bluuebunny/crossref_metadata_2025 huggingface dataset:
The Pathologic Spectrum of Bone Marrow Involvement by Double- and Triple-hit Lymphomas
Authors: Iqbal H , Harrington A , Kroft S H
Published: October 2021

Introduction/Objective

B-cell lymphomas with MYC and BCL2 and/or BCL6 rearrangements (double- and triple-hit lymphomas, DHL/THL) are a distinct entity due to shared biology and aggressive behavior, exhibiting poor outcomes with standard therapies. While pathologic features of DHL/THLs in primary sites have been well described, little information is available regarding the clinicopathologic features of bone marrow involvement by this entity.

Methods/Case Report

Files were searched from 2010-2020 for all DHL/THLs. Since mid-2016, all aggressive B-cell lymphomas were reflexed to DHL/THL FISH testing. Prior to that, criteria for performing FISH varied. Clinical and laboratory data were obtained through chart review. Both BM and primary diagnostic specimens were reviewed when possible.

Results (if a Case Study enter NA)

There were 46 DHL/THL cases with initial staging BM evaluations, of which 13 (28%) were positive for DHL/THL; 11 were available for review (5F:6M; 28-95 years). All patients with positive BMs were stage 3 or 4 irrespective of the BM findings. Lymphoma cytology in positive BMs was blastoid in 6, large cell in 2, and high grade, NOS in 3. The cytology in primary tissues was not significantly associated with the rate of marrow involvement. PB smears were available for 9/11 BM(+) cases; of these, 6 (66.7%) had circulating lymphoma cells in the blood, ranging from rare to greater than 40% lymphoma cells (median, 4%). Lymphoma cells with cytoplasmic vacuoles were present in 5 cases (45%). No BM infiltrates had a starry-sky appearance. Infiltration patterns included diffuse (3), diffuse and interstitial (3), and interstitial (3). One exhibited only rare, scattered lymphoma cells in the aspirate and core biopsy, and another with large cell morphology showed random focal (nodular) and focally paratrabecular infiltration. The proliferation index in the marrow infiltrates ranged from 50% to >90% (median, 65%). Flow cytometry was positive in 9 of 10 cases; the single negative study was from an outside institution

Conclusion

Our study demonstrates 28% of DHL/THLs show BM involvement at diagnosis. Notably, the peripheral blood was involved in 2/3 of cases with marrow infiltration (13% of total cases), ranging from rare circulating cells to frank leukemic involvement. Cytologically, the marrow infiltrates were predominantly blastoid or high grade NOS. Marrow infiltrates generally displayed leukemic rather than lymphomatous patterns of involvement.
PAX5 P80R mutated acute leukemia followed by genetically-related histiocytic proliferation with clonal IGH gene rearrangements
Authors: Wu A , Cheng L , Vance G H , Zhou J , Gulati R , Dave U , Czader M
Published: October 2021

Introduction/Objective

PAX5 is a transcription factor critical for B-cell development and its genetic alterations are common in B lymphoblastic leukemia/lymphoma (B-ALL). We report a case of PAX5 P80R mutated acute leukemia with predominantly monocytic immunophenotype followed by a genetically-related histiocytic proliferation.

Methods/Case Report

A 27-year-old male presented with pancytopenia, epistaxis, and blurry vision. Bone marrow exam showed 95% blasts with nuclear indentations, occasional prominent nucleoli and basophilic cytoplasm. Blasts were positive for bright CD33, HLA-DR, CD14, bright CD64, partial CD123 and partial CD19. In addition, a minute population of B lymphoblasts positive for CD19, CD20, and dim TdT was seen. The AML FISH panel showed markedly aneuploid population with all probes demonstrating 3 to 5 signals. PAX5 P80R and KRAS G13D mutations were detected by NGS. Post induction bone marrow showed no evidence of acute leukemia with normal cytogenetics and FISH results. Subsequent two bone marrow exams performed due to progressive cytopenias demonstrated a prominent histiocytic proliferation with sheets of mature appearing histiocytes with abundant cytoplasm, oval to folded nuclei and occasional hemophagocytosis. This population was positive for CD163, CD14, CD68R, CD68, cyclin D1 with variable OCT2 expression and low proliferative activity. PAX5 P80R and KRAS G13D were detected. AML FISH panel showed aneuploidy in histiocytic appearing cells and IgH gene rearrangement studies by PCR showed prominent clonal population. The patient remained pancytopenic and died of disseminated fungal infection.

Results (if a Case Study enter NA)

NA

Conclusion

PAX5 P80R mutation has been primarily reported in B-ALL and is exceedingly rare in acute myeloid leukemias. This alteration has been linked to downregulation of B-cell lineage genes affecting B-cell maturation, and not surprisingly a proportion of PAX5 P80R mutated B-ALL cases show a switch to a monocytic lineage. The reported case demonstrates diagnostic caveats including unusual features of acute leukemia at the time of initial diagnosis and subsequent genetically-related histiocytic proliferation.
Blinatumomab resistant clone presenting as mixed phenotype myeloid sarcoma causing cord compression
Authors: Dabrowski D S , Wei E
Published: October 2021

Introduction/Objective

Blinatumomab is a monoclonal antibody directed against CD19/CD3 utilized for the treatment of relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) and for the treatment of B-cell precursor ALL in first or second complete remission with minimal residual disease (MRD) ≥0.1%. Although Blinatumomab treatment has shown better overall survival, progression-free survival, and complete remission when compared to chemotherapy, most patients have a relapse and ultimately succumb to the disease. Interestingly, there are a number of cases reporting relapse in extramedullary places. The mechanisms for relapse in these unusual extramedullary sites are not well-understood. We herein report a case of a 20-year-old African American male with primary refractory Philadelphia-negative (Ph-) precursor B cell ALL with MLL rearrangement, who received treatment with Blinatumomab after achieving morphological remission with a pediatric-inspired regimen but found to be MRD +.

