The use of unfixed bone marrow trephines for multicolour flow cytometry.

An adequate bone marrow aspirate is essential for a rapid diagnosis of acute leukaemia by multicolour flow cytometry enabling the simultaneous assessment of multiple antigens on the cell surface as well as intracellular or nuclear ones. In the context of acute leukaemia, it is important to have a diagnosis of the blasts lineage as soon as possible to decide the appropriate treatment. This is sometimes delayed due to difficulties in obtaining a bone marrow aspirate due to a "dry tap". In this study we evaluated retrospectively cell markers results by flow cytometry of unfixed bone marrow trephines of 65 patients with leukaemia at diagnosis and including a few after treatment. Our aims were: 1) To compare cell markers results between bone marrow trephine (BMT) and bone marrow aspirate (BMA) 24 cases and BMT with peripheral blood (PB) 14 cases in paired samples to establish if they were reproducible with results of the unfixed bone marrow trephine biopsies. 2) To ascertain a precise diagnosis in 27 (42%) of the cases in which only a bone marrow trephine was available. We demonstrated that unfixed bone marrow trephine provides an adequate and representative cell suspension for flow cytometry and it is a powerful tool when no other material (bone marrow aspirate or peripheral blood) is available to make a rapid diagnosis. Furthermore when marrow aspirate or peripheral blood paired samples were available, flow cytometry results obtained were identical across all the sample types. Applicability to the clinical laboratory: We described a method to obtain a cell suspension from core biopsies that can easily be implemented routinely in a laboratory that performs diagnostic flow cytometry immunophenotyping. This method is simple, inexpensive and it doesn't require extra equipment.

[Munich Nomenclature III: classification according to risk : Follow-up for conspicuous squamous findings]. / Münchner Nomenklatur III: Klassifikation nach Risiko : Verlaufsbeobachtung bei auffälligen plattenepithelialen Befunden.

AIM: The present study evaluates the risk of progression of cytologic diagnoses which do not require immediate therapy but do need follow-up. The presented data can contribute to risk-adapted management strategies, according to Munich Nomenclature III. METHODS: Between January 2014 and March 2016, 3396 women were diagnosed as group II-p, IIID1, III-p, IIID2, IVa-p, IVb-p, and V­p and represent the study population. Follow-up information on all subsequent cytologic and histologic findings were collected up to July 2017. For the initial cytologic diagnosis, the cumulative risk of CIN2+ or CIN3+ and the risk for persistent pathologic findings was calculated. RESULTS: The cumulative risk of CIN2+ for initial findings II-p, IIID1, III-p, and IIID2 is calculated as 7.3, 17.1, 46.3, and 62.4%, respectively, after a mean observation period of 24.4, 21.1, 15.6, and 14.3 months. The cumulative risk of CIN3+ (%) is determined as 5.0, 9.3, 37.6, and 45.8. For persistent cytologic diagnoses II-p, IIID1, III-p, and IIID2, the risk of CIN2+ increases significantly after the second result (0 to 3.6, 0.21 to 3.6, 7.2 to 58.3, and 8.1 to 64.7%). Risk of CIN2+ and CIN3+ for group III-p is significantly higher for women <35 years and <30 years compared with women of higher age. There are no significant age-dependent differences for findings II-p, IIID1, and IIID2. CONCLUSIONS: The Munich Nomenclature III classifies cytologic findings according to risk. The diagnostic groups of the Munich Nomenclature III provide a solid basis for a risk-adapted clinical management, if the cytologic history of the individual patient is taken into account.

STEM EDX Nitrogen Mapping of Nanoinclusions in Milky Diamonds from Juina, Brazil, Using a Windowless Silicon Drift Detector System.

