bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prostatic Ductal Adenocarcinoma Masquerading as a Rectal Mass: A Case Report
Authors: Sahni Suhalika , Mehta Vikas 
Published: September 2019

Abstract

Objective
The approach to a patient presenting with a rectal mass who has a history of bright red blood per rectum (BRBPR) renders a wide range of differential diagnoses. The clinical reasoning to suspect prostatic ductal adenocarcinoma (PDA) in a patient with BRBPR without a classical clinical presentation is highly unlikely. The incidence of PDA is rare with only 0.4% to 0.8% in pure ductal origin.

Methods
A 71-year-old African American male presented with 3-month history of watery, bloody diarrhea and a recent history of BRBPR with unintentional weight loss. Patient underwent colonoscopy, which showed a large polyp 10 cm from the anal verge, measuring 7 cm. The unclear history of this patient contributed to an initial impression of a colorectal cancer leading to a biopsy of the colonic mass.

Results
An erroneous diagnosis of tubulovillous adenoma was rendered initially. Further workup showed a large mass originating from the prostate area that was seen penetrating the colorectal region on an abdominal CT scan. The patient’s serum prostate-specific antigen (PSA) level was alarmingly high (4,800 ng/mL) and a subsequent prostate biopsy showed PDA. The colonic biopsy was reviewed again by a genitourinary pathologist and a correct diagnosis was rendered.

Conclusion
The role of pathology in diagnosing PDA is crucial as patients with PDA can have normal digital rectal examination (DRE) as well as a normal serum PSA level (less than 4.0 ng/mL). Majority of PDAs originate from periurethral prostatic ducts. The unique presentation of primary prostate pathology offers appreciation into the approach and workups to diagnose PDA. Diagnosing PDA can be challenging due to its more aggressive nature of PDA compared to prostatic acinar adenocarcinoma. The clinical reasoning and pathological findings from this rare case can aid clinicians and pathologists to establish the diagnosis of PDA in a timely and efficient manner.
Multiple Subcutaneous Nodules Leading to the Diagnosis of Colon Cancer
Authors: Madabhavi Irappa , Modi Mitul , Sarkar Malay , K S Sandeep , Shah Mansi , Mallikarjuna Vinay Sakaleshpura 
Published: September 2019

Abstract
Cutaneous metastasis refers to the growth of cancer cells in the skin originating from an internal cancer. The incidence of subcutaneous metastasis from a visceral malignancy, excluding malignant melanoma, lymphoma, and leukemia, is rare with an incidence of 5.3%. Skin involvement, as a presenting sign of a silent malignancy, is a rare event occurring in approximately 0.8%. Here, we report an interesting case of a 39-year-old man who presented with multiple subcutaneous nodules over anterior chest and forehead for the past 3 months. Physical examination showed nontender, firm to hard multiple subcutaneous nodules ranging from 1 to 2 cm in size. The patient also reported unintentional weight loss and altered bowel habits. Complete blood count showed hemoglobin of 8.0 g/dL, with mean corpuscular volume (MCV) of 97 pg/mL and carcinoembryonic antigen (CEA) of 480 IU/mL. Fine-needle aspiration of the cutaneous nodules revealed malignant cells arranged in a glandular pattern with intraglandular mucin, as well as hyperchromatic and vesicular nuclei with prominent nucleoli. Imaging of the abdomen revealed asymmetrical circumferential thickening with luminal narrowing of cecum and ascending colon and mild ascites with no evidence of liver metastasis. Microscopic examination of the ascending colonic mass showed malignant cells with similar microscopic features. Patient was managed with multiple blood transfusions, and palliative right-sided hemicolectomy was performed in view of intermittent constipation. Sixteen cycles of postoperative chemotherapy were given, after which the subcutaneous lesions regressed and the CEA came down to 56 IU/mL. Skin metastases from colorectal cancer are extremely rare and further analysis of the biology of this mode of metastases may shed light on mechanisms of metastases to specific organs and hopefully provide guidelines for novel targeted therapeutic interventions.
Incidental Gallbladder Cancer: A Clinicopathological Study
Authors: Dhorajiya Poojaben , Mannan Rifat , Sharabi Abdelsalam 
Published: September 2019

Abstract

Objectives
Incidental gallbladder cancer (iGBC) is defined as gallbladder cancer (GBC) diagnosed at the time of or after cholecystectomy, performed for unsuspected benign gallbladder disease. Being rare, it is found in 0.2% to 2.9% cases of cholecystectomies performed for cholecystitis and represents approximately 40% of all GBCs. Here, we present the clinical and pathological features of iGBC diagnosed at our institute over a 10-year period.

