The role of self-evaluation and education of radiographers involved in a breast cancer screening program at Clinical Hospital Center Rijeka.

INTRODUCTION: Early breast cancer detection can be achieved by enforcing the quality of mammography screening program. Hence, proper breast positioning is necessary. Systematic education of radiographers on mammographic positioning is a prerequisite for obtaining high-quality mammograms. The aim of this study is to demonstrate the importance of self-evaluation and education of radiographers involved in a breast cancer screening program. METHODS: The First School of Mammographic Positioning was organized in 2018 at Clinical Hospital Center (CHC) Rijeka and 24 radiographers included in the screening program attended. Four months after the School, an analysis and comparison of randomly selected mammograms was performed. Retrospective analysis was performed, and two sets of collected data were gathered from the period before and after the education. The quality criteria for evaluation were set and the mammograms were independently analyzed by two radiographers with experience in mammography. The chi-square test was used to perform statistical analysis. RESULTS: Results showed a statistically significant difference in the quality of mammograms before and after training for all criteria (p < 0.05). CONCLUSION: Self-evaluation and education of radiographers at the CHC Rijeka have led to a significant progress in image quality. IMPLICATIONS FOR PRACTICE: Results of this work imply that there is a strong need to formalize breast imaging education and the need to implement systematic education at the national level in Croatia.

Establishing the European diagnostic reference levels for interventional cardiology.

Interventional cardiac procedures may be associated with high patient doses and therefore require special attention to protect the patients from radiation injuries such as skin erythema, cardiovascular tissue reactions or radiation-induced cancer. In this study, patient exposure data is collected from 13 countries (37 clinics and nearly 50 interventional rooms) and for 10 different procedures. Dose data was collected from a total of 14,922 interventional cardiology procedures. Based on these data European diagnostic reference levels (DRL) for air kerma-area product are suggested for coronary angiography (CA, DRL = 35 Gy cm2), percutaneous coronary intervention (PCI, 85 Gy cm2), transcatheter aortic valve implantation (TAVI, 130 Gy cm2), electrophysiological procedures (12 Gy cm2) and pacemaker implantations. Pacemaker implantations were further divided into single-chamber (2.5 Gy cm2) and dual chamber (3.5 Gy cm2) procedures and implantations of cardiac resynchronization therapy pacemaker (18 Gy cm2). Results show that relatively new techniques such as TAVI and treatment of chronic total occlusion (CTO) often produce relatively high doses, and thus emphasises the need for use of an optimization tool such as DRL to assist in reducing patient exposure. The generic DRL presented here facilitate comparison of patient exposure in interventional cardiology.

Morphometry and digital AgNOR analysis in cytological imprints of benign, borderline and malignant serous ovarian tumours.

AIM: The aim of the study was to determine values of a quantitative morphometry analysis of nuclear characteristics and argyrophilic nucleolar organizer regions (AgNORs) in differential cytodiagnosis of benign, atypically proliferating (borderline) and malignant serous ovarian tumours. METHODS: Cytological imprints of benign (n = 20), borderline (n = 19) and malignant (n = 20) ovarian serous tumours were analysed. A computerized, digital analysis was used to determine morphometric nuclear features, the number and characteristics of single AgNORs, cluster AgNORs, total AgNOR and AgNOR area/nucleus (relative area) ratio. According to their size AgNORs were classified in three categories. A one-way variance analysis and post hoc test (Scheffé) were used for statistical analysis. RESULTS: The morphometric nuclear analysis showed that benign, borderline and malignant serous ovarian tumours are statistically different (P < 0.001) according to the area and outline, the values being highest in malignant tumours and lowest in the borderline group. Digital analysis of AgNORs in benign, borderline and malignant groups showed that the total AgNOR number increases with progression of the lesion (meaning tumour malignancy) significantly (P < 0.001) between benign and malignant as well as between borderline and malignant serous ovarian tumours (P < 0.001). The progression of the lesion malignancy was accompanied by a significant (P < 0.001) progressive increase of the total and relative AgNOR area per nucleus. The AgNOR size increases from benign to malignant tumours and a statistically significant difference (P < 0.001) was observed in all three groups regarding small and large AgNORs. CONCLUSION: Combining different markers of morphometric nuclear characteristics and AgNOR values could improve differential cytodiagnosis of benign, borderline and malignant serous ovarian tumours.

Rapid cervicovaginal smear screening: method of quality control and assessing individual cytotechnologist performance.

