Acute Abdominal Pain and a Whirlpool Sign on Computed Tomography: A Case Report.

Introduction: Mesenteric volvulus is a rare cause of abdominal pain and bowel obstruction in elderly patients. When a mesenteric volvulus occurs in adult patients, the symptoms are often non-specific, which contributes to delays in diagnosis. Case Report: We present a case of a 75-year-old female who presented with non-specific abdominal pain. The rare whirlpool sign on computed tomography identified a mesenteric volvulus as the cause of small bowel obstruction. She was taken to the operating room and, after successful resection of the small bowel, she recovered and ultimately was discharged home. Conclusion: Early identification of a whirlpool sign and early surgical consultation are key to providing the best chance for salvage of ischemic small bowel due to mesenteric volvulus and to prevent a fatal outcome.

Diagnostic interobserver agreement for thyroid fine-needle aspirates: Effects of reviewer experience and molecular diagnostics.

OBJECTIVES: Few cytologically indeterminate thyroid fine-needle aspirations (FNAs) harbor BRAF V600E. Here, we assess interobserver agreement for The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) category III (atypia of undetermined significance [AUS]) FNAs harboring BRAF V600E and contrast their features with those harboring non-BRAF V600E alterations, with attention to cytopathology experience. METHODS: Seven reviewers evaluated 5 AUS thyroid FNAs harboring BRAF V600E. To blind reviewers, cases were intermixed with 19 FNAs falling within other TBSRTC categories and in which genetic alterations other than BRAF V600E had been identified (24 FNAs total). Interobserver agreement against both "index" and most popular ("mode") diagnoses was calculated. Four additional BRAF V600E cases were independently reviewed. RESULTS: Reviewers included 3 trainees and 3 American Board of Pathology (board)-certified cytopathologists. Board-certified cytopathologists, whose experience ranged from 2 to more than 15 subspecialty practice years, had known AUS rates. BRAF V600E was identified in 5 of 260 (2%) AUS FNAs. Interobserver agreement was higher among cytopathologists with more experience. Mode diagnosis differed from index diagnosis in 6 of 11 cases harboring RAS-like alterations; mode diagnosis was AUS in 4 of 5 BRAF V600E FNAs. CONCLUSIONS: Atypia of undetermined significance of thyroid FNAs harboring BRAF V600E is uncommon yet relatively reproducible, particularly among pathologists with experience. It is advisable to sequence BRAF across V600 in such cases.

Combining molecular testing and the Bethesda category III:VI ratio for thyroid fine-needle aspirates: A quality-assurance metric for evaluating diagnostic performance in a cytopathology laboratory.

BACKGROUND: Molecular testing (MT) of thyroid fine-needle aspiration (FNA)-derived genetic material is commonly used to assess malignancy risk for indeterminate cases. The Bethesda System for Reporting Thyroid Cytopathology (TBS) provides limited guidance for the appropriate use of category III (atypia of undetermined significance [AUS]). The authors combined MT with cytomorphology to monitor AUS diagnoses in a cytopathology laboratory. METHODS: Neoplasia-associated genetic alterations (NGAs) were determined by MT of preoperative FNA biopsies or resected malignancies and were categorized as BRAF V600E mutations, RAS-like mutations (HRAS, NRAS, or KRAS mutations or non-V600E BRAF mutations), or other mutations. RESULTS: Among 7382 thyroid FNA biopsies, the AUS rate was 9.3% overall and ranged from 4.3% to 24.2% among 6 cytopathologists (CPs) who evaluated >150 cases. The ratio of specimens falling into TBS category III to specimens falling into category VI (malignant) (the III:VI ratio) was 2.4 overall (range, 1.1-8.1), and the ratio of specimens falling into TBS categories III and IV (follicular neoplasm or suspicious for follicular neoplasm) combined (III+IV) to specimens falling into category VI (the [III+IV]:VI ratio) was 2.9 overall (range, 1.4-9.5). MT was performed on 588 cases from 560 patients (79% women) with a median age of 56 years (range, 8-89 years). BRAF V600E mutation was the most common (76% of cases) in TBS category VI and was rare (3%) in category III. RAS-like mutations were most common in TBS categories III (13%), IV (25%), and V (suspicious for malignancy) (17.5%). The NGA rate in AUS cases fell between 5% and 20% for 5 of 6 CPs and did not correlate with the III:VI ratio or the (III+IV):VI ratio. CONCLUSIONS: Lack of correlation between the NGA rate and easily calculable diagnostic ratios enables the calibration of diagnostic thresholds, even for CPs who have normal metrics. Specifically, calculation of the NGA rate and the III:VI ratio may allow individual CPs to determine whether they are overcalling or undercalling cases that other CPs might otherwise recategorize.