Methods
The pathology reports of GBC in patients who underwent simple cholecystectomies due to sole complain of cholecystitis between 2008 and 2018 were retrieved from electronic medical records. Cases with dysplasia (without invasive component), clinically suspected gallbladder malignancy, polyp (nonincidental), or cholecystectomies performed as a part of any other procedure were excluded.

Results
Twenty-two cases of iGBC were diagnosed during the study period. Average patient age was 69.59 (range; 48-91) years, with a slight female (n = 12, 54.5%) predominance. Most common site was body (n = 7), followed by fundus (n = 4), neck (n = 2), and unknown (n = 9). Mean tumor size was 1.6 cm, where measurement of tumor size was possible (n = 16). Histopathological diagnoses were adenocarcinoma (n = 21) and carcinosarcoma (n = 1). The AJCC tumor staging was pT1a (n = 3), pT1b (n = 3), pT2 (n = 12), pT3 (n = 3), and unidentifiable (n = 1). Four cases were identified with N1 lymph node status. Cystic duct margin was positive in two cases. Perineural invasion was identified in three cases.

Conclusion
iGBC after a cholecystectomy for clinically benign condition is a rare finding. Although cholecystitis is much more frequent in female, iGBC had only a slight predominance for female population in our study. It is more common in people over 60 years of the age, which is comparable to the literature. This entity still remains a diagnostic and therapeutic challenge, and management is often more complicated in cases with advanced stage.
Secretory Carcinoma Ex Pleomorphic Adenoma: A Case Report
Authors: Egal Erika , Souza Reydson , Scarini João , Martins Antonio , Casarini Andre , Altemani Albina , Mariano Fernanda 
Published: September 2019

Abstract
The objective of this study is to report a case of carcinoma ex pleomorphic adenoma subclassified as secretory carcinoma ex pleomorphic adenoma frankly invasive. A 60-year-old male patient attended our service for cervical injury assessment, painless with slow and progressive growth for about 3 years. At the clinical examination, an increase in volume in the submandibular region and a lesion in the region of the nasolabial sulcus were observed. A biopsy of the lesion was performed and the morphological characteristics were compatible with secretory carcinoma of the salivary gland. The patient underwent a radical cervical emptying, excision of the left submandibular gland, and removal of the lesion in the left nasogastric sulcus. At the macroscopic examination, the submandibular gland presented a hardened, heterogeneous nodule, poorly delimited, with gross calcification at the center, measuring 2.0 × 1.5 × 1.5 cm. At the histopathological examination, eosinophilic cells containing intracytoplasmic vacuoles, with a ductal formation and solid arrangement and dystrophic calcification, were observed corresponding to the old hyalinized areas of residual PA. In view of these findings, the diagnosis was secretory carcinoma ex adenoma pleomorphic frankly invasive of the submandibular gland with extension to the nasogenian sulcus. Complementary immunohistochemical examination was carried out evidencing positivity for mammaglobin, S100, and CK7 in tumor cells and negativity for calponin, 1A4, and p63.
Conclusion: Although CXPA is a rare lesion and is more common in parotid glands, it may affect other locations. Several histopathological phenotypes may arise from the malignant transformation of the PA, but to the best of our understanding, this is the first case of secretory carcinoma ex pleomorphic adenoma reported in the literature.
Quality Assurance of the Gallbladder and Relationship Between Gallstones and Abdominal Panniculus Thickness in Adult Hospital Autopsies
Authors: Kaur Gagandeep , Williams Kaitlyn , Vidhun Ramapriya , Dodge Jessica 
Published: September 2019

Abstract

Objectives
Inconsistency in the autopsy report can be a liability issue. We studied the discordance between the presence of the gallbladder and a corresponding abdominal scar and suggest how to improve this error. To our knowledge, the relationship between abdominal panniculus thickness in adult hospital autopsies and the presence of gallstones has not been reported in the literature. We report the correlation between age, sex, average panniculus thickness, and gallstones.