AIM: To validate the method of rapid screening (RS) in the detection of cervical lesions and false-negative results as well as in quality control of cytotechnologist performance. MATERIAL AND METHODS: The RS method was validated on Papanicolaou-stained and initially conventionally analysed vaginal, cervical and endocervical (VCE) smears collected in an opportunistic programme for the detection of cervical carcinoma. The study included 3680 VCE smears from the Department of Gynaecologic Cytology, University Department of Gynaecology and Obstetrics, Zagreb University Hospital Center, Zagreb and from the Department of Clinical Cytology, Osijek University Hospital, Osijek. Histologically verified abnormal findings accounted for 10% of the study samples. Thirteen cytotechnologists, with no previous experience in RS, performed the test. Each slide was examined using the 'step' technique for 1.5 minutes, the findings were classified as negative or abnormal, and the abnormal ones were also classified according to differential cytological diagnosis. The results were compared with those obtained on initial screening. Abnormal findings from a group of initially negative findings were reanalysed using conventional methods to make definitive cytological diagnosis. RESULTS: RS yielded a sensitivity of 83.7%, specificity of 93.7%, positive predictive value of 62.4%, negative predictive value of 97.9% and diagnostic accuracy of 92.6%. Relative to the initial abnormal differential cytological diagnosis, the diagnostic value of RS increased with lesion severity [54.8%, 68.0% and 91.3% for cervical intraepithelial neoplasia (CIN) I, CIN II and CIN III respectively]. RS detected 38 additional positive findings; 94.2% of these were atypical squamous cells of undetermined significance (ASCUS)/abnormal glandular cells undetermined significance (AGUS) and CIN I. The rate of additional positive findings was 1.14% (38/3135). The false-negative rate of initial screening was 9.4% (38/406), and individual cytotechnologist sensitivity was 60.0-100.0%. CONCLUSION: RS could be introduced as an efficient method of quality control to improve the sensitivity of cytological screening as well as for quality control of cytotechnologist performance.

Pap smear adequacy--is the assessing criterion including endocervical cells really valid?

The significance of endocervical cylindrical cells (EC) as a criterion of sample adequacy has been established on 1,000 patients by comparing VCE smears (vaginal, cervical, endocervical) with or without EC in relation to prevalence of abnormal cells, prevalence of histological diagnosed lesions and sensitivity and negative predictive value of Pap smear, as well as by comparison of negative findings without EC with control smears with the aim of discovering overlooked lesions. A considerably greater yield of cytological (107/536 in relation to 49/464) and histological (105/536 in relation to 55/464) (p < 0.05) abnormalities in smears with EC support the hypothesis that the presence of EC is strongly and positively associated with prevalence of disease. In contrast, the presence of EC predicts only a moderate improvement in Pap smear quality with a weaker effect on sensitivity (95% in relation to 80%). During two-years monitoring of patients with negative Pap smear and negative colposcopy (403 with EC and 390 without EC in smears), no positive cytology/histology diagnosis was made. Also, because the prevalence of missed lesions among negative Pap smears is extremely low in absolute terms, no appreciable impact on negative predictive value was observed (98.8% in relation to 97.3%).

Improved national Croatian diagnostic and therapeutic guidelines for premalignant lesions of the uterine cervix with some cost-benefit aspects.

The national Croatian improved diagnostic and therapeutic guidelines for premalignant lesions of the uterine cervix are presented: for atypical squamous cells of undetermined significance (ASCUS), for cervical intraepithelial neoplasia (CIN I, CIN II CIN III) and for microcarcinoma (FIGO grade Ia1). Separately are presented the guidelines for abnormal glandular epithelium: atypical glandular cells of undetermined significance (AGCUS) and cervical glandular intraepithelial neoplasia (CGIN). The guidelines are created according to the guidelines of the FIGO. Improved diagnostic and therapeutic guidelines was presented and accepted at the Symposium of the Croatian Society for Colposcopy and Cervical Pathology and of the Croatian Society of Gynecologists and Obstetricians of the Croatian Medical Association, held on November 25th 2000. There are presented the chief differences and the some cost-benefit aspects between the guidelines before and the new one.

Digital image analysis of silver-stained nucleolar organizer region--associated proteins in endometrial cytologic samples.

