bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Decline of Medicare Reimbursement in Anatomic Pathology
Authors: Miskiel S , Khreshi S , Khraishi R , Pagliaro A , Bombonati A 
Published: October 2024

Abstract

Introduction/Objective
Lack of an annual inflationary update for physician reimbursement from the Centers for Medicare & Medicaid Services (CMS) jeopardizes access to anatomic pathology services at healthcare institutions nationwide. The effects of recent inflationary trends on anatomic pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for anatomic pathology procedures.

Methods/Case Report
The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation-adjusted monetary data.

Results (if a Case Study enter NA)
Prior to adjusting for inflation, the average physician reimbursement increased by 9.7% from 2004 to 2024 for all included anatomic pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 34.2% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for outside slide consultation at 60.5% ($330.12 to $130.49), followed by pathology consultation during surgery at 59.0% ($83.54 to $34.29). The average CAGR was -2.19%.

Conclusion
Our study demonstrates that Medicare physician reimbursement for common anatomic pathology procedures is declining annually at an unsustainable rate. This downward trend necessitates policy action to prevent access barriers to quality anatomic pathology care nationwide, especially for Medicare beneficiaries.
Identifying strengths and weaknesses at the bench, an institution’s quest to improve the Gram stain bench experience and patient care
Authors: Attaway C C , Van Huele H , Rhoads D 
Published: October 2024

Abstract

Introduction/Objective
The Gram stain is the first actionable result reported to guide treatment. In our laboratory, we noted instances of initial Gram stain results discrepant to subsequent cultures. In reevaluating the Gram stain bench, we devised a survey for medical laboratory scientists (MLS) to determine the strengths and weaknesses of the current workflow to search for areas of improvement. Results of the survey will help both leadership and MLS approach improving the interpretation and reporting of Gram stains.

Methods/Case Report
A 16-question survey was issued to all MLS in the microbiology lab over three weeks in January 2024 (Table 1). Questions (Q) 1 through 5 pertain to years of experience, how long it takes to review slides, and shift scheduling. Q6 through Q15 - addressing aspects of the bench including culture of the laboratory to ask for assistance, pressure to read slides, turnaround times, and confidence - were on a Likert scale from 1 to 5, 1 is strongly disagree and 5 is strongly agree; mean responses are in Table 1. Q16 was a free response question to input additional thoughts or comments. Responses were recorded on the secure local network using Microsoft Forms.
Welch’s t-test was performed on the responses for statistical analysis. Statistical significance is achieved in a p-value is &lt; 0.05.

Results (if a Case Study enter NA)
Among the 33 respondents (Table 1), first shift has the longest MLS work experience (Q2). Third shift perceived significantly more pressure to read Gram stains correctly than first shift (Q8 2.6; 4.6), and turnaround time pressure was felt to hinder their ability to read (Q11 2.1; 3.3). Individuals who perceived the field was too large for review also took more time to review slides (Q12 2.2; 3.0). Being staffed on the Gram stain bench less frequently was associated with taking longer to interpret Gram stains.

Conclusion
Our laboratory environment is, overall, conducive to asking for assistance, there is assistance when needed, there is confidence and allotted time to read stains, and there is perceived adequate training. However, the data indicate that second and third shifts are disproportionately comprised of MLS who read the most Gram stains, have the fewest years of experience, and are least inclined to ask for assistance. This information is invaluable for redesigning the Gram stain bench in a manner that benefits and empowers MLS to maximize their expertise to read Gram stains and provide the best care for patients. Further discussion is planned to redesign the workflow using this information.
Optimization of Turnaround Time and Insufficient Quantity Frequency for Molecular Testing on FFPE Material
Authors: Tavares-Macedo R , Homsi H , Galev G , Burns B , McAfee J , Azzato E , Dermawan J 
Published: October 2024

Abstract

Introduction/Objective
With clinical decisions relying progressively more on molecular data extracted from formalin- fixed, paraffin-embedded (FFPE) tissue, it is pivotal to optimize the use of tissue for diagnostic and prognostic purposes. This optimization can be reached by identifying actionable instances that can decrease the turnaround time (TAT) and the rate of “quantity not sufficient” (QNS) results

Methods/Case Report
From January 2023 to December 2023, the total TAT from the time a molecular study is ordered to its delivery to the molecular lab at LL200A (Tomsich Laboratories), as well as the TAT from the time between the ordering pathologist circling the region of interest to its delivery to LL200A were broken down by subspecialty and site. In addition, the QNS results of Caris genomic profiling were evaluated considering subspecialty and site, amount of material present in the initial sample, and number of levels cut for other ancillary testing from the same material.