Methods
The laboratory information system was searched for autopsies performed between 1/1/09 and 12/21/18. Patients <18 years old and partial, nonabdominal autopsies were excluded. Autopsy reports were reviewed, and the following data were recorded: age, sex, presence or absence of gallbladder, abdominal scars, abdominal panniculus thickness, and gallbladder pathology.

Results
Out of 385 autopsies reviewed, 48 (12.5%) had cholecystectomies. Of these 48 patients, 6 (12.5%) abdominal scars were not documented. The presence of the gallbladder was not mentioned in 6 (1.6%) reports. The most common pathology was gallstones, 78 (20.3%); cholesterolosis, 9 (2.3%); and cholecystitis, 6 (1.6%). The average age of females and males with gallstones was 68.9 and 66.4 years, respectively. The average abdominal panniculus thickness in males with and without gallstones and in females without gallstones was 3.3 cm. In contrast, the average abdominal panniculus thickness in females with gallstones was 4.0 cm.

Conclusion
Our study demonstrated that 12.5% of our autopsy reports failed to document the presence of abdominal scars in patients who surgically lacked a gallbladder. There is a need to improve documentation of abdominal scars and the presence or absence of the gallbladder. This can be achieved by creating mandatory fields (eg, gallbladder present/surgically absent) in the autopsy report template. Also, our study found that females with gallstones have a thicker abdominal panniculus than females without gallstones and males with or without gallstones.
Dysphagia Lusoria: A Rare Entity and Underrecognized Cause of Dysphagia
Authors: Estrella Melanie , Chauhan Suman 
Published: September 2019

Abstract
Management of dysphagia lusoria (DL), dysphagia caused by esophageal compression by an aberrant right subclavian artery (ARSA), is a clinical challenge. Sixty percent of patients with ARSA develop an aneurysm in the aberrant artery, which increases the risk of developing worsening dysphagia, tracheal compression, aortic dissections, and aneurysmal ruptures. Surgical management of ARSA has been studied, but no definitive standards have been established. As a result, most patients elect for surgery only when compressive symptoms become too severe.
We present the case of a 68-year-old male found to have worsening dysphagia from an enlarging ARSA aneurysm. A bilateral carotid-subclavian bypass with embolization of both subclavian arteries and aortic endograft placement was performed. Despite imaging showing successful bypass of the aneurysm, the patient’s compressive symptoms worsened. The patient had a prolonged postoperative course that was complicated by pneumonia and tracheal compression, requiring stent placement. On postoperative day 45, the patient went into cardiac arrest and expired.
Postmortem examination revealed an ARSA aneurysm measuring 7.8 × 4.5 × 4.3 cm. All grafts and embolization plugs were in place, without evidence of failure or migration. The aneurysmal sac contained a firm, well-organized clot, occupying 80% of the lumen. Diffuse ulcerative atherosclerotic disease was noted in the aorta. The lungs had gross and histologic findings consistent with pneumonia. Final cause of death was determined to be acute pneumonia with mass effect of the ARSA aneurysm as a contributing factor. Although the cause of the aneurysmal clot formation could not be identified, it raised the question of whether the degree of aortic atherosclerosis and aneurysmal size should be considered while developing indications for surgery.
With the increased detection of ARSA, this case suggests the degree of aortic atherosclerosis and size of the aneurysm should be considered in the establishment of surgical guidelines.
Clinically Unsuspected Invasive Fungal Infections in the Setting of Malignancy
Authors: Hendrix Joshua , Prochilo Gina , Serei Virian , Brister Kathriel , Fyfe Billie , Minerowicz Christine 
Published: September 2019

Abstract

Background
Hospital autopsy rates are currently less than 5% of all nonmedicolegal deaths, significantly decreased from a peak of 40% to 60% in the 1960s. Studies repeatedly demonstrate that advanced imaging and laboratory tests cannot substitute for postmortem examination. We present three cases of clinically unsuspected invasive fungal infections in the setting of malignancy.

