Does routine repeat testing of critical laboratory values improve their accuracy?

BACKGROUND: Routine repeat testing of critical laboratory values is very common these days to increase their accuracy and to avoid reporting false or infeasible results. We figure that repeat testing of critical laboratory values has any benefits or not. METHODS: We examined 2233 repeated critical laboratory values in 13 different hematology and chemistry tests including: hemoglobin, white blood cell, platelet, international normalized ratio, partial thromboplastin time, glucose, potassium, sodium, phosphorus, magnesium, calcium, total bilirubin and direct bilirubin. The absolute difference and the percentage of change between the two tests for each critical value were calculated and then compared with the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error. RESULTS: Repeat testing yielded results that were within the allowable error on 2213 of 2233 specimens (99.1%). There was only one outlier (0.2%) in the white blood cell test category, 9 (2.9%) in the platelet test category, 5 (4%) in the partial thromboplastin time test category, 5 (4.8%) in the international normalized ratio test category and none in other test categories. CONCLUSION: Routine, repeat testing of critical hemoglobin, white blood cell, platelet, international normalized ratio, partial thromboplastin time, glucose, potassium, sodium, phosphorus, magnesium, calcium, total bilirubin and direct bilirubin results does not have any benefits to increase their accuracy.

Sclerosing Microcystic Adenocarcinoma of the Base of Tongue with Signet Ring-Like Cell Component: A Rare Case.

Sclerosing microcystic adenocarcinoma (SMA) is an uncommon neoplasm of the oral cavity, with only 14 reported cases documented in the literature. We present a case of SMA in a 65-year-old woman with a history of high-grade lymphoma who developed clear cell changes in the deep muscular layer of the tongue. Currently, the diagnosis of SMA relies on careful morphological evaluation and the exclusion of other potential differential diagnoses.

Breast cancer knowledge, attitudes and screening behaviors in two groups of Iranian women: physicians and non-health care personnel.

Breast cancer is one of the most frequent malignancies worldwide which is characterized by early onset and diagnosis at advanced stages in Iranian women. Increasing women's awareness and implementing breast cancer screening programs detect cancer earlier and reduce mortality. Physicians play a pivotal role in this regard. Further, there is limited literature about knowledge, attitude, and screening behaviors in Iranian women. Using a questionnaire, we assessed and compared breast cancer knowledge, attitude, and screening behaviors in 102 female physicians and 94 female non-health care personnel, who were mostly from the hospital's cleaning and housekeeping sections. Of the physicians and of non-health care personnel, respectively, 93.1 and 24.7 % felt confident about their knowledge and 37.6 and 26.1 % performed monthly breast self-examination. Of physicians aged 40 and over, 31.25 and 18.75 % had clinical breast examination and mammogram, respectively, within 12 months prior to date of data collection. In non-health care personnel aged 40 and over, the results were 27.59 % for clinical breast examination and 17.24 % for mammogram at the same period of time. Despite the higher knowledge and socioeconomic class of physicians, there were no significant difference in screening behaviors between physicians and non-health care personnel (P > 0.05).

Assessment of a new algorithm in the management of acute respiratory tract infections in children.

OBJECTIVES: To assess the practicability of a new algorithm in decreasing the rate of incorrect diagnoses and inappropriate antibiotic usage in pediatric Acute Respiratory Tract Infection (ARTI). MATERIALS AND METHODS: Children between 1 month to15 years brought to outpatient clinics of a children's hospital with acute respiratory symptoms were managed according to the steps recommended in the algorithm. RESULTS: Upper Respiratory Tract Infection, Lower Respiratory Tract Infection, and undifferentiated ARTI accounted for 82%, 14.5%, and 3.5% of 1 209 cases, respectively. Antibiotics were prescribed in 33%; for: Common cold, 4.1%; Sinusitis, 85.7%; Otitis media, 96.9%; Pharyngotonsillitis, 63.3%; Croup, 6.5%; Bronchitis, 15.6%; Pertussis-like syndrome, 82.1%; Bronchiolitis, 4.1%; and Pneumonia, 50%. CONCLUSION: Implementation of the ARTIs algorithm is practicable and can help to reduce diagnostic errors and rate of antibiotic prescription in children with ARTIs.

