First-in-human study of the safety and viability of intraocular robotic surgery.

Microsurgery of the retina would be dramatically improved by instruments that offer supra-human precision. Here, we report the results of a first-in-human study of remotely controlled robot-assisted retinal surgery performed through a telemanipulation device. Specifically, 12 patients requiring dissection of the epiretinal or inner limiting membrane over the macula were randomly assigned to either undergo robot-assisted-surgery or manual surgery, under general anaesthesia. We evaluated surgical success, duration of surgery and amount of retinal microtrauma as a proxy for safety. Surgical outcomes were equally successful in the robotic-surgery and manual-surgery groups. Differences in the amount of retinal microtrauma between the two groups were statistically insignificant, yet dissection took longer with robotic surgery (median time, 4 min 5 s) than with manual surgery (1 min 20 s). We also show the feasibility of using the robot to inject recombinant tissue plasminogen activator under the retina to displace sight-threatening haemorrhage in three patients under local anaesthesia. A safe and viable robotic system for intraocular surgery would enable precise and minimally traumatic delivery of gene therapy or cell therapy to the retina.

Development of visual diagnostic expertise in pathology.

In this study, we use methods from information-processing to explore the visual diagnostic processes of novice, intermediate, and expert pathologists. Subjects were asked to examine and interpret a set of slides while we collected think-aloud verbal protocols and captured on digital video the actual visual data they examined from the microscope. We performed an in-depth combined video and protocol-based analysis of processes and errors occurring as the task was performed. Additionally, we collected measures of accuracy, certainty, and difficulty for all cases. Our preliminary analysis identified significant differences between groups in all three major aspects of this task: searching skills, perceptual skills and cognitive/reasoning skills. We describe the implications of our preliminary cognitive task analysis on the design of a developing intelligent educational system in Pathology.

A case-matched molecular comparison of extraovarian versus primary ovarian adenocarcinoma.

BACKGROUND: Extraovarian müllerian adenocarcinoma (EOM) resembles primary ovarian carcinoma (POC) both histologically and clinically, yet little is known regarding the molecular genetic characteristics of this entity. The objective of this study was to compare the expression of three molecular markers of tumor behavior in EOMs and POCs. METHODS: Forty-four patients meeting strict criteria for EOM were identified and matched to POC controls for age, stage, tumor histology and grade, cytoreductive surgery, and survival. Immunohistochemistry was used to determine overexpression of p53 and HER-2/neu. DNA content was evaluated by flow cytometry. Direct DNA sequencing of exons 5-8 of the p53 gene was performed in nine EOM tumors. Statistical comparisons were made using chi-square, Kaplan-Meier, and Mantel-Cox log rank methods. RESULTS: Overexpression of HER-2/neu was demonstrated in 59% (26 of 44) of the EOM group versus 36% overexpression (16 of 44) in the POC controls (P = 0.05). Overexpression of p53 was noted in 48% of the EOM cases, similar to the 59% incidence observed in the control group (P = 0.29). Missense mutations were found in 9 of 9 EOM tumors showing strong p53 nuclear immunostaining. No significant difference in the incidence of aneuploidy was observed when EOM cases were compared with POC controls (65% vs. 63%). High tumor grade was strongly associated with HER-2/neu overexpression in the EOM group (P = 0.002). None of the parameters studied were predictive of prognosis within the EOM and POC groups. CONCLUSIONS: Although overexpression of p53 protein, p53 gene mutations, and abnormal DNA content were similar between EOMs and POCs, EOMs demonstrated almost twice the rate of HER-2/neu overexpression. This result suggests that distinct genetic events may be responsible for malignant transformation in EOMs versus POCs.

WebReport: a World Wide Web based clinical multimedia reporting system.

This paper describes WebReport, a World Wide Web (WWW) client for the Image Engine multimedia clinical information system under development at the University of Pittsburgh. WebReport uses advanced HTML features such as frames, forms, tables and inline JPEG image display to provide an easy to use system for retrieving and viewing diagnostic images and reports generated by clinical procedures such as gastrointestinal endoscopy, radiology and surgical pathology. WebReport implements a number of WWW client-side features, such as HTML forms data entry verification and makes extensive use of the JavaScript programming language. The WebReport system uses a number of approaches for ensuring the confidentiality and security of patient data transmitted over the InterNet.