Methods and Materials
We performed clinical chart reviews, postmortem examination with microbiology cultures and special stains, and literature review of three adult autopsy cases.

Results
Case 1: 55-year-old man with multiple myeloma 4 days after autologous stem cell transplant who presented with rapidly deteriorating clinical status despite successful treatment for MRSA sepsis; autopsy confirmed cause of death as disseminated Rhizopus infection.
Case 2: 65-year-old woman with myelodysplastic syndrome with myeloproliferative overlap and neutropenic fever on antimicrobial prophylaxis, including fluconazole. Cause of fever was presumed to be noninfectious etiology; autopsy confirmed cause of death as disseminated Candida krusei, an opportunistic invasive fungus resistant to fluconazole.
Case 3: 28-year-old woman with metastatic high-grade pancreatic neuroendocrine carcinoma. An autopsy was performed for the purposes of tissue retrieval; postmortem examination demonstrated a primary pancreatic head mass with oligometastasis to the liver and disseminated Aspergillus infection.

Discussion
Studies show discordance between the clinical cause of death suggested by the primary care team and the autopsy findings in up to 19% of cases. Additionally, autopsy confirmed the clinical diagnosis only 29% of the time and found that nearly 5% of antemortem diagnoses were completely refuted. Fungal infections are a frequent cause of missed diagnoses. A multi-institutional study examining 192,095 autopsies reported a 9% prevalence of fungal infections contributing to death, half of which were missed clinically. The most common risk factor was leukemia and the most common pathogen was Aspergillus species.
Abbott ARCHITECT STAT Contemporary Troponin I Outlier Detection and Prevention of Erroneous Outlier Result Reporting Using an Immediate Repeat Testing Protocol: A 1-Year Summary
Authors: Morgan Bradley , Droes Dawn 
Published: September 2019

Abstract

Objectives
The laboratory sought to monitor and eliminate reported patient cardiac troponin outlier results using the Abbott ARCHITECT STAT Contemporary Troponin-I test.

Methods
The laboratory implemented an immediate repeat test for all patient samples yielding an Abbott ARCHITECT STAT contemporary Troponin I concentration greater than the combined male and female 99th percentile of 28 ng/L. The lower troponin concentration of the paired testing was reported. Samples with reference range troponin concentration were reported without repeat testing. Blood collected in Becton Dickinson Vacutainer PST Gel and Lithium Heparin tubes was centrifuged using a HemoCue StatSpin Express 4 centrifuge 4,000 g × 5 minutes and immediately tested on the primary tube. Troponin outliers were defined as paired samples showing a percentage change based on the low value of the pair exceeding the significant change threshold of 4.7x%CVanalytical for brackets of troponin concentrations (P0.0005), representing a significant change value for serial tests of 1.41xZxCVa%, where Z is 3.3. Critical troponin outliers were sample pairs with one result exceeding and one result within the 99th percentile reference range. Turnaround time was defined as time of receipt to time of verification.

Results
The outlier rate, based on 4,575 troponin tests performed on 3,797 patient samples, was 0.48% (N = 22) of troponin determinations, 0.58% of test samples, and critical outliers 0.13% (N = 6) of troponin determinations, 0.16% of test samples. The significant change threshold at 28 ng/L was 37%. The worst outlier pair was 5,978 ng/L, true value 3,184 ng/L; critical outlier pair 146 ng/L, true value of 14 ng/L. Twenty-one percent of test samples were tested in duplicate; 777 samples had troponin concentration >28 ng/L. Median and mean turnaround time were 32 minutes; 90% of orders completed in 54 minutes.