Breast metastasis from gastric carcinoma: A case report.

BACKGROUND: There are rare cases of breast metastasis from gastric carcinoma origin. In this regard, we presented a case of signet ring cell stomach cancer with metastasis to the breast. CASE PRESENTATION: The case was a 44-year-old female with a history of gastric cancer and chief complaint of progressive bilateral and gradual breast enlargement and mass palpation 6 years after stomach surgery. An excisional biopsy of the right breast was performed at the early phase of her clinical symptoms with the pathology at the early phase of fibroadenoma and sclerosing adenosis. Given the persistent right breast thickening and enlargement, the ultrasonography and MRI together showed right breast large masses, ductal enhancement in left retro areolar space beside the bilaterally enlarged axillary lymph nodes after 6 months. In this phase, the core needle biopsy showed right breast mass adenocarcinoma consistently with metastatic gastric carcinoma and also core needle biopsy of both axillary lymph nodes indicating the involvement by tumor consistently with metastatic gastric carcinoma. In the IHC, breast tumor cells were negative for ER, PR, HER2/ neu, GATA3, GCDFP15 and CK20, but positive for CK7, CK19, and CDx2. CONCLUSION: The diagnosis of breast metastasis of gastric carcinoma was confirmed according to the past history of patient, histological finding, and immune-histological markers.

Right-side inguinal canal endometriosis at ultrasound: A case report.

Background: The first case of inguinal endometriosis was described by Cullen. Endometriosis in the round ligament could be in the pelvic or inguinal area and is a rare disease occurring in 0.6% of women. Women with inguinal endometriosis have a painful inguinal mass during menstrual cycles and they mostly have a history of surgery. The right side is more commonly involved in inguinal endometriosis than the left side (90-94%). A history of gynecologic or abdominal surgery is common in women with inguinal endometriosis. Case presentation: In our case, a 39-yr-old virgin woman presented with localized pain in the right inguinal that had been present for 4 yr. She did not have any history of previous surgery, and abdominal ultrasonography showed a hypoechoic mass with minimal vascularity. Inguinal endometriosis was correctly diagnosed by two expert radiologists preoperatively, and she underwent laparoscopic surgery. Conclusion: Considering inguinal endometriosis in the differential diagnosis of women with inguinal masses is important, even if there is no history of gynecologic or abdominal surgery.

The association of umbilical coiling and angiogenesis markers: Impact assessment of gestational diabetes.

INTRODUCTION: The purpose of this study was to determine the association between the postnatal umbilical coiling index (pUCI) and vascular endothelial growth factor A (VEGFA) and its receptor (VEGFR2) in parturients with and without gestational diabetes mellitus (GDM). METHODS: Within 24 h following birth, the umbilical cord and pUCI of 29 newborns with GDM and 28 neonates with non-GDM parturients were prospectively examined. Real-time PCR tests were used to determine the expression levels of the VEGFA and VEGFR2 genes, measured from the umbilical cord. The Mann-Whitney and Chi-squared tests were used to compare continuous and discrete variables with and without GDM. RESULTS: The median (IQR) of maternal age was 30 (26-34) years. There were no differences in demographic features between GDM and non-GDM parturients. While there was a marginal difference in VEGFA expression levels between the GDM and non-GDM groups (P-values = 0.07), no difference was detected for VEGFR2 (P-values = 0.75). Comparing hyper- and hypocoiling cords revealed a small difference in VEGFA levels (P-values = 0.05), but no change in VEGFR2 (P-values = 0.50). Furthermore, in both GDM and non-GDM parturients, down-regulated VEGFA was the general rule among abnormal pUCIs. DISCUSSION: The GDM and coiling state both are associated with the amount of VEGFA expression, but neither is related to VEGFR2. Furthermore, regardless of whether the patient has GDM or not, the abnormal coiling pattern appears to be related to the VEGFA down-regulation.

