Optimizing Kidney Replacement Therapy During the COVID-19 Pandemic Across a Complex Healthcare System.

The unprecedented surge of nephrology inpatients needing kidney replacement therapy placed hospital systems under extreme stress during the COVID-19 pandemic. In this article, we describe the formation of a cross campus "New-York Presbyterian COVID-19 Kidney Replacement Therapy Task Force" with intercampus physician, nursing, and supply chain representation. We describe several strategies including the development of novel dashboards to track supply/demand of resources, urgent start peritoneal dialysis, in-house preparation of kidney replacement fluid, the use of unconventional personnel resources to ensure the safe and continued provision of kidney replacement therapy in the face of the unanticipated surge. These approaches facilitated equitable sharing of resources across a complex healthcare-system and allowed for the rapid implementation of standardized protocols at each hospital.

Cystic papillary thyroid carcinoma in fine needle aspiration may represent a subset of the encapsulated variant in WHO classification.

This study audits the reliability of ultrasound-guided fine needle aspiration (FNA) in excluding papillary thyroid carcinoma (PTC) in thyroid cysts containing mural nodules, and investigates the histological counterpart of cystic PTC diagnosed on FNA. Using a 10-5 MHz ultrasound probe and a 27-gauge needle, solid portions of thyroid nodules were sampled and assessed immediately using both Diff-Quik and Ultrafast Papanicolaou stains. Unlike usual PTCs that demonstrate hypercellularity, the aspirates of cystic PTC showed low cellularity and consisted of papillae with atypical nuclei scattered in abundant thin colloid. Over a period of 13 years, histological follow-up was obtained from 11 women and 6 men in whom cystic PTC was reported on FNA. This represented 4.4% of 383 cases of PTC reported and 0.25% of all thyroid FNAs performed. In all 17 cases, histopathology showed encapsulated PTC in various stages of cystic degeneration. Sonography correlated well with histopathology, where findings ranged from cysts with small mural nodules to solid nodules with pockets of thin colloid. In 87 patients with thyroid cysts containing mural nodules, FNA findings were benign, as was clinical follow-up that ranged from 1 to 12 years. In conclusion, ultrasound-guided FNA, if performed in the manner described, can reliably distinguish cystic PTC from a benign cyst with a mural nodule. Cystic PTC on FNA in this series correlates to a subset of the encapsulated variant of PTC, an entity described in the 1988 WHO Histological Typing of Thyroid Tumours in the good prognostic category.

Diagnostic accuracy of follicular variant of papillary thyroid carcinoma in fine-needle aspirates processed by ultrafast Papanicolaou stain: histologic follow-up of 125 cases.

BACKGROUND: Detection of follicular variant (FV) of papillary carcinoma (PC) of the thyroid is considered difficult in cytology. Various ancillary studies have been used to increase the sensitivity in the detection of FVPC in fine-needle aspiration (FNA). We previously reported that the clear nuclei of PC became conspicuous in Ultrafast Papanicolaou (UFP)-stained smears. This study reports our experience on using this UFP-induced artifact in the detection of FVPC. METHODS: Over an 11-year period, 5637 ultrasound-guided thyroid FNAs were performed. All samples were smeared and air-dried. Diff-Quik stain was used to assess the colloid and UFP stain was used to study the nuclei. RESULTS: Histologic follow-up was available from 125 cases. Of the 107 aspirates with diffuse "grape-like" watery clear nuclei, histologic follow-up showed 94 PCs, 8 follicular adenomas containing atypical nuclei, and 5 nonneoplastic lesions. Of the 18 aspirates with focal clear nuclei, histologic follow-up showed 6 PCs, 8 follicular adenomas, and 4 nonneoplastic nodules. As reported previously, histologic follow-up of 147 FNAs contained follicles with normal nuclei showed 107 true follicular neoplasms, 32 hyperplastic nodules, and 8 FVPC. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy in the detection of PC were 93.6%, 94.9%, 93.6%, 94.9%, and 94.3%, respectively, when follicular adenomas containing atypical nuclei were counted as encapsulated FVPC; and 92.6%, 85.6%, 80%, 94.9%, and 88.3%, respectively, when follicular adenomas containing atypical nuclei were counted as benign. CONCLUSION: UFP stain is one of the options to increase the sensitivity of detection of FVPC in preoperative FNA, and to triage microfollicular nodules into those that require surgery no matter how small, and those which can be followed when small.

Should cytopathologists stop reporting follicular neoplasms on fine-needle aspiration of the thyroid?

BACKGROUND: As the consequence of the decreasing incidence of follicular thyroid carcinoma (FC), one wonders whether cytopathologists should stop reporting follicular neoplasms in fine-needle aspiration (FNA) of the thyroid to minimize unnecessary thyroidectomies, if the follicular variant of papillary carcinoma (FVPC) has been excluded. METHODS: Over a 6-year-period, 2667 ultrasound-guided FNAs of the thyroid were performed at our practice. A total of 246 nodules (9.2%) were reported as follicular neoplasms, using abundant blood as the diagnostic clue. All FNA specimens were prepared and reported by one cytopathologist and the final pathology was reported by surgical pathologists in various hospitals in New York City. RESULTS: The histologic follow-up was available for 147 cases and showed 5 cases of widely invasive FC (3.4%), 10 cases of minimally invasive FC (6.8%), 8 cases of FVPC (5.4%), 92 cases of follicular adenoma (62.6%), and 32 cases of nonneoplastic nodules (21.8%). CONCLUSIONS: FVPC cannot be excluded completely from follicular neoplasms by FNA because of the patchy distribution of papillary carcinoma nuclei in the encapsulated variant. Widely invasive FC still exists and may cause considerable morbidity in patients as young as the third decade of life. It is the opinion of the authors that cytopathologists should continue reporting follicular neoplasms in FNA of the thyroid.