Nuclear hypochromasia: Shedding light on the "lightness" of high-grade urothelial carcinoma.

BACKGROUND: The Paris system (TPS) has provided a standardized classification for reporting urinary cytology, specifically high-grade urothelial carcinoma (HGUC). While hyperchromasia is well described in HGUC, there exists little data on nuclear hypochromasia in HGUC. Our focus was to investigate the incidence of hypochromasia in HGUC and if it should become a criterion for HGUC. DESIGN: All cases of HGUC at our institution for a 3-year interval (2017-2019) using TPS were reviewed. Each case had a single ThinPrep slide and concurrent biopsy or resection specimen to confirm the diagnosis within 30 days. The presence of hypochromasia was evaluated, and cases with hypochromasia were stratified based on the tumor cell percentage. Cases with hypochromasia in 5% or greater of the tumor cells were considered "positively identified" for hypochromasia. RESULTS: We reviewed 117 cases of HGUC and identified nuclear hypochromasia in 12 cases (10.2%) within 5% or greater of the tumor cells. These 12 cases were further assessed based on if tumor cells showed hypochromasia in 5%-49% of the sample, or greater than 50% of the sample. Hypochromasia in 5%-49% of tumor cells was present in 8/117 cases (6.8%); whereas in 50% or greater samples 4/117 cases (3.4%) showed hypochromasia. No cases were identified where hypochromasia was noted in less than 5% of the tumor cells. CONCLUSION: TPS and use of hyperchromasia as a feature of HGUC is affirmed. However, hypochromasia, while not diagnostic in isolation, is present in a sub-set of patients with HGUC (10.2%) and should be considered as a variance noted in the nuclei of HGUC.

A Case Report of Acute Prostatitis Secondary to Use of P-valve Condom Catheter During Cave Diving.

INTRODUCTION: Acute bacterial prostatitis is characterized by acute inflammation of the prostate gland accompanied by the presence of pain and other urinary tract or systemic symptoms. Prostatitis is a relatively common disease of the urinary tract in men, However, this case reports a man diagnosed with acute bacterial prostatitis with an unusual presentation, as well as an unusual pathogen and a unique mechanism of colonization. CASE REPORT: A 52-year-old male with no past medical history presented to our facility for right-sided buttock pain associated with dysuria, diarrhea, and perianal burning. The patient was diagnosed with sepsis secondary to acute bacterial prostatitis, and the pathogen identified in his urine was Aeromonas hydrophila/A. caviae. His disease process was later recognized as a complication of the use of a P-valve condom catheter while freshwater cave diving. CONCLUSION: This is the first documented case of prostatitis as a result of the use of a P-valve condom catheter while diving. Furthermore, the pathogen identified is of particular interest as there are very few documented cases of urosepsis secondary to Aeromonas hydrophila or A. caviae.

The Gross-to-Scope Program for Gross Room Personnel: An Innovative Initiative for Providing Case Follow-Up and Education to "Close the Pathology Loop".

Gross room personnel (GRP) work alongside pathologists in grossing, frozen section, and autopsy. We observed that gross room personnel desire follow-up and feedback on the specimens they gross or autopsies they perform. Our goal was to create a sustainable educational program for gross room personnel. Our primary focus was to impact team dynamic, morale, and fulfillment. We assessed the need for an educational program through a preprogram survey, which contained 11 subjective statements scored on a scale from 1 to 10 (1-strongly disagree and 10-strongly agree). These statements assessed topics of current follow-up and team dynamic (core statements), perceived effect of current follow-up, and prospective impact of case follow-up. Core statements received relatively low scores (ie, the perception of being "an integral part in making a diagnosis" received only a mean score of 6.7). In response, we established the Gross-to-Scope educational program hosted by pathology trainees and attendings. This program is comprised of monthly one-hour conferences to discuss/review cases and highlight special topics of interest (ie, "What is a radial margin anyway?"). We distributed the same surveys after the first and fourth conferences and found a statistically significant increase in the mean responses to core statements after the first conference (P = .041). The trend is similar after four conferences. Overall our program addresses various needs by providing educational opportunities for gross room personnel, which strengthens morale and recognizes hard work, and by fostering a working relationship between gross room personnel and pathologists.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes.

PURPOSE OF REVIEW: Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability. RECENT FINDINGS: Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.