Work-related Hazards Among Pathologists and Residents of Pathology:Results of a Cross-sectional Study in Iran.

BACKGROUND & OBJECTIVE: Pathologists as medical professionals involved in the diagnosis and planning of therapies in many diseases are exposed to occupational hazards in workplaces. Hence, we aimed to determine the occupational health problems among Iranian pathologists in this cross-sectional study. METHODS: This cross-sectional study was conducted among the Iranian pathologists. The data required for this study was collected through a self-reported questionnaire containing 48 questions about major occupational health problems, including musculoskeletal problems, visual disorders, workplace characteristics, health behavior, and other medical conditions. RESULTS: Among the study participants (N=350), 87.4% presented with musculoskeletal disorders in the past year, with the neck as the most common location of pain (71%). Musculoskeletal pain was significantly higher in those working with the computer for more than 5 hours per day (P=0.007). Furthermore, 273 (78%) participants reported visual refractive errors, and myopia was the most common error (53%). Acute injuries were reported in 263 (75%) participants, and the cutting injury had the highest frequency (56.6%). Depression was reported in 54 (15.4%) of the participants, followed by burnout (10.3%) and hypertension (4%). Intolerance reactions to formalin were reported by 222 (63.6%) and were significantly more frequent among the residents (P<0.001). The residents were more prone to musculoskeletal pain (P=0.002) and injury (P=0.026). CONCLUSION: We observed a noticeable prevalence of health risks, including musculoskeletal problems, visual disturbances, injuries, and ergonomic problems among the Iranian pathologists. Solving these problems demands thorough prevention and personal protection, as well as educational programs with more attention toward optimization of ergonomics in the workplace and awareness about chemical and biological hazards.

Assessment of Ki67 in Breast Cancer: A Comparison Between the Eye-10 Method, Stepwise Counting Strategy, and International System of Ki67 Evaluation.

BACKGROUND & OBJECTIVE: Ki-67 evaluation is an essential tool to define luminal A and B breast cancers, which is not yet systematized. The International Ki67 in Breast Cancer Working Group suggests the counting of 500 or 1000 cancer cells, which is a time-consuming process. Therefore, novel methods, such as the Eye-10 method and stepwise counting strategy, are proposed to facilitate measurement. METHODS: Immunohistochemical staining of Ki67 was performed on 100 hormone-receptor-positive invasive ductal carcinoma specimens. Ki67LI was evaluated for each case, and then results were dichotomized by a cut-off point of 20%. Next, for each sample, an expert pathologist visually assessed percentages of Ki67-positive cells in 10% intervals at a glance (Eye-10 method). Finally, by using a dynamic process with rejection regions, Ki67 was defined so if the estimate belonged to the upper or lower rejection region, the Ki67 status had been determined and if the rejection region could not be reached after counting the maximum number of 400 tumor cells, the specimen was regarded as equivocal (stepwise counting strategy). RESULTS: The comparison between Eye-10 and Ki67LI revealed almost perfect agreement (kappa coefficient =0.889), and the concordance between the stepwise counting strategy and Ki67LI was substantial (kappa coefficient =0.639). CONCLUSION: Both two methods left some results in the gray/intermediate zone, which is unavoidable. Both methods are much faster and simpler than evaluation of Ki67LI and are also reliable. Regarding the gray zone in both methods, further improvements in the methodology, as well as more analytical studies, are needed.

Histomorphological changes of the placenta and umbilical cord in pregnancies complicated by gestational diabetes mellitus.