Results (if a Case Study enter NA)
83% of subspecialties took longer than 48 hours to have material ordered for molecular studies delivered to LL200A. The median TAT for all specialties was 58 hours (average: 71.6 hours). When examining TAT from circling to LL200A, the median time was 19 hours (average: 28.4 hours). Regarding the QNS rate of the Caris assay, most QNS cases were gastrointestinal tract specimens (27%) or specimens obtained from either CT-guided core needle biopsies (30%) or endoscopic biopsies (32%). The longest dimension of QNS cases ranged from 7.5 cm to 0.1 cm (median: 1.3cm)—the average number of slides ordered before Caris ranged from 1 to 52 (median: 12).

Conclusion
The initial results pointed towards the time from circling to LL200A as one actionable item that could improve the TAT of molecular tests. Possible solutions include enacting a dedicated tumor circling service. In addition, to decrease the rate of Caris QNS results, we propose working together with proceduralists to increase biopsy material yield and to work with pathologists to preserve limited specimens for molecular studies.
Distinct Molecular Alterations in Hepatocellular Carcinoma (HCC) Arising in a Non-Fibrotic Liver Compared to a Cirrhotic Liver
Authors: Wang L , Ramesh R G , Priore S , stashek K , Alipour Z , Furth E E , Tondon R 
Published: October 2024

Abstract

Introduction/Objective
HCC is known to more likely develop in a cirrhotic liver than a non-cirrhotic liver, irrespective of etiology, with TP53 and CTNNB1 being the most frequent driver mutations in this group. Whether there are distinctive molecular pathways for HCCs developing in the non-cirrhotic liver is not known. This study evaluated whether there is any difference in the mutational profile of HCCs arising in a non-fibrotic liver compared to a cirrhotic liver.

Methods/Case Report
Clinicopathologic and in-house next generation sequencing (NGS) data from HCC cases sequenced between 1/1/18-6/30/23 were reviewed. Cases from a targeted precision NGS panel were excluded. Results were correlated with publicly available data from The Cancer Genome Atlas (TCGA).

Results (if a Case Study enter NA)
29 cases were available for review; 24 patients had background cirrhosis at the time of diagnosis, while 5 patients had no evidence of fibrosis. 21 of 24 patients (88%) patients in the cirrhosis group had a variant in TP53 and/or CTNNB1 that was considered to be disease associated or probably disease associated, whereas only 1 of 5 patients (20%) in the non-fibrotic group had a variant detected in one of these genes (Fisher’s exact: p &lt; 0.01). BAP1 and ARID1A variants were detected in two patients in the non-fibrotic group. TP53 and CTNNB1 were generally mutually exclusive (86% of cases), however, 3 patients harbored both TP53 and CTNBB1 variants; interestingly all 3 had background cirrhosis and HCV infection. All 6 poorly differentiated tumors occurred in cirrhotic livers and were found to have TP53 variants (Figure 1). TCGA data (N = 210) similarly showed that patients with intermediate fibrosis or established cirrhosis (N = 138) were more likely than patients without background fibrosis (N = 72) to harbor TP53 or CTNNB1 variants (64% vs 42%; Chi-squared: p &lt; 0.01; Figure 2). Aside from TP53 and CTNNB1, the most common variants seen in the TCGA non-fibrotic group were in TTN (22), ALB (10), FREM2 (9), LRP1B (9), and MUC16 (9).