Determination of lymphocyte immunophenotypic values for normal full-term cord blood.

Normal reference values for flow cytometric immunophenotypic lymphocyte markers for cord blood (CB) were determined using sufficient numbers of subjects for clinical laboratory use. Samples from 202 normal gestations were processed by whole blood lysis and analyzed in the following combinations: CD14/45, CD4/3, CD8/3, CD45RA/4, CD29/4, CD56/3, Cd19/3, CD19/10. Thirty-five adult laboratory volunteers were analyzed as controls. When compared to adults, CB showed increased relative percentages of naive T-helper cells, B cells, immature B cells, and CD8+3-cells and decreased T cells, cytotoxic T cells, activated T-helper cells, and large granular lymphocytes (CD56+3+). Significant differences were also found when CB samples were stratified by sex and race. These results provide clinical laboratory normal reference values for lymphocyte markers for CB, demonstrate the need for determining separate standard reference values for significantly different patient populations, provide the basis for future investigation of pathologic gestations and for clinical laboratory applications, and provide insight into early immunologic development.

Infertility evaluation in fertile women: a model for assessing the efficacy of infertility testing.

A standard infertility evaluation consists of a semen analysis, hysterosalpingogram, post-coital test, endometrial biopsy and laparoscopy. Although these tests are well grounded in clinical experience, information on their ability to discriminate between fertile and infertile couples is limited. In this study, we performed standard infertility tests plus two others--sperm antibodies and cervical culture for Mycoplasma hominis and Ureaplasma urealyticum--on fertile and infertile couples. Women in the fertile group were selected from those who had delivered a child within the previous 2 years and who were scheduled for a laparoscopic tubal ligation. Women in the infertile group were selected from those presenting for an infertility evaluation (mean duration of infertility 4.2 years), and they were matched by age (+/- 3 years) and race with fertile subjects. Subjects were recruited from both private and clinic patients. A total of 64 couples (32 matched pairs) completed the evaluation. At least one 'abnormal' infertility test was found in 69% of fertile and 84% of infertile couples. With the exception of tubal damage and endometriosis, which as expected were more common in infertile couples, no significant differences between groups for remaining infertility factors could be demonstrated. Despite the small size of the current study, these results confirm the feasibility and importance of comparisons of the prevalence of infertility factors in fertile and infertile couples.

Estimation of hepatic hematopoiesis in second and third trimester singleton gestations using flow cytometric light scatter analysis of archival autopsy tissue.

The purpose of this investigation was to develop a simple, quantitative, reproducible and objective method for estimating fetal hepatic hematopoiesis using flow cytometric light scatter measurements and to use this methodology to determine standard values for singleton gestations. Percent hepatic hematopoiesis was estimated from autopsy tissue both flow cytometrically using forward angle and side light scatter characteristics and histologically (single observer) in 67 s and third trimester singleton gestations without evidence of infection, congenital malformation, chronic maternal or placental disorders, or growth retardation. Correlation of flow cytometric and histologic estimates was 0.70 with flow cytometric estimates showing less variability than histologic estimates, especially during the second trimester. Flow cytometric estimates of hepatic hematopoiesis were relatively constant at 50-70% between 16 and 27 weeks gestational age and decreased during the third trimester to a level of approximately 25-30% at term. These results confirm and quantitate the predicted decrease in hepatic hematopoiesis between the second and third trimesters of gestation as well as its persistence at term. In addition, they demonstrate that flow cytometric light scatter analysis is an objective, valid and simple method for estimating hepatic hematopoiesis in archival autopsy tissue and provides objective standard values for comparison with estimates in pathologic gestations.

Prognostic value of flow cytophotometric DNA content analysis in single treatment stage IB-IIA squamous cell carcinoma of the cervix.

