Combined Presigmoid-Subtemporal Approach in a Semi-Sitting Position for Petroclival Meningiomas: A Technical Report.

The removal of petroclival meningiomas (PMs) is considered a neurosurgical challenge due to the critical mobilization of key neurovascular structures. Limited knowledge about the benefits of operating on patients with PMs using the combined presigmoid-subtemporal approach (CPSA) in a semi-sitting position has precluded its generalizability. We report on ten patients with PMs operated in a semi-sitting position using CPSA. We remark that before the surgical approach was accomplished in our group of patients, the CPSA via semi-sitting position was conducted and standardized in six adult cadaveric heads. The neuroanatomic dissections made in cadavers allowed us to confidently use CPSA in our set of patients. There were no comorbidities, perioperative complications, or deaths associated with the surgical procedure. CPSA via a semi-sitting position can be considered a safe approach to remove PMs.

Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

Breastfeeding Is Associated with a Reduced Risk of Attention-Deficit/Hyperactivity Disorder Among Preschool Children.

BACKGROUND: Breastfeeding has been associated with a lower risk of attention-deficit/hyperactivity disorder (ADHD). However, most studies examining this association have focused on small samples outside the United States or were likely subject to substantial residual confounding. Our objectives were to investigate, in a nationally representative sample of preschool children in the United States, the associations between ADHD and both age of breastfeeding cessation and age of formula introduction, as well as associations between ADHD and exclusive breastfeeding duration. METHODS: Analysis of data from children aged 3 to 5 years in the 2011/12 National Survey of Children's Health (n = 12,793). Logistic regressions were used to model current medical diagnosis of preschool ADHD as a function of breastfeeding duration, breastfeeding exclusivity, and the timing of formula introduction with adjustment for 12 potential confounders using propensity scores, including sex, age, race, household income, prematurity, insurance, and medical home. RESULTS: After adjustment for potential confounders, exclusive breastfeeding for at least 6 months was associated with substantially reduced odds of ADHD (adjusted prevalence odds ratio [aPOR] = 0.38; 95% confidence interval [CI], 0.15-0.99). Breastfeeding duration was also associated with ADHD, with 8% reduced odds of ADHD for each additional month of breastfeeding (aPOR = 0.92; 95% CI, 0.86-0.99). The results for exclusive breastfeeding duration were similar, but the confidence interval included the null (aPOR = 0.92; 95% CI, 0.85-1.00). The age of formula introduction was not associated with ADHD (aPOR = 0.92; 95% CI, 0.81-1.05). CONCLUSION: In a nationally representative sample of preschool children, breastfeeding was associated with a lower prevalence of ADHD. These findings provide evidence in support of the neurodevelopmental benefits of breastfeeding.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics.

BACKGROUND: A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA). METHODS: Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA. RESULTS: When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA. DISCUSSION: HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections. CONCLUSIONS: Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room.

BACKGROUND: Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands. METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period. RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness. CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Does Adherence to World Health Organization Hand Hygiene Protocols in the Operating Room Have the Potential to Produce Irritant Contact Dermatitis in Anesthesia Providers?

Anesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.

Outcomes of Deceased Donor Kidney Transplantation Using Expanded Criteria Donor Kidneys Following Pulsatile Preservation.