Methods/Case Report

A 20 year old African American male was found to have B cell precursor ALL. It was found to be Ph-. While initally receiving vincristine, prednisone, and aspariginase, the ALL proved to be refractory to treatment. Blinatumomab was used as second line therapy after the first failed remission. The patient remained with morphological response; however, remained MRD+ after three cycles of Blinatumomab. During the fourth cycle, the patient presented with back pain and lower extremity weakness. A spine MRI revealed an extradural mass in the thoracic spine causing cord compression. A thoracic laminectomy with partial removal of the mass, followed by radiation, was performed with improvement of symptoms. Pathology results of the extradural mass revealed a myeloid sarcoma with MLL rearrangement.

Results (if a Case Study enter NA)

NA

Conclusion

This case report demonstrates how patients treated with blinatumomab can have relapse in unusual extramedullary places. The possibility of leukemia manifesting in extramedullary sites should always be kept in mind by clinicians treating patients with Blinatumomab. The mechanisms of resistance against Blinatumomab are not well- understood and need further elucidation.
Kinetics of Eosin-5-maleimide Binding to Red Blood Cells
Authors: Ventura M
Published: October 2021

Introduction/Objective

The binding of eosin-5-maleimide (EMA) to red blood cells in different pH conditions has not been well-investigated. The current standard protocol uses phosphate buffered saline at pH 7.0 to 7.5 for the binding reaction. The reaction typically uses a sixty-minute incubation. However, the effect of pH on EMA binding remains to be determined, nor have the reaction times at different pH conditions. This study utilizes optimal pH conditions of 6.0, 6.5, 7.0, 7.5, 8.0, and 8.5 to characterize EMA binding. The two parameters, time, and pH were investigated to extensively describe the binding kinetics of eosin-5-maleimide.

Methods/Case Report

The working EMA solutions in phosphate buffered saline at different pHs (specifically 6.0, 6.5, 7.0, 7.5, 8.0, and 8.5) were incubated in the dark with 1 µL of washed red blood cells and 25 µL of working EMA solution. The red blood cells and working EMA solution were vigorously mixed before the specified incubation time. The binding was recorded at specified time points, namely 1, 2, 4, 8, 16, 32, and 64 minutes for each pH condition. The binding reaction was terminated by washing three times with 0.1% bovine serum albumin (BSA) in PBS and centrifuged at 400 g for 5 minutes. The red blood cells were then resuspended with 500 µL of PBS and ran in the BD FACSLyric™ flow cytometer.

Results (if a Case Study enter NA)

The current EMA binding protocol utilizes a. neutral pH of 7.0 to 7.5 recorded at 64 min. Based on our data, better discrimination of hereditary spherocytosis red blood cells from normal red blood cells may be obtained at a more basic pH of 8.5. Thus, a statistical t-test was performed for the comparison between the current setup and the apparent optimal pH conditions at shorter reaction times of 16 min and 32min at pH 8.5.

Conclusion

The resulting data suggest that enhanced discrimination of HS red blood cells can be achieved in a more basic pH. This was evidently observed at pH 8.5, where the highest percentage decrease is recorded, and the most significant difference compared to the other pH conditions. In conclusion, the study identifies that better discrimination of hereditary spherocytosis red blood cells from normal red blood cells can be determined using pH 8.5 with a shorter incubation time of 32 min. The pH 8.5 at 16 min condition could also be considered if the clinical batch size allows precise incubation of 15 min.
Concordance and discordance among antiphospholipid syndrome screening assay
Authors: Reno M , Stefaniuk C
Published: October 2021

Introduction/Objective

The lupus anticoagulant (LA) panel utilizing dilute Russell’s viper venom and LA-responsive APTT remains the front-line screen for detecting the presence of clinically significant antibodies in the diagnosis of antiphospholipid syndrome. Receiving anticoagulant therapy limits the utility of clotting-based methods due to increased risk of false positive results. Anti-cardiolipin (aCL) and anti-ß2-glycoprotein I (a2GßPI) antibody titers have also been employed for the detection of anti-phospholipid antibodies; however, they are not influenced by anticoagulation therapy. The International Society on Thrombosis and Haemostasis recommends that all three tests should be performed to appropriately assess the risk of lupus anticoagulant/antiphospholipid antibodies. In this study, the concordance and discordance of rates of among these three assays were examined.

Methods/Case Report

The electronic medical record was mined according to lab tests codes for the results of the LA panel, aCL and a2GßPI antibody titers for all patients having at least one resulted study at the University of Cincinnati Medical Center in Cincinnati, Ohio, over a one-year period (2020). Results were compared to determine rates of concordance and discordance among the assays as well as Spearman’s correlation. Non-parametric binary regression analysis was applied to explore the relationship connecting aCL and a2GßPI titers to LA panel findings.

Results (if a Case Study enter NA)

Strong concordance was seen between the results of LA panels and antibody titer assays. A weak but significant positive correlation was found among the three assays. A robust logarithmic relationship was developed from which the LA panel result could be predicted utilizing outcomes from aCL and a2GßPI antibody titer findings.