Conclusion
Both in-house and TCGA data showed that TP53 and/or CTNNB1 variants were more likely to be seen in HCC cases arising in a cirrhotic liver compared to a non-fibrotic liver. This data suggests there may be unique and less-well characterized molecular pathways involved in the neoplastic progression of HCC in a non-fibrotic liver.
Cervical spinal metastasis of unsuspected hepatocellular carcinoma on initial presentation
Authors: Panjshiri F , Lopez C A , moroz K 
Published: October 2024

Abstract

Introduction/Objective
In this case, a 66-year-old female reported to the emergency room (ER) for severe worsening neck and shoulder pain bilaterally for one month. Associated symptoms included bilateral hand weakness, swelling of the hands, inability to pick up objects, and inability to press buttons. MRI and CT scan of the spine demonstrated irregular marrow signals within C5, C6, and C7 vertebral bodies associated with anterior epidural thickening and the C6 vertebral body extending along C4-C5 nerve roots. Further imaging demonstrated a distended hepatic lesion measuring 6.3 x 6.4 x 6.9 cm. CT-guided biopsy of right hepatic lobe mass was performed. The cuboidal tumor cells showed abundant clear cytoplasm and centrally located nuclei demonstrated high nuclear:cytoplasmic ratio, and trabecular architecture. Tumor was immunoreactive to CK-7, CK-20, and Hep par 1, consistent with HCC. The Ki-67 proliferative activity is at 10%. Additionally, AFP, Napsin A, Pax 8, and RCC stains were negative. CT- guided biopsy of the longus colli muscle and anterior cervical spine at the C6 vertebrae performed at the same time demonstrated tumor positive for Hep par 1, consistent for metastatic HCC from just established liver primary. Bone metastasis of hepatocellular carcinoma (HCC) on initial presentation is rare, with an incidence rate of 0.9%. Of these cases, most incidents involve the vertebrae, pelvis, ribs, and skull, with poor patient morbidity and mortality. The thoracic and lumbar spinal locations are common in the field of view of standard abdominal imaging protocols and possibly are the most commonly reported regions of HCC spinal metastasis.

Methods/Case Report
Case report.

Results (if a Case Study enter NA)
NA

Conclusion
This case report demonstrates an unusual clinical presentation of spinal radiculopathy initially thought secondary to degenerative changes, which led to additional diagnostic imaging revealing a hepatic mass biopsied positive for hepatocellular carcinoma with metastasis to the spine.
Primary Malignant Peripheral Nerve Sheath Tumor in the Liver with Glandular Differentiation
Authors: Niu C , Ma Q 
Published: October 2024

Abstract

Introduction/Objective
Malignant peripheral nerve sheath tumors (MPNST) most commonly affect the proximal extremities and paraspinal region. Primary hepatic MPNST is extremely rare. Here we report a primary hepatic MPNST with heterologous glandular differentiation in a patient with Neurofibromatosis type 1 (NF1).

Methods/Case Report
Review of the clinical features and histopathological findings of the resected specimen. A review of all the published cases of primary liver MPNST.

Results (if a Case Study enter NA)
A 69-year-old male patient with a history of NF1, Gastrointestinal Stromal Tumor and treated hepatitis C without pre-existed neurofibroma presented with jaundice. Imaging revealed an ill-defied hypodense mass in the left hepatic lobe. A segmentectomy of the liver revealed an infiltrating 10 cm heterogenous yellow-white-pink slightly firm tumor with 5% necrosis. The tumor showed biphasic histology composed of predominantly spindle cells and clusters of glandular components. The spindle cells showed fascicular growth pattern with vaguely marbled appearance. Focal osteoclast-like multinucleated cells were seen. The glands were well defined, mostly appeared to be low grade, and lined by cuboidal to columnar cells, with a bile-duct and intestinal-like appearance. However, focal malignant glands with hepatic differentiation were also noted. Immunohistochemistry showed patchy loss of H3K27me3 in the spindle cells. The glandular cells were positive for AE1/AE3, CK7 and CK20. The tumor cells showed rare reactivity to TLE1 and were negative for S-100, SOX10, CD34, CD117 and DOG1.
These findings supported the diagnosis of MPNST with glandular differentiation. 13 cases of primary MPNST of liver have been reported, and only one case described epithelioid differentiation.