Aim We compared the outcomes of transplanting expanded criteria donor (ECD) kidneys undergoing machine perfusion (MP) versus cold storage (CS). Material and methods Data on all expanded criteria deceased donor kidney transplants performed at the University of Pittsburgh Medical Center from January 2003 through December 2012 were collected from an in-house electronic repository. There were 78 patients in the MP group and 101 patients in the CS group. The majority of the ECD kidneys were imported from other organ procurement organizations: 69 of 73 in the MP group (94.5%, 5 from unknown sources); and 90 of 99 in the CS group (91%), 2 from an unknown source). Most of the patients in the MP group (77 of 78) received a combination of MP and static CS. MP was performed just prior to transplantation in all MP patients. We used descriptive statistics to characterize our sample. We used logistic regression analysis to model the binary outcome of delayed graft function (DGF; i.e., "yes/no") and Cox (proportional hazard) regression to model time until graft failure. The Kaplan-Meier product-limit method was used to estimate survival curves for graft and patient survival. Results A total of 179 transplants were done from ECD donors (MP, 78; CS, 101). The mean static cold storage time was 14 ± 4.1 hours and the mean machine perfusion time was 11.2 ± 6.3 hours in the MP group. The donor creatinine was higher (1.3 ± 0.6 mg/dl vs. 1.2 ± 0.4 mg/dl, p = 0.01) and the cold ischemia time was longer (28.9 ± 10 hours vs. 24 ± 7.9 hours, p = 0.0003) in the MP patients. There were no differences between the two groups in DGF rate (20.8% [MP] vs. 25.8% [CS], p = 0.46), six-year patient survival (74% [MP] vs. 63.2% [CS], p = 0.11), graft survival (64.3% [MP] vs. 51.5% [CS], p = 0.22), and serum creatinine levels (1.5 mg/dl vs. 1.5 mg/dl) on univariate analysis. On unadjusted analysis, MP subjects without DGF had longer graft survival compared to CS subjects with DGF (p < 0.0032) and MP subjects with DGF (p < 0.0005). MP subjects without DGF had longer death-censored graft survival compared to CS subjects with DGF (p < 0.0077) and MP subjects with DGF (p < 0.0016). However, on regression analysis, MP subjects had longer graft survival than CS subjects when DGF was not present. MP subjects without DGF had longer patient survival compared to CS subjects with DGF (p < 0.0289), on unadjusted analysis. MP subjects had a reduced risk of graft failure (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.17, 0.68) and death-censored graft failure (HR, 0.44; 95% CI, 0.19, 1.00), compared to CS subjects when DGF was not present. Conclusions Reduction of DGF rates for imported ECD kidneys is vital to optimize outcomes and increase their utilization. One strategy to decrease DGF rates may be to reduce static CS time during transportation, by utilizing a portable kidney perfusion machine.

Interprofessional Collaboration and Peer Mentors for Bowel Education in Spinal Cord Injury: A Case Consultation.

BACKGROUND: Evidence shows that having a bowel management program prevents rehospitalization postacute rehabilitation discharge for persons with a spinal cord injury (SCI). Peer mentors have been used to assist patients in managing their care. PURPOSE: The aim of the study was to illustrate how interprofessional collaboration led to utilizing resources of the inpatient rehabilitation facility's peer mentor program and incorporating peer mentors into bowel education for persons with SCI. METHODS: A descriptive case review of a continuous quality improvement (CQI) project, using an eight-item Likert scale evaluation survey with three open-ended questions to assess the utility of incorporating peer mentors into bowel education. FINDINGS AND CONCLUSIONS: Twenty-seven of the 28 participants responded to the survey. Results showed that the education program was useful, should be continued, and include the peer mentors. Responses from open-ended questions included themes related to knowledge, adherence, and taking charge of one's own care. Interprofessional collaboration and involvement of peer mentors as copresenters in SCI bowel education were feasible.

Diagnosis of Lymphoma Using Fine-Needle Aspiration Biopsy and Core-Needle Biopsy: A Single-Institution Experience.

OBJECTIVE: The objective is to study the efficacy of fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) in the diagnosis of lymphoma in a single institution. STUDY DESIGN: We retrospectively reviewed 635 FNAB/CNB cases performed in our institution to rule out lymphoma during a 4-year period and collected the relevant clinical and pathological information for statistical analysis. RESULTS AND CONCLUSIONS: This cohort comprised 275 males and 360 females, with a median age of 57 years. Among the 593 cases with adequate diagnostic materials for lymphoma work-up, 226 were positive for lymphoma, 286 were negative for lymphoma, and 81 were nondiagnostic. Each case had an FNAB, and 191 cases also underwent a CNB. The subclassification rate according to the WHO (2008) was 67% overall, 81% for the FNAB with CNB group, and 40% for the FNAB group. In the FNAB with CNB group, the subclassification rates for cases with and without a history of lymphoma were not significantly different. A definitive diagnosis of lymphoma relied on ancillary studies, but was not affected by location, or the needle gauge of CNB. Follow-up data revealed a high diagnostic accuracy of FNAB with CNB. In conclusion, the use of FNAB and CNB with ancillary studies is effective in providing a definitive diagnosis of lymphoma in our experience at the Northwell Health System.