Conclusion

These data further support the reliability of aCL and a2GßPI titers in the evaluation of antiphospholipid syndrome. Furthermore, the robust relationship among these three assays suggests that antibody titers may provide a reliable diagnostic avenue for patients actively undergoing anticoagulation therapy.
Individual and Combined Evaluation of Specific Inflammatory Biomarkers along with Neutrophil, Lymphocyte, and Platelet Counts in Predicting Poststroke Disability Severity Among Acute Ischemic Stroke Patients in a Tertiary Hospital in Pampanga, Philippines
Authors: Marcadejas E R , Lagman M P , Mendoza A S , Marzan R E , Manongdo A Z , Maniego L S , Meriales M M , Marin E P , Sison R G , Nieto X A
Published: October 2021

Introduction/Objective

Numerous studies considered Neutrophil-to-Lymphocyte ratio (NLR), Platelet-to-Lymphocyte ratio (PLR), and Mean Platelet Volume (MPV) as inflammatory biomarkers in assessing the functional outcomes of Acute Ischemic Stroke (AIS) Patients. Presumably, no other study has evaluated all three markers in varying levels of combinations. The study aims to evaluate the predictive potential of specific CBC parameters (Neutrophils, Lymphocytes, and Platelets), their individual ratios (NLR, PLR, and MPV), and their combinations (NLR-PLR, NLR- MPV, PLR-MPV, and PLR-NLR-MPV).

Methods/Case Report

This retrospective study involved 52 AIS patients from a hospital in Pampanga, Philippines, at least 18 years of age, have no pre-existing conditions and prior treatments/medications. Modified Rankin Scale (mRS) score, medical history, age, and gender were gathered. Specific CBC parameters upon admission were analyzed to derive individual ratios. The combined biomarkers, categorized into Levels 2, 1, and 0, indicate high values for all biomarkers involved, high values for any of the biomarkers (one or two high value/s for PLR-NLR-MPV), and no high values for any of the biomarkers, respectively.

Results (if a Case Study enter NA)

Results showed that elevated NLR (OR=14.5; p=0.021) and MPV (OR=24.1; p=0.047) are risk factors in developing evident poststroke disability (mRS 2-5) and mortality (mRS 6), respectively. Furthermore, level 2 NLR-MPV (OR=77.0; p=0.040) and PLR-MPV (OR=105; p=0.027) are risk factors on mortality. Level 2 PLR-NLR (OR=15.0; p=0.021) and level 1 NLR-MPV (OR=13.5; p=0.024) are risk factors in developing evident poststroke disability. Lastly, levels 1 (OR=13.5; p=0.024) and 2 (OR=77.0; p=0.040) PLR-NLR-MPV are risk factors in developing evident poststroke disability and mortality, respectively.

Conclusion

Patients with neutrophilia, elevated NLR, level 2 PLR-NLR, and level 1 NLR-MPV and PLR-NLR-MPV are more likely to develop evident poststroke disability; while patients with elevated MPV and Level 2 NLR-MPV, PLR- MPV, and PLR-NLR-MPV pose higher mortality risk. Greater sample size is recommended for studies with the same purpose to advance research for better AIS outcomes.
The Prognostic Significance of Established Hematological Parameters and Inflammatory Biomarkers in Assessing Dengue Infection Severity and Progression among Patients Ages 5 to 14 in a Tertiary Government Hospital in Pampanga, Philippines
Authors: Cai J R , Camacho I B , Caras E M , Carayugan J A , Carmona K H , Castillo C O , Castillo E D , Nieto X A , Sison R G
Published: October 2021

Introduction/Objective

Dengue virus (DENV) is an arthropod-borne virus which imposes a significant burden on the health system in most tropical and subtropical countries. In 2009, WHO classified Dengue into Dengue Without Warning Signs (DNWS), Dengue With Warning Signs (DWWS), and Severe Dengue (SD). This study aims to establish the prognostic value of predetermined hematological parameters and inflammatory biomarkers in assessing severity and progression of dengue infection among ages 5-14.

Methods/Case Report

A retrospective study was conducted to evaluate the Complete Blood Count, Inflammation biomarkers, and severity of dengue patients (5-14 of age). The diagnosis must be serologically confirmed by a positive NS1/IgM.

Results (if a Case Study enter NA)

A total of 36 patients participated in the study, having 18 from each groups of DWWS and SD. The mean age of Dengue cohort was 13.9 years with 59% (19/36) being male. Laboratory findings reveal SD to have lower platelet count (<100.00x109/L) during day 1-3 (p<0.001). Low WBC count (<4.00x109/L), Relative Eosinophil (<2.00%), and Absolute Lymphocyte count (<1.52x109/L) were evident on days 1-3 among DWWS and SD cases (p=0.023; p=0.045; p=0.033). Low relative neutrophil (<0.45%) was a constant finding in both clinical types throughout disease progression. SD group had significantly higher Neutrophil to Lymphocyte ratio (NLR) values among SD cases on days 4-6 (p<0.001). In contrast, Platelet to Lymphocyte ratio (PLR) was significantly lower among DWWS cases on days 4-6 (p=0.020). Monocyte to Lymphocyte (MLR) ratio had poor discriminative power (p=0.560).