Conclusion
The laboratory detected and prevented reporting erroneously high outlier troponin results in 0.58% and critical outlier troponin results in 0.16% of test samples using an immediate repeat testing protocol.
Calling Critical Troponin Values Using Significant Delta Rises in Serial Draws Instead of a Hard Cutoff to Help Identify Non-ST-Elevated Myocardial Infarction
Authors: Sheehy Patrick , Skelton Tim 
Published: September 2019

Abstract

Introduction
Non-ST-elevated myocardial infarction diagnoses rely more heavily on lab values. In this study, we examined the effectiveness of an algorithm calculating delta rise in troponins to identify critical values. Using this algorithm in combination with a system to directly call physicians for critical values would improve treatment time for these patients.

Methods
Troponin values were measured using Abbott Architect Stat TnI assay. Reports for 09/01/17 to 11/30/17 were generated using Beaker module of our Epic EHR.

Results
A total of 11,233 troponin values were evaluated for critical values. A total of 108 patients were identified as NSTEMI patients (troponin ordered as well as dual antiplatelet and/or high-dose heparin treatment). In total, 106 NSTEMI patients, or 98.14%, had a critical value using a 0.3-ng/mL cutoff. Eighty-six patients, or 79.63%, had critical values using the algorithm. Of the 106 criticals from a 0.3-ng/mL cutoff, only 76 would be called before treatment was ordered compared to 66 of the 86 criticals using the algorithm. Over 3 months, the algorithm would have called 485 total critical results while a 0.3-ng/mL cutoff would have called 1,913.

Conclusions
A 0.3-ng/mL cutoff had a higher percentage of critical results for NSTEMI patients, but similar numbers of clinically actionable critical results were identified by both methods. Upon further chart review of the 10 discrepant criticals identified by the cutoff but not the algorithm, 2 were identified as false-positive NSTEMI and 5 could be caught with minor algorithm adjustments. The algorithm was able to identify NSTEMI within a clinically actionable timeframe as effective as a 0.3-ng/mL cutoff with 75% fewer criticals called over a 3-month period, allowing criticals called directly to treating physicians to improve time to treatment.
Incidence Rates of Critical Low Glucoses (<40 mg/dL) Among Inpatients Before and After Adoption of a Policy for Laboratory Call-Back Notification of Clinically Significant Hypoglycemia (<54 mg/dL)
Authors: Castillo Jesus Rico , Stickle Douglas 
Published: September 2019

Abstract

Objectives/Background
Beginning in 2017, the American Diabetes Association defined clinically significant hypoglycemia (CSH) as glucose <54 mg/dL. In January 2018, our hospital initiated a call-back policy for inpatient CSH results made in the central laboratory, along with a new nursing policy for CSH response to measurements made either by the central laboratory or by point-of-care testing. Our objective was to determine whether these new policies had affected the incidence rate of low critical values for glucose (CRITICAL, <40 mg/dL) among inpatients at our institution, a 950-bed academic medical center hospital.

Methods
Glucose results for two 12-week intervals before (PRE) and after (POST) adoption of the CSH call-back policy were obtained retrospectively for both central laboratory (C) and point-of-care (P) measurements. Critical incidence rate (R) was defined as number of critical results per total number of measurements of glucose in the interval.

Results
There were four data sets: C-PRE (n = 44,142; CRITICAL = 35), C-POST (n = 46,341; CRITICAL = 66), P-PRE (n = 76,745; CRITICAL = 169), and P-POST (n = 78,838; CRITICAL = 218). For C, R increased in POST by 80% (PRE = 0.79E-3; POST = 1.42E-3). For P, R increased in POST by 26% (PRE = 2.20E-3; POST = 2.77E-3). Combining C and P data, overall R increased in POST by 34% (PRE = 1.69E-3; POST = 2.27E-3). These calculations for R did not, however, exclude possible repeated measurements on individual patients. Counting first or only CRITICAL results from unique individual patients, obtained either from C or P, a revised overall R was still significantly increased in POST, by 22% (PRE = 0.87E-3; POST = 1.06E-3) (P < .01).

Conclusion
After CSH policy changes, the rate of identification of new patients having critical low glucose increased substantially (+22%). This increase was unanticipated, and the exact cause was unknown. Potentially, the increase may reflect an increased awareness of CSH by clinical staff, leading to a higher preselection rate for measurement of CRITICALS and identification of a greater number of patient cases.