INTRODUCTION: The objective of this study was to compare the histomorphological changes of placenta and umbilical cord (UC), between gestational diabetes mellitus (GDM) and non- GDM pregnancies. METHODS: In this prospective study, 222 parturients were recruited (117 GDM and 105 non-GDM). GDM was confirmed at 24-28 weeks of gestation, using one-step strategy. A full record of demographic, laboratory, histologic and gross morphology data of placenta and UC was extracted and analyzed. RESULTS: Overall, 222 placentas/UCs met inclusion criteria. The mean (SD) of gestational age of GDM diagnosis was 20.68 (10.02) and the GDM duration was 16.76 (8.98) weeks. The mean HbA1C was 6.03 (0.41) % in the GDM group. The gross morphology findings including UC diameter and thick edematous UC differed significantly between two groups and more presented in GDM group, 1.41 (0.03) vs. 1.28 (0.03) centimeters; p-value = 0.006 and 34.19% vs. 16.19%; p-value = 0.002, respectively. The umbilical coiling index (UCI) was similar in two groups (p-value = 0.61). In the histological evaluation, persistence of central vessels differed significantly between two groups, more detected in non-GDM (47.62% vs. 32.97%; p-value = 0.04). No other significant histomorphological changes were detected between two groups. DISCUSSION: This study showed that gross morphologic features such as UC diameter increment and thick edematous UC happened more frequently, among the GDM parturients. Due to early diagnosis, diagnosis strategy, and optimal glycemic control, the histomorphological changes were less in GDM comparing of non-GDM group.

Prediction of postnatal abnormal coiling of the umbilical cord in gestational diabetes mellitus: a diagnostic accuracy study.

Objective: To investigate whether evaluations of antenatal umbilical coiling index (aUCI) could predict postnatal umbilical coiling index (UCI) (pUCI) in people with gestational diabetes mellitus (GDM) compared with normal pregnancy independent of maternal demographic and reproductive characteristics.Method: In this prospective study, 105 women with normal pregnancy, and 117 women with pregnancy complicated by GDM were recruited. Ultrasound scan of umbilical cord was performed at 18-23 and 37-41 weeks of gestation (WG). Evaluation of pUCI, as the reference standard, was performed within 24 hours after delivery.Findings: There was no significant relationship between aUCI and maternal demographic and reproductive characteristics. The mean for pUCI was 0.21 ± 0.12 in the GDM group, and 0.21 ± 0.09 in the normal pregnancy (p = .61). In the GDM group, a significant association was found between aUCI and pUCI categories (p = .004). The area under curve (AUC) was less than 0.5 for hypocoiling in both groups. For hypercoiling it was 0.84 ± 0.04 in the GDM group and 0.75 ± 0.06 in the normal pregnancy group (18-23 WG). In the GDM group the cutoff points that predict hypercoiling were 0.28 (18-23WG), and 0.21 (37-41WG). These were 0.35 (18-23WG), and 0.33 (37-41WG) in the normal pregnancy group. Diagnostic accuracy analysis revealed that in the GDM group, the sensitivity and specificity of hypercoiling for prediction of pUCI were 0.94 and 0.70 respectively at 18-23 WG.Conclusions: Antenatal hypercoiling at the second trimester of pregnancy strongly predict postnatal hypercoiling in pregnancies complicated by GDM.

Gestational diabetes mellitus: the correlation between umbilical coiling index, and intrapartum as well as neonatal outcomes.

OBJECTIVES: The objective of this study was to investigate the relationship between the postnatal umbilical coiling index (pUCI), and intrapartum and neonatal outcomes in parturients with gestational diabetes mellitus (GDM) and non-GDM. METHODS: An evaluation of the umbilical cords and pUCI of 117 neonates of GDM and 105 of non-GDM parturients were prospectively studied within 24 h after delivery. Furthermore, obstetric history, intrapartum and neonatal data were recorded. RESULTS: Premature rupture of membrane (PROM) (p = 0.001), emergency cesarean delivery (p = 0.01), spontaneous preterm delivery (p = 0.006), duration of hospital admission (p < 0.001), and congenital malformations (p = 0.03) were significantly higher in the GDM group. Moreover, pUCI had a significant association with large for gestational age (LGA) (p = 0.009), and meconium-stained amniotic fluid (p = 0.04) in the GDM group. In addition, increment of pUCI had significant association with spontaneous preterm delivery in both groups (p = 0.002) (OR = 1.23). CONCLUSIONS: GDM is associated with spontaneous preterm delivery, PROM, emergency cesarean delivery, duration of hospital admission, and congenital malformations. Increase in pUCI could increase the rate of spontaneous preterm delivery in normal pregnancy and pregnancy complicated by GDM, as well as, the rate of LGA and meconium-stained amniotic fluid in GDM.