Conclusion

The findings highlight decreased platelet, WBC, relative eosinophil, and absolute lymphocyte count to be common among Dengue patients. NLR and PLR were found to be good predictors of dengue severity during the initial phase of infection. Evaluating these values may aid clinicians in early diagnosis of severe dengue. However, larger samples are needed to further validate the predictive values of these parameters.
Coping with the COVID-19 Pandemic: An adapted approach to preclinical teaching of Pathology- Pathophysiology
Authors: Huq Ronny F M , Mares A , Harris Petersen K , Risucci D , Catano D , Lento P
Published: October 2021

Introduction/Objective

The COVID-19 pandemic affected all aspects of medicine, from patient care to medical education. Pandemic-related restrictions regarding in-person teaching activities at our medical college required adoption of an online, live, virtual format for all activities in our preclinical Pathology-Pathophysiology (PP) courses. Adaptation of teaching approaches using available technology allowed for uninterrupted learning and may serve to contribute to future innovations in medical education.

Methods/Case Report

Using Zoom as a platform, all lectures and interactive group exercises were converted to a live virtual format. Live Zoom lectures were also recorded and, subsequently, made available to students, in order to provide additional opportunities for engaged learning. Interactive, case-based and self-directed exercises, and gross specimen reviews were also held using the live virtual format. Fourth year students enrolled in our education concentration helped provide intermittent virtual peer reviews for the 2nd year students. All exams were administered via an electronically monitored virtual format.

Results (if a Case Study enter NA)

Overall, performance of the 2020-2021 class on in-house, multiple choice question (MCQ) exams in our PP courses was typically at or above the performance of prior classes, while class performance on a standardized national subject exam (NBME) in Pathology was above the national average, which was consistent with prior class performances, and significantly higher (p = 0.01) on average in 2021 than in 2019 (2.28 points) and 2020 (2.27 points). Additional analyses are being conducted on demographic subgroups within each cohort (sex, MCAT score, socioeconomic status, underrepresented in medicine, registered for disability accommodations) to determine if any particular group’s performance was impacted by this change of format.

Conclusion

Despite the restrictions imposed by the pandemic, student performance on in-house and standardized national exams in the NYMC Pathology-Pathophysiology courses were similar to recent pre-pandemic years. Our endeavors to provide a strong preclinical educational experience in Pathology-Pathophysiology during the pandemic resulted in learning outcomes on a par with those in recent years, despite the rapid transition to a completely online, live virtual format.Our data suggest that continued use of virtual teaching methods is a viable option in on-going medical curricula
SATB2 expression in human tumors: A tissue microarray study on more than 15,000 tumors
Authors: Dum D , Krech T
Published: October 2021

Introduction/Objective

Introduction: Special AT-rich sequence-binding protein 2 (SATB2) binds to DNA in specific nuclear matrix attachment regions and facilitates chromatin remodeling. SATB2 immunostaining is commonly used as a marker for colorectal adenocarcinoma and osteosarcoma.

Methods/Case Report

Methods: To comprehensively evaluate SATB2 expression in normal and tumor tissues, a tissue microarray containing 15,012 samples from 120 different tumor types and subtypes and 608 samples of 76 different normal tissue types were analyzed by immunohistochemistry.

Results (if a Case Study enter NA)

Result: SATB2 positivity was found in 89 different tumor types including 59 with at least one moderately positive and 38 tumor types with at least one strongly positive tumor. Most frequent and strongest expression were found in adenomas (94-96%), adenocarcinomas (86%) and various subtypes of neuroendocrine neoplasms (43-100%) of the colorectum and appendix, Merkel cell carcinoma (74%), osteosarcomas (60%), and papillary renal cell carcinoma (RCC) (52%). In colorectal cancer, weak SATB2 expression was linked to high pT (p<0.0001), nodal metastasis (p<0.0001), right-sided tumor location (p<0.0001), microsatellite instability (p=0.0004), and BRAF mutations (p<0.0224). In papillary RCC, low SATB2 was associated with high pT (p=0.0197), distant metastasis (p=0.042), and reduced tumor specific survival (p=0.0395). In clear cell RCC, low SATB2 was linked to high pT (p<0.0001), high UICC stage (p<0.0001), high Thoenes grade (p=0.0178), and reduced recurrence free survival (p=0.0216).

Conclusion

SATB2 expression can occur in many different tumor entities. Strong SATB2 expression argues for a colorectal tumor origin within adenocarcinomas and neuroendocrine neoplasms. Weak SATB2 expression reflects cancer progression and poor prognosis in colorectal and kidney cancer.
Mobilizing COVID-19 Testing: Impact and Challenges
Authors: Odenbrett R , Ingemansen D , Baumgart T , Hieb V , Ross A , McDowell J , Chang R , Strouts F
Published: October 2021

Introduction/Objective

In response to the rapidly evolving COVID-19 pandemic, Sanford Health developed a mobile diagnostic testing program capable of reaching geographically dispersed sites and communities. These mobile laboratories provided on-site testing and sensitive detection of SARS-CoV-2 by leveraging Cepheid’s GeneXpert platform, enabling rapid reporting of results directly to the patient and physician. Aggregation of these results allowed monitoring population infection rates and public health reporting.

Methods/Case Report

Within 3 weeks of conception, the first mobile unit was designed, engineered and deployed. Key requirements for successful implementation included mobile lab licensure, CLIA certification, COLA enrollment, Quality and Risk assessments, inventory management, lab maintenance and ongoing monitoring. Testing was performed using the Xpert Xpress SARS-CoV-2 test and the population tested were primarily asymptomatic individuals.