Conclusion
The differential diagnoses of a primary hepatic biphasic tumor include sarcomatoid carcinoma, carcinosarcoma, biphasic synovial sarcoma and MPNST. Our case illustrates a rare biphasic hepatic MPNST. The morphology and loss of H3K27me3 expression by immunohistochemistry in a patient with NF1 support this challenging diagnosis.
Metastatic Melanoma of Unknown Primary with Plasmacytoid Morphology Presenting as Acute Liver Failure
Authors: Chinchanikar S , Hassan A , Lankachandra K 
Published: October 2024

Abstract

Introduction/Objective
Viral hepatitis, drug toxicity, and autoimmune disorders are common etiologies of acute liver failure (ALF). Very rarely, a cause like metastatic melanoma may present as a primary driver of ALF. Malignant melanoma is histologically diverse and plasmacytoid melanoma is an unusual variant that may present as a solitary tumor or metastatic disease.

Methods/Case Report
A 48-year-old female presented with 2 weeks of right upper quadrant pain, nausea, coffee ground emesis and bleeding per rectum. She had no history of liver disease or alcohol use. On presentation, AST was 83 U/L, ALT was 29U/L, ALP was 159U/L and total bilirubin was 12.7g/dl. Viral hepatitis panel, HIV and chronic liver disease workup was negative. Esophagogastroduodenoscopy and colonoscopy showed no sources of bleeding. She was diagnosed with decompensated cirrhosis, ALF, and acute kidney injury from hepatorenal syndrome. Cirrhosis and multifocal indeterminate T1 hyper/T2 hypo intense lesions (dysplastic or regenerative nodules) were seen on MRI. Liver biopsy revealed metastatic melanoma. Almost entire liver parenchyma on biopsy was replaced by a population of neoplastic cells with plasmacytoid features. Immunostaining was positive for MART-1, HMB45 and SOX-10.
Staining for Pan Cytokeratin and CK-7 highlighted the bile ducts and negative staining was seen for CK20, CD3, CD20, PAX-8, GATA-3, CDX-2 and P63. No primary lesion was found. It was deemed unlikely that she would benefit from therapy before complications occur. She passed away in 16 days.

Results (if a Case Study enter NA)
NA

Conclusion
In most cases of ALF associated with malignant melanoma, the liver may have a seemingly normal appearance on imaging studies due to the distinctive histology of leukemoid tumor infiltration within the liver sinusoids, resulting in sinusoidal obstruction and subsequent hepatocellular dysfunction. The rapidity of liver failure in these cases is related to the replacement of liver parenchyma by malignant cells. The plasmacytoid morphology is seen in a variety of malignancies and to avoid a potential misdiagnosis of an aggressive malignant melanoma, it is imperative to perform a thorough histopathological evaluation aided with immunohistochemistry. It is important to keep in mind that the potential involvement of malignant tumor cell infiltration may cause ALF and early histological assessment with a liver biopsy may be of paramount significance and may possibly change the course of the disease.
Mycobacterium terrae Complex Associated Lymphadenitis: Negative AFB PCR
Authors: Golden K E , Doan J V , Zhang S 
Published: October 2024

Abstract

Introduction/Objective
Nontuberculous mycobacteria included with the Mycobacterium terrae complex (MTC) include a ubiquitous, slow-growing collection of mycobacteria known for causing severe resistant skin, joint, and bone infections. There are limited reports of M. Arupensis, included under MTC, causing human infections despite environmental ubiquity. Low sequencing sensitivity for species such as M. Arupensis may result in negative preliminary PCR speciation thus influencing the negative predictive value of this method of organism detection. No prior case reports have described MTC infection presenting as subacute lymphadenitis.

Methods/Case Report
A 48 year old El Salvadorian male with known diagnosis of HIV presented with oral thrush and significant left-sided lymphadenopathy. He was initially diagnosed with HIV in El Salvador and on ART until immigrating to the US six months prior. HIV antigen and antibody was positive with positive reflex viral PCR. QuantiFERON-TB Gold resulted positive, but CXR was without evidence of pulmonary TB. TB1, TB2, and mitogen minus NIL were negative. He was referred for fine needle aspiration and core needle biopsy of the left cervical lymph node. AFB and AFB FITE stains were performed, but no definitive mycobacteria were identified. GMS was performed and negative for fungal elements. A final histological diagnosis of necrotizing granuloma was given and the tissue was sent for bacterial, AFB, and fungal DNA PCR; no organisms were detected. A sputum sample was obtained and cultured four months after initial presentation and was positive for acid fast bacilli: Mycobacterium terrae complex, most closely resembling Mycobacterium arupensis. The Fite and AFB stains were again reviewed, revealing one single acid fast bacilli organism identified on Fite stain in the necrotizing granuloma.