Pathologic and molecular features of screening low-dose computed tomography (LDCT)-detected lung cancer: a baseline and 2-year repeat study.

Detailed studies on the pathologic and molecular features of low-dose computed tomography (LDCT)-detected carcinomas and comparison with unscreened tumors are still lacking. We evaluated the histopathologic features of 89 LDCT-detected lung cancers resected between 2004 and 2006. These tumors occurred within a cohort of 5202 volunteers undergoing annual LDCT, aged > or =50 years, and with a minimum 20 pack-year index. In adenocarcinomas, central scar diameter, invasion foci size and K-ras mutations were also assessed. The results were compared with those of 89 consecutive lung carcinomas matched for confounding factors (sex, smoking habit), selected from group of 363 consecutive clinically worked-up lung cancer, surgically resected in the same period and at the same Institution. The tumors were diagnosed in 63 males and 26 females (range 50-79 years), 55 of which diagnosed at the baseline (1.05%) and 34 (including 10 repeat cancers) operated after work-up during the second year (0.72%). LDCT-detected tumors showed high resectability rate (89%), earlier stage (63%) and prevalence of adenocarcinoma nodules (72%), most often of the mixed subtype, in comparison with unscreened tumors. A similar prevalence of K-ras mutations was found in both screened and unscreened adenocarcinomas. Repeat cancers were found in 10 screened patients, and were predominantly stage I adenocarcinomas of mixed subtype exhibiting smaller dimension but greater central scar diameter and stromal invasion size in comparison with the other second-year, slower-growing adenocarcinomas. Multiple tumor nodules were identified in 10 patients exclusively at the baseline, were mostly mixed adenocarcinomas and differed in their K-ras mutation profile. Screening-detected lung cancers shared most of the histologic features of fully malignant tumors, in addition to a similar prevalence of K-ras mutations, despite their earlier detection and less advanced clinical stage. Repeat cancers are potentially aggressive tumors. K-ras mutation analysis supports the impression that multifocal tumors at baseline are separate synchronous primaries.

Fine needle aspiration of salivary gland lesions with multinucleated giant cells.

OBJECTIVE: To report on multinucleated giant cells (MNGCs) in salivary fine needle aspiration (FNA). STUDY DESIGN: The cytologic reports of salivary gland region FNA during a 10-year period was searched using the keyword giant cell in the final diagnosis or microscopic description. Cases with foreign body-type giant cells secondary to previous biopsy or FNA were excluded. Histologic correlations and immunohistochemical staining for CD68, CK, EMA, S100, HMB45 and CD1a were performed on selected cases. RESULTS: Twenty-six aspiration smears containing MNGCs were identified from 1040 salivary gland FNAs (2.5%). MNGCs were seen in some reactive or inflammatory conditions, benign neoplasms and malignant neoplasms. By type of MNGC, the salivary lesions were categorized in 3 groups: those with foreign body type, osteoclast type and tumor giant cells. CONCLUSION: MNGCs can be seen in a wide spectrum of salivary gland lesions ranging from reactive to benign and malignant. They are of nonepithelial origin or can be of true neoplastic nature in metastatic lesions.

Concurrent diagnosis of infective endocarditis and acute rheumatic fever: A case report.

Rheumatic heart disease has been classically considered as a risk factor for infective endocarditis (IE). Although valvulitis is frequently present in patients with acute rheumatic fever (ARF), the established valve disease after initial episode of ARF is usually considered as a predisposing factor for IE. We hereby present a biopsy-proven case of IE co-diagnosed with the first episode of ARF. .

Osteoclast-like giant-cell tumor of the parotid with salivary duct carcinoma: case report and cytologic, histologic, and immunohistochemical findings.