Energy-dispersive X-ray spectroscopy (EDX) performed using scanning transmission electron microscopy (STEM) in combination with a windowless detector setup allows high-resolution imaging and chemical composition mapping even of light elements present in low concentrations. The used TEM-system combines a field emission electron source with four silicon drift detectors allowing for high detection sensitivity. We used this enhanced system to investigate 20 to 200 nm sized inclusions in milky diamonds from Rio Soriso, Juina area, Brazil. The diamonds act as a chemical inert container and therefore protect their inclusions from further chemical reactions with their surroundings. We visualize the presence and distribution of nitrogen within focused ion beam (FIB) slices containing these nanoinclusions. The investigation of these specific diamonds may open a new window to deeper parts of the Earth (>660 km) as they represent pristine material of this deep mantle environment.

[Cervical cancer in Mecklenburg-Western Pomerania. Tumor stage, histological tumor type, age and screening participation of 985 patients]. / Zervixkarzinome in Mecklenburg-Vorpommern. Tumorstadium, histologischer Tumortyp, Alter und Screeningteilnahme von 985 Patientinnen.

BACKGROUND: In view of the discussion on primary human papillomavirus (HPV) screening it was necessary to evaluate recent and reliable data from the current cytology-based screening program. METHODS: Since the year 2004 all cases of cervical cancer must be reported to the Joint State Quality Control Commission in Mecklenburg-Western Pomerania, corrected and supplemented by data of the State Cancer Registry. The screening histories of all patients, age, tumor stages and histological tumor types were analyzed. RESULTS: Over a 10-year period (2004-2013) 985 women with invasive cervical cancer and complete data were identified, of whom 573 patients (58 %) had not had a cervical smear within the past 5 years, an irregular screening history was found in 312 patients (32 %) and 100 patients (10 %) had cervical cancer despite regular participation. In women who did not participate in the screening program, tumor stages T1b and higher were found in 85 %. In the group of women with regular screening 53 % were diagnosed with microinvasive cancer and in 38 % of women with irregular screening. The age distribution showed a peak for cervical cancer in the age group of 40-54 years. Squamous cell carcinoma dominated and adenocarcinoma was found in 17 % which showed a tendency to increase over the investigation time period. CONCLUSION: Most cervical cancers and the advanced stages were found in women who did not participate in the screening program.

Secure Secondary Use of Clinical Data with Cloud-based NLP Services. Towards a Highly Scalable Research Infrastructure.

OBJECTIVES: The secondary use of clinical data provides large opportunities for clinical and translational research as well as quality assurance projects. For such purposes, it is necessary to provide a flexible and scalable infrastructure that is compliant with privacy requirements. The major goals of the cloud4health project are to define such an architecture, to implement a technical prototype that fulfills these requirements and to evaluate it with three use cases. METHODS: The architecture provides components for multiple data provider sites such as hospitals to extract free text as well as structured data from local sources and de-identify such data for further anonymous or pseudonymous processing. Free text documentation is analyzed and transformed into structured information by text-mining services, which are provided within a cloud-computing environment. Thus, newly gained annotations can be integrated along with the already available structured data items and the resulting data sets can be uploaded to a central study portal for further analysis. RESULTS: Based on the architecture design, a prototype has been implemented and is under evaluation in three clinical use cases. Data from several hundred patients provided by a University Hospital and a private hospital chain have already been processed. CONCLUSIONS: Cloud4health has shown how existing components for secondary use of structured data can be complemented with text-mining in a privacy compliant manner. The cloud-computing paradigm allows a flexible and dynamically adaptable service provision that facilitates the adoption of services by data providers without own investments in respective hardware resources and software tools.

Loss of GluN2A-containing NMDA receptors impairs extra-dimensional set-shifting.