DNA content was measured flow cytometrically in archival tissue from 65 single-treatment stage IB and IIA squamous cell carcinomas of the cervix with at least 5 years of clinical follow-up. Thirty-five cases were treated exclusively by hysterectomy and thirty exclusively by radiation therapy. Tumors were categorized into four groups on the basis of DNA content and cell cycle distribution. DNA content was measured relative to the position of the first resolvable cell peak. G2/M and S-phase fractions were estimated as percentage of cells with DNA contents greater than or equal to relative position 1.70 and percentage of cells with relative positions between 1.20 and 1.70, respectively. The 40 tumors characterized as either aneuploid or nondemonstrably aneuploid with high S-phase fraction estimate had a 5-year recurrence rate significantly higher than that of the 25 tumors categorized as tetraploid or nondemonstrably aneuploid with low S-phase fraction estimate (52 and 4%, respectively; chi 2 = 15.8, P less than 0.001). Similar results were found when radiation and surgically treated tumors were considered independently (chi 2 = 7.95, P less than 0.005 and chi 2 = 5.7, P less than 0.025, respectively). These data suggest that an increased 5-year recurrence rate is associated with both abnormal DNA content and elevated S-phase fraction in stage IB-IIA squamous cell carcinoma of the cervix, and that this relationship is largely independent of treatment method.

Endodermal sinus tumor of the ovary: a case series with flow cytometric DNA content analysis.

Endodermal sinus tumors (EST) are rare germ cell ovarian malignancies occurring primarily in young women. A retrospective review of the Magee-Womens Hospital tumor registry revealed eight cases of pure EST and two mixed tumors in which the EST component was predominant. Mean patient age was 18.2 years. Abdominal pain was the most common presenting symptom and a pelvic mass was palpable in all patients. Four patients are currently alive and well with no evidence of disease. All were treated with surgery and combination chemotherapy. Flow cytometric DNA content analysis of paraffin-embedded tumor tissue identified similar aneuploid cell populations in three of five tumors analyzed with relative peak positions of 1.72, 1.62, and 1.70. The management of women with endodermal sinus tumor remains controversial with regard to type of chemotherapy employed and the use of second-look laparotomy. The prognosis role of flow cytometric DNA content analysis is yet to be determined.

Squamous cell carcinoma in situ arising in an ovarian mature cystic teratoma. Report of one case with histopathologic, cytogenetic, and flow cytometric DNA content analysis.

A squamous cell carcinoma in situ arose in an ovarian mature teratoma (ie, dermoid cyst) in a 62-year-old woman. Flow cytometric DNA content analysis of paraffin-embedded in situ carcinoma showed a normal DNA content with moderate to high proliferative activity (S-phase fraction estimate, 16% to 18%). Cytogenetic analysis of the in situ cancer and the benign cystic portion of the tumor revealed a 46,XX karyotype. In addition, the benign cystic portion of the tumor revealed homozygous chromosomal heteromorphisms, compared with heterozygous markers found in peripheral blood lymphocytes. These results show that this squamous cell carcinoma in situ was euploid and suggest that the mature cystic teratoma was derived from a single germ cell after meiosis I.

The incidence of luteal phase defect in normal, fertile women, determined by serial endometrial biopsies.

Five regularly menstruating women of proven fertility, with normal prolactin and thyroid function studies, underwent a total of 39 endometrial biopsies (EMBs). The slides were dated in blinded fashion, and the cycle date determined by considering the date of the next menstrual period as day 28 and counting backward. Using a 2-day or greater lag in endometrial maturity to define a luteal phase defect (LPD), the incidence of single and sequential out-of-phase EMBs was 51.4% and 26.7%, respectively. Using a 3-day or greater lag to define a LPD, the incidence of single and sequential out-of-phase EMBs was 31.4% and 6.6%, respectively. These incidences in normal, fertile women are as high as the rates quoted for infertile populations, and call into question the standard criteria for defining this condition and evaluating therapies to correct it.

Flow cytometric determination of nuclear DNA content in benign adrenal pheochromocytomas.