Results (if a Case Study enter NA)

Between May 3rd, 2020 and June 23rd, 2021, a total of 31,148 Xpert Xpress SARS-CoV-2 tests were run across 3 mobile laboratories, with an average of 600 tests performed per week. The percent positivity ranged from 0% to 5.8%, reaching highest positivity in week beginning May 10th, 2020. The average turnaround time from sample collection to result verification was 2.0 hours, and the average time from sample receipt to result verification was under 1 hour.

Conclusion

Sanford Health’s mobile testing program brings SARS-CoV-2 PCR testing to the community and dramatically reduces the time from sample collection to result reporting compared with traditional testing labs, enabling rapid intervention following a positive result. The flexibility of the GeneXpert platform, including the instrument’s robustness, the independently functioning analyzers, and the wide range of tests available, makes it particularly well suited to mobile laboratories. This program demonstrates the impact of on-site testing and highlights the challenges that were overcome for successful implementation, providing a blueprint to support the development of other mobile laboratories in the US.
Assessment of Clinical Laboratory Personnel Protective Equipment Inventory Management During COVID-19 Pandemic in the Philippines
Authors: Pingol M
Published: October 2021

Introduction/Objective

COVID-19 pandemic has brought a worldwide scarcity of personal protective equipment, which prompted medical technologists to explore the inventory management strategies, specifically the maintenance, conservation, and alternative use of personal protective equipment. The study aimed to assess the impact of these strategies on the personal protective equipment shortage in laboratories, as well as identify and describe the clinical laboratory supply and demand of personal protective equipment during the outbreak.

Methods/Case Report

The researchers utilized a quantitative survey involving one hundred thirty-six medical technologists working in an institution-based laboratory of Makati and Taguig City. The collated data were encoded in Microsoft Excel for descriptive statistics containing frequency distribution.

Results (if a Case Study enter NA)

27.9% of the respondents affirmed that they experienced a shortage of personal protective equipment in their workplace but most were unsure whether the contributing factors caused it. The respondents resorted to inventory management strategies to alleviate their lack of personal protective equipment. However, 41.9% and 38.2% of the respondents were undecided whether the efforts to conserve personal protective equipment and the supply management strategies were effective, respectively. Meanwhile, 40.4% of the respondents agreed that personal protective equipment alternatives can help in mitigating the demand for traditionally manufactured personal protective equipment.

Conclusion

Nonetheless, they were able to utilize inventory management strategies in which they were unsure if conservation and maintenance of personal protective equipment were effective but affirmed with the competency of an alternative use for alleviation.
Histology Slide Quality Improvement Project Utilizing DMAIC principle of Six Sigma Quality Improvement Methodology
Authors: Wang Y , Loboda A , Chitsaz M , Ganesan S
Published: October 2021

Introduction/Objective

DMAIC (an acronym for Define, Measure, Analyze, Improve and Control) refers to a data- driven improvement cycle used for improving, optimizing, and stabilizing business processes and designs. Our goal was to utilize DMAIC principle of six sigma quality to improve histology slide quality.

Methods/Case Report

We “defined” the problem as suboptimal quality in endometrial biopsy slides (defects). Utilizing the DMAIC principle and adhering to a strict timeline, the defects found during baseline slide quality review were “measured” by linking the defects to specific histology competencies, which were addressed systematically for process improvement (PI). After PI, a follow up review (“improve” and “control” phases) was carried out to identify measurable outcomes as a testament to quality.

Results (if a Case Study enter NA)

During the problem “measurement” phase, the defects found in the baseline review of 175 slides were linked to four specific histology competencies (fixation, embedding, cutting, and staining). Processing was excluded as it is completely automated and standardized. Our analysis showed that 83.3 % of defects were linked to embedding (“tissue too dispersed”). As embedding competency depends on the size and nature of the tissue (e.g. mucus and blood admixed with tissue), grossing competency was also addressed along with embedding at the respective workstations. Recommendations were offered to the grosser, embedder, and cutter to reduce variables during the “improvement” phase. Follow up review was done on 196 slides. The number of defective slides decreased and the defects that linked to “tissue too dispersed” had an overall improvement of 91.3%. Once the PI is proven to be effective, in service to histotechnology personnel biannually were also offered during “control” phase.

Conclusion

We have demonstrated successful methods for improving histology slide quality utilizing DMAIC principle of quality improvement by six sigma methodology DMAIC principle can be creatively adapted in laboratory practice management to enhance quality.
Impacts of the Virtual Landscape During the COVID-19 Pandemic on the 2020 Application Cycle
Authors: Cutshall H , Amerson C , Singh N , Hattaway R , Rais-Bahrami S , McCleskey B
Published: October 2021

Introduction/Objective

In response to the COVID-19 pandemic, the 2020 application cycle adapted to a mostly virtual setting. This project focused on the impact of these changes on the 2020 application cycle with the elimination of in- person away rotations and interviews, as well as the implementation of new virtual opportunities for learning and interacting with residents and programs.

Methods/Case Report

This study was conducted through an anonymous survey sent out to programs that engaged in social media usage in the 2020 application cycle. The survey was made available to program directors, faculty, residents and the matched applicants and focused on their usage and opinion of impact of virtual opportunities, virtual interviews and social media encounters.