Current hand hygiene education is suboptimal.

BACKGROUND: To address the low levels of hand hygiene compliance (HHC) at our academic medical centre, we developed an annual patient safety course required for all incoming third-year medical students. Based on previous observations of medical students, it was determined that hand hygiene (HH) would be a central component of the course. METHODS: Over a 1-year period (2015/16), we observed third- and fourth-year medical students who had participated in the annual patient safety course entering three intensive care units (ICUs) at two teaching hospitals. A total of 150 medical students failed to perform HH on entry and were subsequently asked why they did not comply. RESULTS: Of the 150 medical students observed entering an ICU without performing HH, 74.7% were male and 25.3% were female. Males cited inadequate time (21.4%), lack of role models (10.7%) and provided incorrect information regarding HH requirements (58.9%). Females cited concerns about dry or cracked skin (34.2%) and forgetting (23.7%). DISCUSSION: Our study demonstrates that even when medical students receive intensive HH education, compliance remains low. Of note, males and females offered different reasons for why they failed to perform HH. To address the suboptimal HHC, we developed an annual patient safety course required for all third-year medical students immediately prior to beginning clinical rotations. In this study, we sought to understand why medical students' HH remains suboptimal even after an intensive course.

Modeling a Carrington-scale Stellar Superflare and Coronal Mass Ejection from κ 1 Cet.

Observations from the Kepler mission have revealed frequent superflares on young and active solar-like stars. Superflares result from the large-scale restructuring of stellar magnetic fields, and are associated with the eruption of coronal material (a coronal mass ejection, or CME) and energy release that can be orders of magnitude greater than those observed in the largest solar flares. These catastrophic events, if frequent, can significantly impact the potential habitability of terrestrial exoplanets through atmospheric erosion or intense radiation exposure at the surface. We present results from numerical modeling designed to understand how an eruptive superflare from a young solar-type star, κ 1 Cet, could occur and would impact its astrospheric environment. Our data-inspired, three-dimensional magnetohydrodynamic modeling shows that global-scale shear concentrated near the radial-field polarity inversion line can energize the closed-field stellar corona sufficiently to power a global, eruptive superflare that releases approximately the same energy as the extreme 1859 Carrington event from the Sun. We examine proxy measures of synthetic emission during the flare and estimate the observational signatures of our CME-driven shock, both of which could have extreme space-weather impacts on the habitability of any Earth-like exoplanets. We also speculate that the observed 1986 Robinson-Bopp superflare from κ 1 Cet was perhaps as extreme for that star as the Carrington flare was for the Sun.

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features: An interobserver study of key cytomorphological features from a large academic medical centre.

OBJECTIVE: Because of the indolent nature of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and potential requisite for a more conservative treatment, it is crucial to identify features of this entity preoperatively. Our group recently published findings that there are several cytomorphological features that may be used as clues to distinguish NIFTP, papillary thyroid carcinoma (PTC) and follicular adenoma (FA) on fine needle aspiration. Therefore, we aimed to determine the interobserver reproducibility of these findings. METHODS: Presurgical fine-needle aspiration slides from NIFTP (n = 30), classic PTC (n = 30) and FA (n = 30) collected from 1/2013-8/2016 were reviewed by seven cytopathologists blindly. Presence of selected cytomorphological features was recorded and compared to determine percent agreement and inter-rater reliability among study cytopathologists using Gwet's AC1 statistics. RESULTS: For all the cytomorphological features, the overall percent agreement amongst the pathologists ranged between 65.1% and 86.8% (Gwet's AC1 0.30-0.80). There was substantial or almost perfect agreement (Gwet's AC1 > 0.60) in seven cytomorphological features in the classic PTC group, in six features in the NIFTP group and in five features in the FA group. There were no features with poor agreement (Gwet's AC1 < 0.0). CONCLUSIONS: The current study supports the reproducibility of our previous findings. The high level of agreement amongst pathologists for these groups, and particularly the NIFTP group, supports the notion that when viewed in combination as a cytological profile, these cytomorphological features may assist the cytopathologist in raising the possibility of NIFTP preoperatively. This can potentially aid clinicians in deciding whether more conservative treatment may be appropriate.

