Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens.

OBJECTIVES: Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS: Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS: Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS: We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.

A Randomized Study Comparing Digital Imaging to Traditional Glass Slide Microscopy for Breast Biopsy and Cancer Diagnosis.

BACKGROUND: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. METHODS: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. RESULTS: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). CONCLUSIONS: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.

Altitude Decompression Sickness Risk and Physical Activity During Exposure.

INTRODUCTION: Earlier research described a linear relationship between the highest 1 min of oxygen consumption (Vo2) during a recurring physical activity and incidence of decompression sickness (DCS) during research chamber exposures to high altitude. The current effort was designed to determine if that relationship holds true at a lower altitude. METHODS: Male subjects (20) were exposed without prebreathe to 22,500 ft (6858 m; 314 mmHg; 6.1 psi) for 4 h while seated, nonambulatory the entire time, with echo-imaging at 16-min intervals (Non-Amb Echo), breathing 100% oxygen. Average highest 1 min of Vo2 and level of activity was determined. Results during Non-Amb Echo were compared with earlier research data acquired under identical conditions except for higher levels of activity. RESULTS: No DCS was reported or observed and no venous gas emboli were observed. Combined with earlier data, a strong linear relationship (r > 0.99) was observed between DCS incidence and level of activity. DISCUSSION: These results suggest physiological envelopes might be expanded or prebreathe time reduced for some high-altitude aircraft operations that involve very low levels of physical activity. They may also help to explain the higher DCS risk for inside observers vs. trainees during altitude chamber training. The data imply potential for update of altitude DCS risk prediction models by adjustment with quantified level of activity during exposure.

Identifying and processing the gap between perceived and actual agreement in breast pathology interpretation.

We examined how pathologists' process their perceptions of how their interpretations on diagnoses for breast pathology cases agree with a reference standard. To accomplish this, we created an individualized self-directed continuing medical education program that showed pathologists interpreting breast specimens how their interpretations on a test set compared with a reference diagnosis developed by a consensus panel of experienced breast pathologists. After interpreting a test set of 60 cases, 92 participating pathologists were asked to estimate how their interpretations compared with the standard for benign without atypia, atypia, ductal carcinoma in situ and invasive cancer. We then asked pathologists their thoughts about learning about differences in their perceptions compared with actual agreement. Overall, participants tended to overestimate their agreement with the reference standard, with a mean difference of 5.5% (75.9% actual agreement; 81.4% estimated agreement), especially for atypia and were least likely to overestimate it for invasive breast cancer. Non-academic affiliated pathologists were more likely to more closely estimate their performance relative to academic affiliated pathologists (77.6 vs 48%; P=0.001), whereas participants affiliated with an academic medical center were more likely to underestimate agreement with their diagnoses compared with non-academic affiliated pathologists (40 vs 6%). Before the continuing medical education program, nearly 55% (54.9%) of participants could not estimate whether they would overinterpret the cases or underinterpret them relative to the reference diagnosis. Nearly 80% (79.8%) reported learning new information from this individualized web-based continuing medical education program, and 23.9% of pathologists identified strategies they would change their practice to improve. In conclusion, when evaluating breast pathology specimens, pathologists do a good job of estimating their diagnostic agreement with a reference standard, but for atypia cases, pathologists tend to overestimate diagnostic agreement. Many participants were able to identify ways to improve.

G Protection When Adding Pressurized Sleeves and Gloves to a Representative G-Suit Ensemble.

BACKGROUND: In a previous study, pressurized sleeves and gloves were found to substantially diminish or eliminate G-induced arm pain. Since this equipment presumably acts similarly to a G suit for the arms and hands, it was hypothesized that higher inflation pressures might provide an additional increment of G protection. METHODS: In a human-rated centrifuge, 15 well trained subjects using Combat Edge and ATAGS G-protective equipment were exposed to gradual and rapid onset relaxed G exposures as well as rapid onset straining and simulated aerial combat maneuver G exposures up to + 9 Gz with and without pressurized sleeves and gloves. RESULTS: The pressurized sleeves and gloves did not show any improvement in G tolerance or endurance compared to the control. However, significantly lower heart rates (6-12%) and subjective effort (11%), along with slightly less peripheral vision loss, suggest a decreased work load when wearing the pressurized sleeves and gloves. A trend to shorter time on target in a tracking task was found with the pressurized sleeves and gloves, likely due to decreased mobility of the hands, thus affecting control stick input. CONCLUSIONS: G tolerance and endurance were not improved by the pressurized sleeves and gloves. However, a lower heart rate and a decreased subjective effort level and peripheral vision loss indicated that the subjects did not have to work as hard with this equipment.

Acceleration endurance with pressure breathing during G with and without a counterpressure vest.