Glutamate neurotransmission via the N-methyl-D-aspartate receptor (NMDAR) is thought to mediate the synaptic plasticity underlying learning and memory formation. There is increasing evidence that deficits in NMDAR function are involved in the pathophysiology of cognitive dysfunction seen in neuropsychiatric disorders and addiction. NMDAR subunits confer different physiological properties to the receptor, interact with distinct intracellular postsynaptic scaffolding and signaling molecules, and are differentially expressed during development. Despite these known differences, the relative contribution of individual subunit composition to synaptic plasticity and learning is not fully elucidated. We have previously shown that constitutive deletion of GluN2A subunit in the mouse impairs discrimination and re-learning phase of reversal when exemplars are complex picture stimuli, but spares acquisition and extinction of non-discriminative visually cued instrumental response. To investigate the role of GluN2A containing NMDARs in executive control, we tested GluN2A knockout (GluN2A(KO) ), heterozygous (GluN2A(HET) ) and wild-type (WT) littermates on an attentional set-shifting task using species-specific stimulus dimensions. To further explore the nature of deficits in this model, mice were tested on a visual discrimination reversal paradigm using simplified rotational stimuli. GluN2A(KO) were not impaired on discrimination or reversal problems when tactile or olfactory stimuli were used, or when visual stimuli were sufficiently easy to discriminate. GluN2A(KO) showed a specific and significant impairment in ventromedial prefrontal cortex-mediated set-shifting. Together these results support a role for GluN2A containing NMDAR in modulating executive control that can be masked by overlapping deficits in attentional processes during high task demands.

[Immunocytochemistry of p16(INK4a) and Ki-67 as adjunctive method for routine gynecological cytology of mild and moderate dysplasia]. / p16(INK4a)- und Ki-67-Immunzytochemie als Zusatzmethode für die Gruppe IIID der gynäkologischen Zytologie.

Especially the cytological diagnoses of mild and moderate dysplasia are often followed by unnecessary stigmatization of patients and uncertainty in further clinical follow-up and therapy. Data from 222 patients including additional investigations by high-risk human papillomavirus (HPV) testing and combined immunocytochemistry for p16(INK4a) and Ki-67 were documented, including cytological and histological follow-up. Overall for cytology, high risk HPV testing and dual staining the following characteristics concerning the presence of cervical intraepithelial neoplasia (CIN) 2+ were calculated (in %): sensitivity 100, 95.8 and 92.4, specificity -, 23.3 and 72.8, positive predictive value 53.6, 59.1 and 79.7, negative predictive value -, 82.8 and 89.3, respectively.There was a statistically significant advantage for higher specificity and positive predictive value for dual staining, especially for cytological diagnosis of low grade dysplasia. An objective individual risk stratification of patients with cytology of mild or moderate dysplasia is not available but the uncertainty in the management of these patients will be clearly reduced.

[Correlation of cervical cytology and histology]. / Korrelation zytologischer und histologischer Befunde an der Cervix uteri.

A lack of correlation of cytological diagnoses with subsequent histological tissue diagnoses in cervical pathology is caused by either sampling or by interpretation errors. The term sampling error refers to both obtaining cytological material by a cervical smear as well as obtaining tissue samples by surgical procedures such as biopsy or conization. The term interpretation error refers to a lack of correlation as a consequence of the subjective variability in the diagnostic evaluation of cytological, histological or colposcopic findings. This so-called interobserver variability is well known and of considerable significance. Cytological-histological correlation is an important and mandatory method of quality assurance in the cytology laboratory. Lack of correlation can be crucial for the patient because of possible over treatment or under treatment. It can also undermine the relationship between cytopathologists and clinicians. It is therefore crucial to recognize the sources of error presented in this review and to make an effort to resolve discordances by communication and second review.

Manufacture of a cell-free amnion matrix scaffold that supports amnion cell outgrowth in vitro.

We manufactured a cell-free extracellular matrix scaffolds in order to obtain a support material for amnion cell outgrowth, eventually being used for repair of prematurely ruptured fetal membrane. Human preterm or term amnion tissue was separated into its collagenous extracellular matrix and cell components. The acellular scaffold was explored for its capacity to support regrowth of isolated human amnion epithelial or mesenchymal cells in vitro. The outgrowth of amnion cells on and in the scaffold was investigated by scanning and transmission electron microscopy, and confocal laser scanning microscopy. Cell-free amnion matrix scaffolds demonstrated a porous collagen fiber network similar as in native amnion. Inoculation of acellular amnion scaffolds with human amnion cells revealed that its property to support amnion cell outgrowth was retained. Amnion epithelial and mesenchymal cells were found to grow into dense layers on the surface of the scaffold within 3-4 days and 7-8 days, respectively, and to some extent, invaded the scaffold during the culture period. Manufactured acellular amnion matrix retains structural and functional properties required for cell outgrowth in vitro. It may become useful to repair prematurely ruptured fetal membranes.

