.