Quality assurance in gynecologic cytology. The value of cytotechnologist-cytopathologist discrepancy logs.

We describe a simple method for displaying and evaluating the concordance or discordance between cytotechnologists (CTs) and cytopathologists (CPs) on gynecologic cases. The provisional diagnoses made by the CTs and the final diagnoses of the CPs are captured by the laboratory information system; data generated for specified periods are displayed as a 10 x 10 matrix that classifies each possible diagnosis made by the CT and CP into 1 of 10 major categories. Matrices are generated for the entire laboratory and for individual CTs; individual CTs are evaluated based on their deviation from the laboratory average. Three statistical measures are generated: percentage of discordant diagnoses, a kappa statistic, and a weighted measure. During a 2.5-year period, approximately 4,200 cases were referred to a CP for review every 6 months. The median discordance in diagnoses increased during 2 years from 21% to 34%, and the kappa value fell from 0.69 to 0.38. This was attributed primarily to 1 CT, whose performance, as well as that of the entire laboratory, improved after remedial action. Measures of CT-CP diagnostic concordance are a useful and efficient measure of CT performance and can be incorporated into mandatory semiannual performance evaluations.

[Arrhythmias in the aged: prevalence and correlation with symptoms]. / Le aritmie nell'anziano: prevalenza e correlazione con la sintomatologia.

Objective of our study was to evaluate the prevalence of arrhythmias as well as their correlation with the reported anamnestic symptomatology in the elderly population. With 24 hour ambulatory electrocardiography (Holter ECG) 913 patients, (440 males and 473 females, range 60-89 years, mean age 71) were consecutively studied and subdivided according to the following criteria: (1) age (3 classes: 60-69 [I], 70-79 [II], > or = 80 [III]; (2) presence/absence of "guide" symptoms (syncope/faintness, chest pain, palpitation), and (3) Holter electrocardiography results. We have demonstrated a high prevalence of arrhythmias: 72% (657), which was significantly higher in age classes II (80.5%) and III (79.1%) in comparison to class I (60.6%). A notably higher prevalence of tachyarrhythmias is documented compared to bradyarrhythmias (5:1). With a higher age the prevalence of supraventricular tachyarrhythmias increases significantly, while bradyarrhythmias do not have the same trend. We have a similar prevalence of arrhythmias between symptomatic (77.4%) and asymptomatic patients (63.6%) and no significant correlation between anamnestic symptoms and presence of arrhythmias are observed. Considering the high prevalence of arrhythmias during Holter ECG we think that the clinical importance and prognosis should be evaluated with caution.

Heart rate variability and cardiac autonomic function in systemic lupus erythematosus.

The cardiac autonomic function was evaluated in 23 patients with Systemic Lupus Erythematosus (SLE) without clinical expression of dysautonomia and in 14 healthy volunteer subjects as a control group, by analysis of Heart Rate Variability (HRV) from 24h ambulatory electrocardiography. All the patients were taking corticosteroids and 10 of them also Ciclosporin A (CsA). The following parameters of HRV were performed: Time domain: standard deviation of the RR intervals average (SDNN) and percentage of RR adjacent intervals differing from each other more than 50 msec (pNN50). Frequency domain: low frequencies (LF) and high frequencies (HF). Significant lower values were detected in SLE patients vs controls: SDNN = 69.40 vs 127.72; pNN50 = 16.44 vs 25.95; LF = 8.34 vs 34.97; HF = 3.21 vs 12.18. The incidence of autonomic dysfunction in our SLE population evaluated by considering intervals of normality is approximately 78% for SDNN; 17% for pNN50; 91% for LF and, finally, 56% for HF. The analysis of HRV may be a valuable technique in the study of the incidence of dysautonomia for these patients.

[The prevalence of arrhythmias in subjects over 80 years old. The prognostic role of anamnestic symptomatology and the therapeutic directions]. / Prevalenza dei disturbi del ritmo in soggetti di oltre 80 anni. Ruolo predittivo della sintomatologia anamnestica e orientamenti terapeutici.

24-hour Holter monitoring was performed in 129 unselected subjects older than 80 years (69 women and 60 men) in order to evaluate arrhythmia incidence and to establish significance of symptoms; 56% patients had lipothymia and/or syncope, chest pain and palpitations, 44% were asymptomatic. All patients showed high incidence of hyperkinetic and hypokinetic arrhythmias; no significant differences between symptomatic and asymptomatic patients in arrhythmia incidence were seen. Moreover, no correlation could be seen of the symptoms reported by the patient to the incidence of any particular type of arrhythmia. In conclusion, these preliminary data suggest a criticism of the opportunity of indiscriminate and long term antiarrhythmic therapy. Nevertheless, Holter monitoring is useful in detecting hypokinetic arrhythmias of asymptomatic patients in whom pacemaker implantation is essential and curative.

