Empirical ordering of stains in cytology-are we saving or losing?

INTRODUCTION: Bronchoalveolar lavage (BAL) and body cavity fluids (pleural and peritoneal) have a useful role in the detection of infectious diseases, especially when combined with ancillary stains (Grocott methenamine silver, acid-fast bacilli, Fite, and cytomegalovirus). However, empirical ordering of stains and duplicate testing by concurrent microbiology cultures leads to unnecessary wastage of resources. The aim of our study was to optimize the use of resources. MATERIALS AND METHODS: We performed a retrospective review of all BALs and body cavity fluids from 2016 to 2018 to determine the baseline stain order rate, which was then used in conjunction with clinical information to create a reasonable target for 2019. The methods implemented included communication with the clinical team to modify current ordering practice, monitoring stain orders prospectively through 2019, and updating the cytology requisition form to limit upfront ordering of ancillary stains. RESULTS: From 2016 to 2018, of the 1270 specimens reviewed, 323 (55%) were BALs and 108 (16%) were body cavity fluids that had had ≥2 stains preordered. This was reduced by the end of 2019 to 10% of BALs and 3.4% of body cavity fluids, leading to $25,935.24 in costs savings (including 275 hours of technician time and 39.3 hours of pathologist time). CONCLUSIONS: We found that ancillary microorganism stains have limited utility in cytology specimens and should only be ordered when indicated after a review of the initial smears. In today's era of cost savings, upfront ordering of ancillary stains can lead to significant wastage of resources that can be prevented by improving workflow.

Stage IV Gestational Choriocarcinoma Diagnosed in the Third Trimester.

BACKGROUND: Gestational trophoblastic neoplasia rarely occurs in term pregnancies. Stage IV choriocarcinoma treated with conventional chemotherapy can result in death as a result of hemorrhagic sequelae at tumor sites. CASE: A 30-year-old woman at 34 weeks of gestation presented with a persistent cough, worsening dyspnea, and vaginal bleeding. Chest radiograph demonstrated innumerable lung nodules, and quantitative ß-hcg concentration exceeded 1.3 million milli-international units/mL. Cesarean delivery was performed for presumed abruption. Placental pathology demonstrated choriocarcinoma, and imaging confirmed stage IV disease with a World Health Organization score of 14. Remission was achieved after two courses of low-dose induction chemotherapy followed by 10 cycles of combination chemotherapy. CONCLUSION: Gestational trophoblastic neoplasia should be considered in a pregnant or postpartum woman presenting with atypical vaginal bleeding. Coexistent pulmonary or neurologic findings may suggest advanced disease.

Foxp3+ regulatory T cells impede the priming of protective CD8+ T cells.

T cell activation is controlled by incompletely defined opposing stimulation and suppression signals that together sustain the balance between optimal host defense against infection and peripheral tolerance. In this article, we explore the impacts of Foxp3(+) regulatory T cell (Treg) suppression in priming Ag-specific T cell activation under conditions of noninfection and infection. We find the transient ablation of Foxp3(+) Tregs unleashes the robust expansion and activation of peptide-stimulated CD8(+) T cells that provide protection against Listeria monocytogenes infection in an Ag-specific fashion. By contrast, Treg ablation had nonsignificant impacts on the CD8(+) T cell response primed by infection with recombinant L. monocytogenes. Similarly, nonrecombinant L. monocytogenes administered with peptide stimulated the expansion and activation of CD8(+) T cells that paralleled the response primed by Treg ablation. Interestingly, these adjuvant properties of L. monocytogenes did not require CD8(+) T cell stimulation by IL-12 produced in response to infection, but instead were associated with sharp reductions in Foxp3(+) Treg suppressive potency. Therefore, Foxp3(+) Tregs impose critical barriers that, when overcome naturally during infection or artificially with ablation, allow the priming of protective Ag-specific CD8(+) T cells.

Comparative analysis of lighted ureteral stents: lumination and tissue effects.

PURPOSE: The objectives of the present study were to compare the luminescence of three types of ureteral illuminated stents and analyze their effects on urothelial histology. MATERIALS AND METHODS: Three types of illuminating ureteral stents; the Cook single illuminating catheter, Cook double illuminating catheter and Stryker illumination system stent were laparoscopically placed in nine female white pigs (50 kg), under general anesthesia. After leaving the stents illuminated for 3 hours, during which time peritoneal insufflation was maintained at 18 mm Hg, the ureter was transected and the intraluminal temperature of the ureter was measured with a digital thermometer. The ureteral tissue was then harvested for histologic evaluation, and the animal was euthanized. RESULTS: Statistical analysis confirmed that Stryker and Cook double illuminated stents were equally efficient in illuminating the ureter (P 0.46) whereas, the Cook single stent was significantly superior (P = 0.000004). There was no significant difference in mean intraluminal temperatures between the Cook single (95.2 degrees F), Cook double (92.3 degrees F), and Stryker (95.1 degrees F) stents. When compared with the intraluminal temperature of control unstented ureters, no significant increase was noted with the Cook single (P = 0.85), Cook double (P = 0.57), or Stryker (P = 0.82). Histologic analysis did not show any evidence of thermal injury to the urothelium or any remarkable alteration in the ureteral mucosa. CONCLUSION: The Cook single illuminated stent presented the highest luminescence. All three devices did not cause any remarkable injury to the urothelium after 3 hours of exposure.

Pulmonary complications after bone marrow transplantation: an autopsy study from a large transplantation center.

CONTEXT: Bone marrow transplantation (BMT) is used to treat various malignant and nonmalignant disorders. Pulmonary complications are some of the most common causes of mortality in BMT recipients. Poor general health and bleeding tendency frequently preclude the use of definitive diagnostic tests, such as open lung biopsy, in these patients. OBJECTIVE: To identify pulmonary complications after BMT and their role as the cause of death (COD). DESIGN: The autopsy and bronchoalveolar lavage (BAL) slides and microbiology studies of BMT recipients from a 7-year period were reviewed. RESULTS: Pulmonary complications were identified in 40 (80%) of the 50 cases. The most common complications were diffuse alveolar damage (DAD) and diffuse alveolar hemorrhage (DAH). Pulmonary complications were the sole or 1 of multiple CODs in 37 cases (74%). All complications were more common in allogeneic BMT recipients. In 19 (51%) of the 37 cases in which pulmonary complications contributed to the death, cultures were negative. Both DAD and DAH, complications commonly reported in the early post-BMT period, were seen more than 100 days after BMT in 33% and 12% of cases, respectively. Five (83%) of 6 cases of invasive pulmonary aspergillosis diagnosed at autopsy were negative for fungi ante mortem (by BAL and cultures). CONCLUSIONS: Pulmonary complications are a significant COD in BMT recipients, many of which, especially the fungal infections, are difficult to diagnose ante mortem. The etiology of DAD and DAH is likely to be multifactorial, and these complications are not limited to the early posttransplantation period. Autopsy examination is important in determining the COD in BMT recipients.