Nuclear DNA content of paraffin-embedded tissue from 19 clinically benign adrenal pheochromocytomas and 18 control adrenal glands was analyzed using flow cytometry. All control adrenal glands and 6 pheochromocytomas were diploid. Four tumors were tetraploid. Nine were aneuploid with relative DNA indices in the near diploid range in 2, in the peritriploid range in 5, and in the near tetraploid range in 2. These results indicate that aneuploid DNA content is a frequent occurrence in benign adrenal pheochromocytomas. Aneuploidy per se is not a specific marker of malignancy in these tumors as has been suggested by previous reports.

Flow cytometric analysis of nuclear DNA from adrenocortical neoplasms. A retrospective study using paraffin-embedded tissue.

Nuclear DNA content of paraffin-embedded tissue from 48 adrenocortical neoplasms, 18 histologically normal control adrenal glands, and five hyperplastic adrenal glands was analyzed retrospectively using flow cytometry. Aneuploidy was compared with morphologic criteria as a predictor of recurrence. All 18 controls, five hyperplastic glands, and 39 neoplasms were diploid. Nine neoplasms were aneuploid. Compared with their diploid counterparts, aneuploid neoplasms were more likely to weigh more than 50 g (P less than 0.0001) and to have three or more histologic features of carcinoma (P less than 0.0001). Thirty-six neoplasms were followed clinically for at least 2 years (range 24 to 120 months, mean = 64.6 months) or until local recurrence, metastasis, or death. Five were clinically malignant. Neoplasms which recurred or metastasized were more apt to be aneuploid (P less than 0.005) than those showing no evidence of further disease during the follow-up period. They were also more likely to weigh more than 50 g (P less than 0.005) and to have three or more histologic features of carcinoma (P less than 0.0025). However, neither aneuploidy, large size, nor unfavorable histology result was a consistent feature in every malignant neoplasm. Flow cytometric DNA content analysis appears to be as effective a predictor of clinical outcome as size and histology and may be of particular value when the morphologic features are ambiguous.

Prostacyclin production in vitro by rabbit aortic endothelium: correction for unstirred diffusional layers.

The degree of mixing in fluid layers immediately adjacent to the endothelial surface is a major variable in assessment of prostacyclin (PGI2) production by cultured endothelial cells or intact vessel endothelium in vitro. Lack of adequate mixing should lead to underestimation of true production because PGI2 immediately adjacent to endothelium would be only poorly sampled upon buffer collection. Thoracic aortas from 38 New Zealand white rabbits were therefore excised, opened longitudinally, and mounted endothelial side uppermost in a buffer-filled chamber which excluded cut tissue edges from study. Production of PGI2 under unstirred and magnetically stirred conditions was measured by radioimmunoassay (RIA) for 6-keto-PGF1 alpha. For animals pretreated with the combination of papaverine and heparin (see below), unstimulated and arachidonate-stimulated 6-keto-PGF1 alpha increased with stirring rate toward limits of 2.9 and 28.5 ng/cm2/min, respectively. Unstimulated and stimulated 6-keto PGF1 alpha measured at 650 rpm, for example, were greater than their values at 0 rpm by factors of 3.5 (2P less than .01) and 3.7 (2P less than .001), respectively. The process of vessel excision, however, produces another variable: degree of injury to endothelium caused by such factors as secondary vessel contraction and thrombin generation. Vessel contraction and thrombin generation can be minimized, respectively, by the use of a smooth muscle relaxant and heparin administered prior to killing of the animals. The rabbits were, therefore, grouped according to intravenous (IV) treatment, prior to killing, with saline, papaverine (4 mg/kg), heparin (200 U/kg) or the combination of papaverine and heparin (same doses). As compared with pretreatment with saline, papaverine alone, or heparin alone, pretreatment with the combination of papaverine and saline led to increases in stimulated 6-keto-PGF1 alpha of 1.6- to 2.8-fold. By transmission electron microscopy, endothelium from animals pretreated with saline showed ultrastructural changes, including disruption of cytoplasm, separation without detachment of most endothelial cells from subendothelium, and focal areas of denudation. In contrast, ultrastructural integrity of endothelium was preserved in aortas of animals pretreated with combined papaverine and heparin. These results support the hypothesis that unstirred diffusional layers lead, in vitro, to underestimation of PGI2 production, especially when vessels are protected from excisional injury.(ABSTRACT TRUNCATED AT 400 WORDS)