Results (if a Case Study enter NA)
N/A

Conclusion
The negative AFB DNA PCR result may have been a false negative result due to poor sensitivity or selectivity for M. arupensis. There are no former reported cases of M. Arupensis associated necrotizing granulomas in lymph node. This unusual MTC infection presenting as chronic unilateral lymphadenitis underscores the importance of broadening clinical laboratory AFB DNA PCR sensitivity especially in cases of suspected AFB or modified AFB associated necrotizing granulomas.
PAS Staining Variability in Fungal Infections of Skin
Authors: Hebert A , Love G 
Published: October 2024

Abstract

Introduction/Objective
Developed in 1946 by J. F. A. McManus, the Periodic Acid Schiff (PAS) stain is among the most frequently used stains in histopathology as a cost-effective ancillary study for the detection of fungal organisms. Despite its wide use in dermatopathology, little research exists comparing PAS to its commonly used counterpart, Gomori methenamine silver (GMS), or to hematoxylin and eosin (H&E) alone. The variation in PAS staining between different fungi causing skin infections has been poorly studied.

Methods/Case Report
Eighteen cases of fungal skin infections from 1995-2023 were reviewed by a resident pathologist and attending medical mycologist. All eighteen cases possessed H&E, GMS, and PAS stains (staining preservation was confirmed). These cases were selected to represent the following categories of fungal skin infections: 1) superficial or cutaneous; 2) subcutaneous; and 3) systemic (including opportunistic mycoses and endemic dimorphic fungi). The following criteria were used to grade each specimen: ability of PAS to stain the organism’s cell wall; the demonstration of fungal morphology by PAS; and the ease of differentiating PAS-stained organisms from background compared to H&E alone.

Results (if a Case Study enter NA)
PAS allowed for ready visualization of fungal morphology for all organisms except for Histoplasma spp. and Blastomyces spp. in which organisms tended to blend in with background staining particularly in inflamed tissues. Both fungi were visualized better by GMS. The muriform bodies of chromoblastomycosis, while staining well with PAS, were easy to miss due to their tiny size.

Conclusion
Compared to H&E alone, PAS allowed for detection of organisms at a lower magnification (40X) for fungal infections except for those in chromoblastomycosis, histoplasmosis, and blastomycosis. PAS is a useful, cost- effective ancillary study for the detection of fungal organisms in dermatopathology; however, care must be taken when there is clinical suspicion for certain fungal organisms that are less well-visualized by PAS.
Evaluation of Electronic Hand Hygiene Monitoring Systems in UAE Hospitals
Authors: Abdelmonem M , Saleh Abdelfattah M , Alzehmi A , Alzaabi R , Alhosani H , Tanous J , Abdulrazzaq N 
Published: October 2024

Abstract

Introduction/Objective
Introduction: Hand hygiene (HH) compliance is pivotal in preventing infections in healthcare settings, necessitating robust monitoring systems. This abstract outlines the assessment of three electronic HH monitoring systems across four United Arab Emirates (UAE) hospitals.

Methods/Case Report
Methods: A prospective observational study was conducted in four UAE governmental hospitals, evaluating three HH monitoring systems. Sensors were strategically positioned on alcohol-based dispensers, healthcare workers’ ID badges, and patients’ beds in these systems. Additionally, a comparative analysis was performed between direct observation data and automated system data.

Results (if a Case Study enter NA)
Results: System 1 was evaluated at Hospitals A and B, revealing HH compliance rates of 65% and 46%, respectively, contrasting with direct observation rates of 88% and 80%. Hospital C assessed System 2, reporting a compliance rate of 70%, compared to direct observation’s 94%. System 3, evaluated at Hospital D, showed a compliance rate of 39%, in contrast to the 88% observed directly.

Conclusion
Conclusion: While electronic monitoring systems offer continuous surveillance and data analysis benefits, they also present limitations. These include challenges in accurately distinguishing HH indications and opportunities, identifying all required HH moments, and capturing technique nuances. Understanding these strengths and limitations is vital for healthcare institutions aiming to implement effective HH monitoring strategies to enhance patient safety and reduce healthcare-associated infections (HAI