Results (if a Case Study enter NA)

A total of 17 program directors/faculty, 17 residents and 19 matched applicants completed the survey across 91 programs surveyed. Virtual opportunities that were offered across these programs include: open houses, sub-internships, didactic lectures, grand rounds, Q&A sessions, and virtual facility tours. Responses showed that 4 programs (16%) moved applicants up on their rank list based on pre-interview virtual interactions. From the applicant perspective, 13 (76.5%) said virtual opportunities impacted the way they evaluated programs with 13 (68.4%) ranking programs higher and 3 (15.7%) ranking programs they otherwise would not have ranked. On the other hand, 21 faculty/residents (80.7%) felt that applicants missed out on fully experiencing the program due to lack of in person interviews and away rotations. However, 14 programs (56%) interviewed more candidates and offered more interview days during the 2020 application cycle. Applicants also applied to a greater number of programs with 42% of surveyed applicants applying to more than 50 programs, however none attended more than 30 interviews.

Conclusion

In conclusion, adaptations in response to the COVID-19 pandemic have provided an unexpected opportunity to explore the impact of the virtual landscape on residency recruitment.
Reducing IV-contaminated blood specimens in the clinical laboratory: A Quality Improvement Project
Authors: Harrington A , Kroft S H , Wells T , Gannon V
Published: October 2021

Introduction/Objective

Preanalytical errors constitute the most common errors in the laboratory, with improper specimen collection accounting for many errors. In our laboratory, we had a sentinel event related to repeated deletions of suspected IV-contaminated draws, and herein report our quality improvement project (QIP) to reduce deleted test results and IV-contaminated specimens.

Methods/Case Report

Our QIP initiated with creating a core-lab task force. Several interventions were launched: (A) policy/definition standardization, (B) nursing IV-line/cathedar in-services, (C) in-services on deleting test results and identifying IV-contamination, (D) policy updates to reflect no deletions without evidence of IV-contamination, and (E) mitigation steps requiring supervisory approval for result deletions. We measured: patient safety events (PSRs); RECOLLECTION comment usage and efficacy (disclaimer attached to results thought to be IV-contaminated, requesting recollection); and mitigation failures. Efficacy of the comment usage was measured by comparing subsequent collections to the original and determining likelihood of IV-contamination (contaminated, not contaminated, and unsure). Prior to the QIP, lab practice was to delete suspected IV-contaminated results and those requested by the care team.

Results (if a Case Study enter NA)

PSRs attributable to IV-contamination dropped from 47/mo. (time 0) to 18/mo. over an 11-month period (min-8/mo.; max-64/mo.), with the greatest decrement seen following intervention C. The RECOLLECTION comment was attached to 38 results (0.06% of total accessions) at the start and 73 results (0.12% of total accessions) at time 11 mos. and showed greatest increase in use immediately prior to interventions C and D (approximately 3-fold increase). At time 0, 54% of RECOLLECTION comments were deemed contaminated and 31% were not; at time 11mos., 74% (50/68) were contaminated and 24% (16/68) were not. Mitigation failures numbered 5/mo. initially and 1/mo. at time 11 mos.

Conclusion

With multiple educational and supervisory interventions, we demonstrate a reduction in PSRs attributable to IV-contamination collections at our hospital. Use of cautionary disclaimers was overall minimal and appropriately used.
Adherence to Choosing Wisely Campaign Guidelines at Three Health Systems
Authors: Windham A K , Whitted M , Brimhall B , Buckley J , Nichols G , Weddell B , Thomas D , Leung B
Published: October 2021

Introduction/Objective

With rising healthcare costs in the United States, there has been a push for lab stewardship to improve the quality of patient care while reducing costs. To optimize the use of clinical laboratory testing, the ASCP working with other medical specialty organizations, developed the Choosing Wisely Campaign to promulgate evidence-based guidelines to optimize clinical laboratory testing.

Methods/Case Report

We examined adherence to three Choosing Wisely guidelines over a four-year period (2017- 2020), through queries of internal cost accounting databases to return aggregate volumes as well as variable and total costs at three large academic health systems. We measured concurrent orders for: 1) erythrocyte sedimentation rate (ESR) with C-reactive protein (CRP), 2) serum/plasma amylase with lipase, and 3) free thyroxine (FT4) and/or total triiodothyronine (TT3) with thyroid stimulating hormone (TSH) when the TSH is within the reference range (using an frequency estimate of 85% based on other studies). We also examined another guideline for concurrent orders for serum aldolase with creatine kinase (CK). We also quantified aggregate variable costs for the non-recommended test in each Choosing Wisely guideline (amylase, ESR, FT4 and/or TT3), and for serum aldolase when ordered with CK.

Results (if a Case Study enter NA)

Over the four-year period, there were 322,853 unnecessary tests based on these four guidelines (120,587 ESR and CRP, 30,444 amylase and lipase, 164,818 FT4 and/or TT3 with TSH, and 7,004 aldolase). Overall, unnecessary testing decreased between 2017 and 2020 for amylase with lipase, remained essentially unchanged for aldolase, and increased for the other two test guideline scenarios. The largest changes were concurrent orders for amylase and lipase at one health system (38% decrease), and orders for TT3 with a normal TSH result at another health system (324% increase). The four-year variable cost of these unnecessary tests was $1,215,309 ($303,827 mean annual cost), resulting in potential annual variable cost savings of $101,276 for each health system for the four guidelines we examined. Variable costs for unnecessary testing increased by 16.5% ($45,571) over the four-year period.