Continuous arterial and venous blood gas monitoring during cardiopulmonary bypass.

A new monitoring technique, based on optical fluorescence chemistry, allows continuous monitoring of all blood gas variables during cardiopulmonary bypass. To evaluate the clinical performance of this monitor, we drew 220 arterial and 216 venous blood samples from 15 patients, and simultaneous blood gas values displayed by the monitor were compared with standard laboratory measurements. The continuous monitor predicted laboratory values with varying degrees of accuracy. (R2 values by linear regression: arterial oxygen tension 0.86, venous oxygen tension 0.36, arterial carbon dioxide tension 0.58, venous carbon dioxide tension 0.72, arterial pH 0.53, venous pH 0.58; pH 0.53, venous pH 0.58; p less than 0.0001). Monitor values of arterial oxygen tension overestimated laboratory values (bias = + 43.5 mm Hg), but the laboratory reference method likely underestimated true arterial oxygen tension in the high range achieved on bypass. Monitoring of venous oxygen tension was imprecise (precision = +/- 6.51 mmHg), regardless of whether stable conditions existed during the sampling period. Monitoring of carbon dioxide tension and pH showed small bias (carbon dioxide tension within 2 mm Hg, pH within 0.03) and good precision (carbon dioxide tension within 3 mm Hg, pH within 0.03). With the development of unstable conditions on bypass, monitor arterial oxygen tension values showed a changing relationship to corresponding laboratory values. In conclusion, arterial and venous carbon dioxide tension and pH monitoring provide acceptably accurate alternatives to laboratory measurement of these variables during cardiopulmonary bypass. Arterial oxygen tension monitoring accurately indicates changes in oxygen tension in the arterial oxygen tension range typically produced during extracorporeal circulation. Oxygen tension monitoring in the venous oxygen tension range is too imprecise for clinical decision-making purposes.

Hyperventilation with hypoproteinemia.

Hypoproteinemia by itself produces a metabolic alkalosis. It is not clear whether a respiratory compensation (hypercapnia) develops with this alkalosis; patients with liver cirrhosis, most of them with hypoproteinemia, are known to hyperventilate. We studied 23 clinically stable patients with hypoproteinemia, with very low albumin-to-globulin ratios (range 0.4 to 1.1), who had either liver cirrhosis (n = 12) or other medical conditions (n = 11). In both groups, there was marked hypocapnia, accompanied by alkalemia (PaCO2 values (mean +/- SD) 31 +/- 2 and 32 +/- 3 torr; pH (mean +/- SD) 7.45 +/- 0.03 and 7.47 +/- 0.03, for the patients with cirrhosis and those without, respectively). Hypoxemia was not the stimulus provoking hyperventilation. The lowering of PaCO2 was proportional to the reduction of serum albumin and total protein concentrations; no detectable difference was seen between the patients with cirrhosis and those without cirrhosis in this apparent dependence of PaCO2 on the concentration of serum proteins. Many of these clinically stable patients with hypoproteinemia, with or without liver cirrhosis, had appreciable concentrations of unidentified anions in plasma (inappropriately high anion gap). Whatever the nonrespiratory acid-base status of the patients with hypoproteinemia, their pulmonary ventilation (hypocapnia) appeared excessive when compared with subjects (presumably) without proteinemia who had similar nonrespiratory acid-base states. The mechanism responsible for the hyperventilation in hypoproteinemia and the nature of the unidentified anions in this condition are obscure.

Acid-base effects of altering plasma protein concentration in human blood in vitro.

We altered the concentration of plasma proteins in human blood in vitro by adding solutions with [Na+], [K+], and [Cl-] resembling those in normal blood plasma, either protein-free or with a high concentration of human albumin. After equilibrating the samples with a gas containing 5% CO2-12% O2-83% N2 at 37 degrees C, we measured pH, PCO2, and PO2; in separated plasma, we determined the concentrations of total plasma proteins and albumin and of the completely dissociated electrolytes (strong cations Na+, K+, Mg2+ and anions Cl-, citrate3-). With PCO2 nearly constant (mean = 35.5 Torr; coefficient of variation = 0.02), lowering plasma protein concentration produced a metabolic alkalosis, whereas increasing plasma albumin concentration gave rise to a metabolic acidosis. These acid-base disturbances occurred independently of a minor variation in the balance between the sums of strong cations and anions. We quantified the dependence of several acid-base variables in plasma on albumin (or total protein) concentration. Normal plasma proteins are weak nonvolatile acids. Although their concentration is not regulated as part of acid-base homeostasis, hypoproteinemia and hyperalbuminemia per se produce alkalosis and acidosis, respectively.