Continuous cytomegalovirus seroconversion in a large group of healthy blood donors.

BACKGROUND AND OBJECTIVES: Transmission of cytomegalovirus (CMV) to seronegative, immunocompromised recipients can cause serious and fatal complications. Although the seroprevalence of CMV is high, the risk of primary CMV infection among healthy blood donors has not yet been analysed in a large population. MATERIALS AND METHODS: We developed an algorithm to determine the rate of CMV seroconversion in an overall cohort of 24,260 subjects who donated 176,474 blood units during an 11-year observation period. RESULTS: We detected CMV seroconversion in all relevant age groups (18-60 years) with an overall seroconversion rate of 0.55% per year. Both CMV seroconversion and seroprevalence occurred more frequently in female donors (P = 0.02 and P < 0.001, respectively). We identified 30-35-year-old blood donors as the group with the highest rate of CMV seroconversion per year (1.33% vs. 0.46%; P < 0.0001). CONCLUSIONS: We conclude that the risk of primary CMV infection is a continuous lifelong event and correlates with age and female gender.

An Anesthesia Information Management System (AIMS) as a tool for controlling resource management of operating rooms.

OBJECTIVES: In our department, we have been using an Anesthesia Information Management System (AIMS) for five years. In this study, we tested to what extent data extracted from the AIMS could be suitable for the supervision and time-management of operating rooms. METHODS: From 1995 to 1999, all relevant data from 103,264 anesthetic procedures were routinely recorded online with the automatic anesthesia record keeping system NarkoData. The program is designed to record patient related time data, such as the beginning of anesthesia or surgical procedure, on a graphical anesthesia record sheet. The total number of minutes of surgery and anesthesia for each surgical subspecialty per hour/day and day of the year was calculated for each of the more than 40 ORs, amounting to a total of 112 workstations. RESULTS: It was possible to analyze the usage and the utilization of ORs at the hospital for each day of the year since 1997. In addition, annual and monthly evaluations are made available. It is possible to scrutinize data of OR usage from different points of view: queries on the usage of an individual OR, the usage of ORs on certain days or the usage of ORs by a certain surgical subspecialty may be formulated. These data has been used repeatedly in our hospital for decision making in OR management and planning. CONCLUSIONS: In assessing the results of our study, it should be considered that the system used is not a specialized OR management tool. Despite these restrictions, the system contains data which can be used for an exact and relevant presentation of OR utilization.

Evaluation of the suitability of a patient data management system for ICUs on a general ward.

The development of the ICUData patient data management system (PDMS) for intensive care units (ICU), by IMESO GmbH, Hüttenberg, Germany, was based on the assumption that processes and therapies at ICU are the most complex with the highest data density compared with those in other wards. Based on experience with the system and on a survey conducted among users at our pain clinic, we evaluated whether the concept of the present software architecture, which sufficiently reproduces processes and data at an ICU, is suitable as a PDMS for general wards. The highly modular and client-centric approach of the PDMS is founded on a message-based communications architecture (HL7). In the beginning of the year 2000, the system was implemented at the pain management clinic (12 beds) of our hospital. To assess its user friendliness, we conducted a survey of medical staff (n=14). From April 1st 2000 to August 31st 2000, all clinical and administrative data of 658 patients at the pain management clinic were recorded with the PDMS. From the start, all users had access to data and information of other connected data management systems of the hospital (e.g. patient administrative data, patient clinical data). Staff members found the system mostly useful, clearly presented, practical, and easy to learn and use. Users were relatively satisfied with stability and performance of the program but mentioned having only limited knowledge of the program's features. The need for external support during a computer crash was rated negatively. Despite the need for further usage training and improved program performance, the software architecture described seems to be a promising starting point for the construction of a PDMS for general wards.