Conclusion

Guideline-based unnecessary testing remains as a target to improve laboratory diagnostic testing. There is potential to realize significant achievable cost savings if guidelines are implemented and maintained.
Addressing Opportunities & Misunderstandings of ASCP International Certification in the Philippines
Authors: Finnegan K , Tanabe P , Baker J
Published: October 2021

Introduction/Objective

The objective of this study is to identify the positive viewpoints and misunderstandings Filipino applicants have about the BOC’s international credential and credential maintenance programs. With a total of 10,836 MLS(ASCPi) certificants, the Philippines is the BOC’s largest and most successful international certification market. However, despite the Philippines being the BOC’s largest international certification market, the BOC only certifies about a third of eligible Filipino graduates each year.

Therefore, to encourage additional interest in achieving BOC credentials and to eliminate misunderstanding surrounding the BOC’s Credential Maintenance Program (CMP), the ASCP BOC International Credentialing Committee created and deployed a survey.

The purpose of the survey was to learn as much as possible about the medical laboratory scientist certification market in the Philippines, as well as determine what opportunities Filipino‘s were afforded after they earned their credential. The resulting report based on analysis of the survey results showed there are a number of issues affecting Filipino participation in the BOC’s credential and CMP offerings.

Methods/Case Report

422 individuals from 44 countries of education participated in the survey. This study is a summary of results from the 265 Filipino respondents.

Results (if a Case Study enter NA)

This study confirmed a number of assertions the BOC had about the Filipino credential market. The most important of these assertions is MLS(ASCPi) certification is appealing to Philippine- educated individuals due to its portability (i.e., work eligibility, emigration, etc.).

Conclusion

The BOC should continue leaning into the portability of MLS(ASCPi) certification, but also needs to do a better job of promoting our other international certifications for which Filipinos may be eligible. The BOC needs to place greater emphasis on educating Filipinos on the importance of CMP and on what can be used for CE towards CMP. For example, the BOC needs to create an outreach campaign that helps Filipino credential holders understand CE earned for their PRC (i.e., Philippines-licensure requirements) can also be used for their CMP. Finally, considering the popularity of BOC certification in the Philippines, the BOC should work on creating more content that focuses on promoting the usefulness of pursing an advanced credential, the portability of certification, and the overall demystification of CMP.
Comparison of the Institute for Credentialing Excellence Multi-Organization Survey of Certificants
Authors: Francis E , Harrington A , Eschliman P J , Harrington S , Duzan D , Tanabe P
Published: October 2021

Introduction/Objective

The Institute for Credentialing Excellence (ICE) conducted a study to measure the value that credential holders place on certification, collecting survey data from a large sample of more than 12,000 credential holders representing six organizations (4 of which were healthcare). In May of 2019, ASCP BOC sent the survey to 47,384 individuals certified within the last 5 years. Of those who received the survey; 2,038 completed the 80 required questions. A comparison of survey data provided an overview of the top five differences in the full survey data (n=9,407) and the data from respondents credentialed by ASCP BOC (n = 2,038 or 22% of full survey respondents) and highlighted the primary reasons individuals pursue certification.

Methods/Case Report

This survey sought to define certificants’ attitudes toward and experiences with certification. Survey questions were grouped by four primary subject areas:

The Value of Certification for Respondents’ Professions

The Value of Certification for Employers

The Value of Certification Outside the U.S. and Canada

The Value of Certification for Certificants

- Responses of themed queries of full survey data and BOC survey data were viewed side by side and averages, standard deviations and medians were calculated. The top 5 items indicating the highest difference from the full survey data results were highlighted.

- Ranked primary motivational factors for the pursuit of certification were viewed side-by-side.

Results (if a Case Study enter NA)

Based on a side-by-side comparison of full survey data and BOC survey data, only minor differences were noted with the exception of the question pertaining to the perceived value of recertification. Both differences and items of agreement were highlighted.

The top 10 reasons for seeking certification were the same amongst both the full survey and ASCP BOC survey respondents, with minor differences in priority order.

Conclusion

With the exception of the question regarding the value of recertification, discrepancies noted were minor. On most questions pertaining to the various benefits of certification, a majority of respondents gave a positive response about certification and its relationship to beneficial outcomes for their professions, employers, or themselves. It is clear that certificants place a high value on certification and believe that certification provides a number of valuable benefits.
Cytokeratin 7 and Copper Stains Facilitate Diagnosis of Small Duct Primary Sclerosing Cholangitis
Authors: Wilhelm A , Stevenson H L , Kline K
Published: October 2021

Introduction/Objective

Classic primary sclerosing cholangitis (PSC) involves extrahepatic and/or intrahepatic biliary ducts with segmental biliary strictures and dilatations that often allow the diagnosis to be made via cholangiogram. Small duct PSC (sdPSC) is a rare subtype that presents similarly with a cholestatic pattern of injury, yet due to the small size of involved ducts, a cholangiogram is non-diagnostic and diagnosis is dependent on clinical suspicion and liver biopsy. The histopathological features of sdPSC are often subtle and may easily be overlooked. Diagnosis of this entity- though difficult- is important, as early recognition can facilitate the identification of associated disease processes and life-threatening complications.

Methods/Case Report

We encountered a 33-year-old female presenting with intermittent pruritis, episodes of jaundice, and persistently elevated alkaline phosphatase who was misdiagnosed with only fatty liver at an outside institution. Evaluation with MRCP showed no abnormalities within the biliary tract and a liver biopsy was performed to aid in the diagnosis. The H&E and trichrome findings of atrophic bile ducts and some peribiliary sclerosis were extremely subtle and may have been overlooked without clinical suspicion. Cytokeratin 7 (CK7) highlighted cholangiolar metaplasia in hepatocytes and the bile ductular reaction that occurs in cholestatic disease states. A Rhodamine copper stain showed periportal deposition suggestive of chronic biliary obstruction. Use of CK7 and copper stains supported the presence of chronic biliary injury and suboptimal bile flow, confirming the diagnosis of sdPSC.