INTRODUCTION: The purpose of this study was to test whether pressure breathing during G (PBC) without a counterpressure vest negatively influences G endurance or increases breathing fatigue during extended duration high-G exposures. METHODS: While using PBG, 10 subjects underwent 2 trials of +3 Gz exposures: once when wearing a counterpressure vest and once without. The exposures consisted of a relaxed, gradual G onset run until peripheral or central light loss, a straining rapid onset GC run to +6 Gz for 15 s, and a simulated aerial combat maneuver (SACM) G profile consisting of 10-s periods varying between +5 Gz and +9 Gz, during which subjects executed a hand-eye tracking task. The SACM endpoint was light loss or exhaustion. Subjects provided ratings of subjective effort and discomfort after the SACM. RESULTS: Significant differences were found between the vest and no-vest conditions for only 3 of 19 measures: heart rate under G and two measures of tracking ability. The vast majority of data indicated no difference between the vest and no-vest conditions for performance under G. DISCUSSION: This experiment supports previous studies and expands those previous results by increasing the duration of PBG exposure shown to not be influenced by wearing of the vest. We conclude that there is likely no practical advantage to wearing a counterpressure vest during PBG.

U.N. guidance note on HIV and sex work "reworked" by activists.

In 2007, UNAIDS issued a guidance note on HIV and sex work, the tone and contents of which angered sex workers, activists and public health workers worldwide. In this article, based on presentations at the conference, M. Seshu et al describe the problems with the guidance note, discuss the reaction to its publication, and explain how a group of activists got together to develop a reworked version of the guidance note.

Heat stress effects for USAF anti-G suits with and without a counter-pressure vest.

BACKGROUND: Aircrew have reported increased heat stress when wearing the USAF Combined Advanced Technology Enhanced Design G-Ensemble or COMBAT EDGE (CE). The perceived thermal burden has been attributed to the fact that CE includes an inflatable counter-pressure vest to ease the work of positive pressure breathing during G (PBG). This study compared the heat load of CE with that of the standard USAF anti-G system (STD) without the vest, and measured heat stress effects on G-tolerance in both suits. METHODS: This study had 12 subjects (6 of them aircrew) who participated. Simulated preflight thermal stress (20 min walking at 35 degrees C with 85% relative humidity and radiant heat) was followed by return to a cooler environment (21 degrees C). G-tolerance and subjective stress levels were determined on the human centrifuge before and after the heat stress. Body weight, rectal and skin temperatures, and blood parameters were also assessed. RESULTS: Baseline relaxed tolerance for +Gz gradual onset runs (GORs) were (mean +/- SD) 7.6 +/- 1.3 G for CE and 7.1 +/- 0.8 G for STD (p < 0.05). Maximal rectal temperature following heat stress peaked at 38.1 +/- 0.4 degrees C for both CE and STD, and mean nude weight loss was 1.10 +/- 0.24 kg for both. Relaxed GOR tolerances after heat stress were 7.1 +/- 1.3 for CE and 6.3 +/- 0.9 for STD (p < 0.01). The heat stress significantly reduced G tolerance for both CE and STD (p < 0.01). CONCLUSIONS: Simulated preflight activity in hot conditions revealed no significant difference between CE and STD with regard to maximal core and skin temperature elevations or dehydration levels. CE supported a significantly higher baseline relaxed G-tolerance than STD, an advantage that persisted after heat stress and dehydration.

AIDS prevention in the sex industry.

PIP: Most sex work research examines the impact of HIV on prostitutes and on society and involves testing prostitutes for HIV antibodies, but it does not examine the role of others in the sex industry. Sex industry workers include female prostitutes, transvestites, transsexuals, and male prostitutes, bar and brothel owners, taxi drivers, sex workers' partners, and sex business managers. Since sex workers provide sexual services to clients, they are in a perfect position to teach them about sexual health. Society must recognize that we cannot wish the sex industry away and that we need an effective health promotion strategy now. Some successful relevant AIDS education campaigns provide us some guidelines on how to develop campaigns. Any campaign targeting the sex industry should also target the public. Sex workers should participate in developing health messages and educational activities. They should also participate in the project. Any campaign must deal with major obstacles to safer sexual practices of which sex workers are aware and be consulted. Common obstacles are client demand for unprotected sex and irregular and inadequate supply of inexpensive condoms. A health promotion strategy cannot be effective, however, if sex workers do not have access to social support and health care services. Health promotion workers should also encourage local authorities to end discrimination of sex workers so they can freely obtain needed services. In some countries, sex workers operate fantasy workshops providing peers with ideas to sell sex services which reduce the risk of HIV transmission. Other campaigns distribute safer sex messages on small cards, cigarette lighters, key rings, condom packages, and T shirts. Training of sex workers other than prostitutes to reinforce safer sex messages to clients is also effective, e.g., taxi drivers can say they will take a client to a woman who uses condoms rather than to a clean girl. Street theater and puppets have also successfully disseminated safer sex messages.^ieng