Why Money Alone Can't (Always) "Nudge" Physicians: The Role of Behavioral Economics in the Design of Physician Incentives.

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Comparison of Disposable Goldmann Applanation Tonometer, ICare ic100, and Tonopen XL to Standards of Care Goldmann Nondisposable Applanation Tonometer for Measuring Intraocular Pressure.

PURPOSE: To compare intraocular pressure (IOP) measurements by Goldmann applanation tonometer (GAT), disposable Goldmann applanation prism, ICare, and Tonopen. MATERIALS AND METHODS: A total of 74 patients with varying glaucoma status were examined in our outpatient clinic and IOP was measured with 3 tonometers. The disposable Tonojet prism (dGAT), Tonopen XL, and ICare ic100 were compared with the GAT. RESULTS: There were good intraclass correlation coefficients between IOP measurements by GAT and dGAT (0.95), Tonopen (0.83), and ICare (0.77), all P<0.001. The IOP mean differences between dGAT and GAT were mean 0.80 mm Hg; 95% limits of agreement: -3.35 to 4.96 mm Hg. For Tonopen and GAT: mean, -1.67 mm Hg; limits of agreement, -8.55 to 5.21 mm Hg. For ICare and GAT: mean, 0.44 mm Hg; limits of agreement, -8.18 to 9.06 mm Hg. CONCLUSIONS: The most reliable modality, with good correlation with the Goldmann tonometer values, was the GAT with dGAT, followed in descending order by the Tonopen XL and ICare. There was good interdevice agreement and consistency between all devices. On subgroup analysis, all 3 modalities were found to be less reliable at extreme IOP values (<10 and >24 mm Hg). These disposable modalities should be avoided in extreme IOP ranges outside the normal range.

Potentially Avoidable Readmissions in United States Hemodialysis Patients.

INTRODUCTION: Patients with end-stage kidney disease have a high risk of 30-day readmission to hospital. These readmissions are financially costly to health care systems and are associated with poor health-related quality of life. The objective of this study was to describe and analyze the frequency, causes, and predictors of 30-day potentially avoidable readmission to hospital in patients on hemodialysis. METHODS: We conducted a retrospective cohort study using the US Renal Data System data from January 1, 2008, to December 31, 2008. A total of 107,940 prevalent United States hemodialysis patients with 248,680 index hospital discharges were assessed for the main outcome of 30-day potentially avoidable readmission, as identified by a computerized algorithm. RESULTS: Of 83,209 30-day readmissions, 59,045 (70.1%) resulted in a 30-day potentially avoidable readmission. The geographic distribution of 30-day potentially avoidable readmission in the United States varied by state. Characteristics associated with 30-day potentially avoidable readmission included the following: younger age, shorter time on hemodialysis, at least 3 or more hospitalizations in preceding 12 months, black race, unemployed status, treatment at a for-profit facility, longer length of index hospital stay, and index hospitalizations that involved a surgical procedure. The 5-, 15-, and 30-day potentially avoidable readmission cumulative incidences were 6.0%, 15.1%, and 25.8%, respectively. CONCLUSION: Patients with end-stage kidney disease on maintenance hemodialysis are at high risk for 30-day readmission to hospital, with nearly three-quarters (70.1%) of all 30-day readmissions being potentially avoidable. Research is warranted to develop cost-effective and transferrable interventions that improve care transitions from hospital to outpatient hemodialysis facility and reduce readmission risk for this vulnerable population.

Blunt traumatic scapular fractures are associated with great vessel injuries in children.

BACKGROUND: Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients. METHODS: Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC). RESULTS: We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck). CONCLUSIONS: Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III; Therapeutic, level IV.

Putting POP-Q to the test: does C - D = cervical length?