Results (if a Case Study enter NA)

NA

Conclusion

Diagnosis of sdPSC has historically relied on H&E and trichrome stains. In this case, the findings on H&E and trichrome stains were non-diagnostic, while the use of CK7 and copper stains confirmed the diagnosis of sdPSC. We recommend using CK7 and copper stains to evaluate for sdPSC.
Liver histology in short telomere syndrome: A case report and review of the literature
Authors: Bai L , Liu Y
Published: October 2021

Introduction/Objective

Short telomere syndrome (STS) is a genetically inherited syndrome resulting in premature telomere shortening. STS encompasses a spectrum of clinical manifestations, including dyskeratosis congenita, premature hair graying, bone marrow failure, immunodeficiency, pulmonary fibrosis and liver disease. Liver histopathologic features in STS patients have not been well characterized.

Methods/Case Report

A 46-year-old man presented for dyspnea and cryptogenic cirrhosis. He had a complicated medical history significant for immune thrombocytopenic purpura and splenectomy, recurrent respiratory tract infections, pneumonia, sepsis, primary immunodeficiency, pulmonary mucosa-associated lymphoid tissue lymphoma, and severe hepatopulmonary syndrome. He and his brother had gray hair in their late 20s. He also had a long history of intermittently elevated liver enzymes starting at age 33. A liver biopsy performed 12 years before showed chronic portal inflammation with hepatocellular damage without significant fibrosis. These clinical manifestations prompted an evaluation for a possible telomere biology disorder, which revealed the telomere length was critically short and fell at or below the first percentile for age, supportive of the diagnosis. The most recent liver biopsy showed marked portal lymphocytic inflammation with interface hepatitis, bile ductular reaction and frequent foci of lobular inflammation with focal hepatocyte dropout. Some hepatocytes around the portal tracts were swollen with feathery degeneration and occasional Mallory-Denk bodies. A Rhodanine stain highlighted copper granules in the periportal hepatocytes, suggesting chronic cholestasis. Trichrome and reticulin stains demonstrated portal/periportal/pericellular/perisinusoidal fibrosis and focal bridging fibrosis.

Results (if a Case Study enter NA)

NA

Conclusion

Partly due to the rarity of STS and the risk of bleeding associated with biopsies, liver histology was described in only few limited studies with small samples of STS patients, including inflammation, nodular regenerative hyperplasia, steatohepatitis, hemosiderosis, cholestasis, cirrhosis, and large cell change of hepatocytes. Our case and others suggest liver disease associated with STS demonstrates a spectrum of histopathology. Being aware of these histomorphologic features in STS is important for establishing the correct diagnosis.
Public risk from antibiotic resistant Escherichia coli colonized in urban wildlife
Authors: Leu-Burke G , Madsen C , Bish A , Madsen J
Published: October 2021

Introduction/Objective

Escherichia coli is an especially dangerous health threat to humans when it develops multi- drug resistance. Decreased sensitivity to quinolone and beta-lactam antibiotics has been documented with antibiotic use in health care and agriculture. Migrating birds interact with wastewater treatment plants colonized with drug resistant Escherichia coli potentially transfer to other wildlife. Anchorage is home to 1500 moose and migrating geese providing a potential risk for Escherichia coli colonization. Because fecal contamination is abundant in Anchorage’s greenspaces, we evaluated the presence of Escherichia coli and antibiotic resistance in urban moose.

Methods/Case Report

Between 2018-2020, moose fecal samples were ground collected during the spring thaw within Anchorage Alaska, placed in transport media and cultured to MacConkey agar. Lactose fermenting colonies were further identified as Escherichia coli by biochemical testing and sub-cultured to sheep blood agar for antimicrobial evaluation. Using the Kirby Bauer method, antimicrobial sensitivity for cefpodoxime, ampicillin, piperacillin/tazobactam, gentamycin and ciprofloxacin were performed and interpreted using Clinical Laboratory Standards Institute guidelines

Results (if a Case Study enter NA)

A total of 150 samples were analyzed with 39% positive for Escherichia coli: fourteen in 2018, seventeen in 2019, and twenty-eight in 2020. In 2018, resistance was significant in ampicillin (43%), limited in piperacillin/tazobactam and cefpodoxime (14%). In 2019 found a 40% overall increase of antimicrobial resistance and by 2020 Escherichia coli isolates were resistant in all antibiotics tested: cefpodoxime (100%), ampicillin (96%), piperacillin/tazobactam (43%), gentamycin (35%), and ciprofloxacin (32%).

Conclusion

Measuring resistant patterns of Escherichia coli in wildlife is essential to understand the risk of colonization. Transmission of infectious agents can occur due to environmental exposure and Anchorage has expanded greenspaces resulting in increased human interaction with urban wildlife. In 2018, we found antimicrobial resistance only to ampicillin but subsequent years discovered decrease sensitivity and by 2020 Escherichia coli isolates resistant to one or more antibiotics including beta-lactams, quinolones, and aminoglycosides. The risk of zoonosis of multi-drug resistant Escherichia coli, especially in our housing insecure, has a significant impact for patient outcome.