Primary giant-cell tumor of the salivary gland is a rare lesion with an incompletely characterized histogenesis. To the best of our knowledge, only 16 cases have been previously documented in the English-language literature. We report a new case, which occurred in a 75-year-old man who presented with a parotid mass and cervical lymphadenopathy. The patient underwent a left total parotidectomy and cervical lymph node dissection. As far as we know, ours is the only reported case of a primary giant-cell tumor of the salivary gland in which the patient presented with lymph node metastasis. Because so little is known about giant-cell tumor of the salivary gland, we use the occasion of this case report to describe the cytologic, histologic, and immunohistochemical characteristics that we observed.

Primary Hepatic Lymphoma Mimicking Cholangiocarcinoma.

Primary hepatic lymphoma (PHL) presenting with obstructive jaundice is rare and can mimic a preoperative diagnosis of cholangiocarcinoma. We should consider PHL in patients with radiological hepatic disease with normal serum alpha-fetoprotein and carcinoembryonic antigen levels, and elevated lactate dehydrogenase. We present the case of a 67-year-old male with no significant medical history presented with abdominal pain, jaundice, fever, and abnormal liver function tests. Abdominal sonography and computed tomography scan suggested a diagnosis of obstructive jaundice and cholangitis due to cholangiocarcinoma (Klatskin tumor). A subsequent liver biopsy diagnosed PHL, and the patient was treated with combination chemotherapy, including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). PHL should be considered in patients presenting with biliary obstruction.

Missing Elements in Surgical Pathology Reports: Breast, Colon and Stomach Cancers.

Cancer pathology reports play an important role in choice of patient care. They provide crucial information concerning diagnosis, therapy options, and prognosis. Professional pathology institutions, such as the College of American Pathologists (CAP), have developed checklists to ensure the presence of all the required elements in reports. In this study, 438 surgical pathology reports of patients with breast (148), colon (147), and stomach cancer (143) were evaluated with respect to the presence of mandated elements according to CAP checklists. The most common missing element in all the three types of cancer was 'staging' (73.6, 53.1, and 56.6% in breast, colon, and stomach cancer reports missed 'staging', respectively). The second most missing element was 'tumor site' in breast (64.2%) and stomach cancer (30.1%), and 'procedure' in colon cancer (29.3%). 'Perineural invasion' was the third most missing element in the three types of cancer (25.7, 17.0, and 22.4% in breast, colon, and stomach cancer, respectively). Only 11.4% of reports included all key elements required by CAP. The use of checklists was associated with higher rate of completeness. This study demonstrates that the key elements requiring the information on the requisition forms from the clinicians are commonly missed, leading to ambiguity.

Prominent Cold Nodule in Multinodular Goiter Revealed to Be Thyrolipoma: A Case Report.

The presence of adipose tissue in the thyroid gland is a rare finding. Thyrolipoma or adenolipoma of the thyroid is a benign, encapsulated lesion of the thyroid composed of variable amounts of fat and glandular elements. This report presents a case of thyrolipoma in a 69-yr-old female presenting with neck swelling and respiratory distress. Differential diagnosis of the fat-containing thyroid lesion is also presented. Differentiation of the condition from similar lesions is necessary for accurate diagnosis of thyrolipoma.

Laparoscopic approach to a large ovarian fibroma: a case report.

BACKGROUND: Ovarian fibroma is the most common benign solid tumor of the ovary, which is often difficult to diagnose preoperatively. The choice treatment for ovarian fibroma is surgical removal, but discussions for the operative approach, laparoscopic or open, in the literature seem to be scant. CASE PRESENTATION: We presented a unique clinical experience of laparoscopic approach to a case of 15 cm unilateral ovarian fibroma in a 24 year old patient, with a successful and complete resection of the tumor beside ovarian tissue preservation in December 2012 in Rasoul-e-Akram hospital, Tehran, Iran. CONCLUSION: In conclusion, we should not forget the role of laparoscopy as a diagnostic procedure even in suspicious cases of ovarian fibroma with solid tumor, ascites, and pleural effusion.