OBJECTIVE: Digital image analysis was applied to determine the number, area and size of silver-stained nucleolar organizer regions (AgNORs) in cytologic samples from curettage in normal, hyperplastic and malignant endometrium. STUDY DESIGN: Thirty-two archival cytologic smears from curettage (previously stained by the Papanicolaou method) with the histologic diagnosis (4 inactive endometrium, 5 secretion, 5 proliferation, 5 simple hyperplasia, 5 complex hyperplasia, 3 atypical hyperplasia, 5 adenocarcinoma, grade 1) were analyzed with the AgNOR technique. Count, area and size of AgNORs were analyzed in 50 cells per sample using a magnification of 1,000x. Quantitative analysis was performed on an SFORM digital imaging system. Data were analyzed with the SPSS/PC+ program. Mann-Whitney and chi 2 tests were performed. RESULTS: The average value of AgNOR count increased from normal to hyperplastic endometrium and well-differentiated adenocarcinoma. Differences were significant except between atypical hyperplasia and adenocarcinoma. Four, five and more AgNORs in 40% or more of the nuclei were found in complex and atypical hyperplasia and adenocarcinoma. Proliferation, and simple and atypical hyperplasia had similar mean values of AgNOR area. The mean total AgNOR area value increased from normal to hyperplastic had similar mean values of AgNOR area. The mean total AgNOR area value increased from normal to hyperplastic and well-differentiated adenocarcinoma. Differences were statistically significant. AgNOR size in well-differentiated adenocarcinoma was significantly different from that in normal endometrium and different grades of hyperplasia. CONCLUSION: Digital image analysis of AgNOR count, area and size enabled a distinction to be made between normal, hyperplastic and malignant endometrium.

Loop excision of the transformation zone (LETZ) as an outpatient method of management for women with cervical intraepithelial neoplasia: our experience.

Between March 1996 and July 1998, 90 patients were treated with diathermy loop excision (LETZ) for cytologically, colposcopically and histologically verified cervical intraepithelial neoplasias (CIN), at the outpatient clinic. In average, the patients were 30.22 years of age, and 61.1% of them were nulliparas. In 80 surgical samples (88.9%), the exocervical and endocervical margins were histologically free of disease. From the total of 65 patients with CIN III diagnosis, 58 (89.2%) had free margins samples. In the post-operative period the patients had a changed vaginal discharge for 16 days. A slight feeling of pain in the abdomen lasted for 2.5 days on the average, and most patients did not take analgetics. Moderate postoperative hemorrhage from the excision site occurred in 5 (5.5%) patients, and was outpatiently treated with electrocoagulation, with no need for blood replacement. In 65 patients (90.3%), the cytological control results were normal. During the follow-up period, 9 patients became pregnant, which resulted in 6 terminal deliveries so far; 2 pregnant women are about to deliver, and one is in the first trimester of pregnancy. Cerclage cervicis has not been performed on any of the patients. LETZ is a safe and simple procedure which can be done at outpatient clinics, it is relatively easily mastered, it is short, quite bearable for patients if done only under local analgesia, the equipment costs are acceptable, and the treatment can be used both diagnostically and therapeutically, since an adequate surgical sample is obtained for histological assessment. Cytological and colposcopical check ups are imperative in the postoperative period.

PCR amplification of DNA from stained cytological smears.

DNA from archival Papanicolaou stained smears was successfully amplified using the polymerase chain reaction (PCR) to see if it could be used for retrospective genome studies such as detection of the presence of human papilloma virus (HPV) and changes in p53 gene expression. DNA was isolated and purified by treatment with proteinase K, phenol/chloroform, and isoamyl alcohol. Segments of the human beta actin and TGF beta 1 gene were amplified by PCR. Of all stains used in the preparation of Papanicolaou smears, only eosin was detectable as a greenish band in ethidium bromide treated DNA gels under ultraviolet illumination.

Growth and treatment of Ehrlich tumor in mice with alloxan-induced diabetes.

Hypoglycemia and hypoinsulinemia accompanied i.p. or i.m. growth of the Ehrlich tumor in CBA/H and BALB/c mice. Simultaneously, insulin accumulated in the ascitic fluid of tumor-bearing mice. In hosts rendered diabetic by means of alloxan, the tumor decreased the blood glucose almost to the level seen in nondiabetic mice. Tumor growth was retarded in diabetic hosts, but cells from such tumors, transplanted into secondary diabetic recipients, grew faster than in their primary diabetic hosts, similarly to "nondiabetic" tumor cells growing in nondiabetic hosts. This phenomenon of "adaptation" of the tumor to the diabetic state was prevented if diabetic tumor-bearing mice were daily treated with insulin. The tumor did not grow in all diabetic recipients; the frequency of takes correlated with severity of the diabetes, i.e., with the dose of alloxan given to induce it. The greater the dose, the less mice accepted the tumor. Insulin injection into diabetic tumor-bearing mice promoted the tumor growth. Simultaneous treatment of diabetes and the tumor afforded the best antitumor effect.