INTRODUCTION AND HYPOTHESIS: We investigated the correlation between calculated cervical length (CCL) and gross specimen cervical length (GCL) after total vaginal hysterectomy (TVH) at the time of surgery for pelvic organ prolapse (POP). METHODS: This was a retrospective chart review of patients who had undergone TVH with reconstructive surgery for POP between 2013 and 2015. Patients without an intact specimen or documented cervical length in the pathology report were excluded. CCL was defined as the absolute difference between Pelvic Organ Prolapse Quantification (POP-Q) points C and D. GCL was obtained from the pathology report as the distance from the external to the internal os. The Bland-Altman method was used to assess the accuracy of POP-Q measurements with a priori ranges. Symptom severity was evaluated using the PFDI-20 questionnaire. Analysis of variance was used to model both GCL and CCL as a function of prolapse stage and the leading compartment. RESULTS: The final analysis included 202 subjects. Of the CCL measurements, 56.93% were within ±2 cm of GCL, while 36.14% were within ±1 cm. POP stage was significantly associated with GCL (P < 0.0024). CCL was significantly longer in patients with stage 4 POP (3.57 cm, 95% CI 3.13-4.00) than in those with stage 2 POP (P < 0.0017; mean 2.68 cm, 95% CI 2.45-2.92) and stage 3 POP (P < 0.0300; mean 2.94 cm, 95% CI 2.73-3.15). There were no significant correlations between PFDI scores and CCL or GCL. CONCLUSIONS: The agreement between POP-Q CCL (|C - D|) and GCL decreases with increasing POP-Q stage. There was no correlation between POP symptom severity and GCL or CCL. GCL significantly increased with increasing POP stage.

Learning curve and competence for volumetric laser endomicroscopy in Barrett's esophagus using cumulative sum analysis.

BACKGROUND AND STUDY AIMS: Little is known about the learning curve for image interpretation in volumetric laser endomicroscopy (VLE) in Barrett's esophagus (BE). The goal of this study was to calculate the learning curve, competence of image interpretation, sensitivity, specificity, and accuracy of VLE among novice users. METHODS: 31 novice users viewed 96 VLE images electronically at three academic institutions after a brief training session. There were 24 images of each histologic type: normal gastric cardia, normal esophageal squamous epithelium, non-neoplastic BE, and neoplastic BE. The users were asked to identify the correct tissue type and level of confidence. The cumulative summation (CUSUM) technique was used to construct a learning curve. RESULTS: 22 (71 %) of the physicians achieved VLE interpretation competency during their 96-slide review. Half of the physicians achieved competency at 65 images (95 % confidence interval [CI] 45 - 85). There was a statistically significant association between confidence in diagnosis and selecting the correct histologic tissue type (P < 0.001). The median accuracy for esophageal squamous epithelium, normal gastric cardia, non-neoplastic BE, and neoplastic BE was 96 % (95 %CI 95 % - 96 %), 95 % (95 %CI 94 % - 96 %), 90 % (95 %CI 88 % - 91 %), 96 % (95 %CI 95 % - 96 %). The overall accuracy was 95 % (95 %CI 93 % - 95 %). CONCLUSION: The majority of novice users achieved competence in image interpretation of VLE for BE, using a pre-selected image set, with a favorable learning curve after a brief training session. An electronic review of VLE images, prior to real-time use of VLE, is encouraged.

Analysis of the Cytomorphological Features in Atypical Urine Specimens following Application of The Paris System for Reporting Urinary Cytology.

BACKGROUND: This study investigates the use of The Paris System (TPS) for Reporting Urinary Cytopathology and examines the performance of individual and combined morphological features in atypical urine cytologies. METHODS: We reviewed 118 atypical cytologies with subsequent bladder biopsies for the presence of several morphological features and reclassified them into Paris System categories. The sensitivity and specificity of individual and combined features were calculated along with the risk of malignancy. RESULTS: An elevated nuclear-to-cytoplasmic ratio was only predictive of malignancy if seen in single cells, while irregular nuclear borders, hyperchromasia, and coarse granular chromatin were predictive in single cells and in groups. Identification of coarse chromatin alone yielded a malignancy risk comparable to 2-feature combinations. The use of TPS criteria identified the specimens at a higher risk of malignancy. CONCLUSION: Our findings support the use of TPS criteria, suggesting that the presence of coarse chromatin is more specific than other individual features, and confirming that cytologic atypia is more worrisome in single cells than in groups.