Treatment of hydroxychloroquine overdose.

Hydroxychloroquine overdoses are rarely reported with 7 previous cases found in the English medical literature. We report a case and review the literature. A 16-year-old girl ingested a handful of hydroxychloroquine 200mg, 30 minutes before presentation and presented with tachycardia (heart rate 110 beats/min), hypotension (systolic blood pressure 63 mm Hg), central nervous system depression, conduction defects (QRS = 0.14 msec), and hypokalemia (K = 2.1 meq/L). She was treated with fluid boluses and dopamine, oxygen, and potassium supplementation. Toxicologic tests confirmed the presence of hydroxychloroquine. The patient's hypotension resolved within 4.5 hours, serum potassium stabilized in 24 hours, and tachycardia gradually decreased over 3 days. Although hydroxychloroquine overdoses are very rare, life-threatening hypotension, conduction problems, and hypokalemia can occur within 30 minutes of ingestion. Symptoms are similar to chloroquine and treatment must be implemented quickly and should be modeled after experience with chloroquine overdoses. Treatment modalities need further study, but current recommendations are: (1) diazepam for seizures and sedation; (2) early intubation and mechanical ventilation; (3) epinephrine for treatment of vasodilation and myocardial depression; (4) potassium replacement with close monitoring of levels; (5) charcoal for gastrointestinal decontamination if ingestion occurred within an hour; (6) high dose diazepam for life-threatening symptoms, until more information becomes available. No value was found for serum alkalinization or extracorporeal methods of drug removal.

Influence of the method of data collection on the documentation of blood-pressure readings with an Anesthesia Information Management System (AIMS).

The influence of methods for record keeping on the documentation of vital signs was assessed for the Anesthesia Information Management System (AIMS) NarkoData. We compared manually entered blood-pressure readings with automatically collected data. These data were stored in a data-base and subsequently evaluated and analyzed. The data sets were split into two groups, "manual" and "automatic". We evaluated the effect of automatic data collection on the incidence of corrected data, data validity and data variation. Blood-pressure readings of 37,726 data sets were analyzed. We could assess that the method of documentation did influence the data quality. It could not be assessed whether the incorrectness of data during automatic data gathering was caused by artefacts or by the anesthesiologist.

A family of 16-kDa pancreatic secretory stress proteins form highly organized fibrillar structures upon tryptic activation.

A group of 16-kDa proteins, synthesized and secreted by rat pancreatic acinar cells and composed of pancreatic stone protein (PSP/reg) and isoforms of pancreatitis-associated protein (PAP), show structural homologies, including conserved amino acid sequences, cysteine residues, and highly sensitive N-terminal trypsin cleavage sites, as well as conserved functional responses in conditions of pancreatic stress. Trypsin activation of recombinant stress proteins or counterparts contained in rat pancreatic juice (PSP/reg, PAP I and PAP III) resulted in conversion of 16-kDa soluble proteins into 14-kDa soluble isoforms (pancreatic thread protein and pancreatitis-associated thread protein, respectively) that rapidly polymerize into insoluble sedimenting structures. Activated thread proteins show long lived resistance to a wide spectrum of proteases contained in pancreatic juice, including serine proteases and metalloproteinases. In contrast, PAP II, following activation with trypsin or pancreatic juice, does not form insoluble structures and is rapidly digested by pancreatic proteases. Scanning and transmission electron microscopy indicate that activated thread proteins polymerize into highly organized fibrillar structures with helical configurations. Through bundling, branching, and extension processes, these fibrillar structures form dense matrices that span large topological surfaces. These findings suggest that PSP/reg and PAP I and III isoforms consist of a family of highly regulated soluble secretory stress proteins, which, upon trypsin activation, convert into a family of insoluble helical thread proteins. Dense extracellular matrices, composed of helical thread proteins organized into higher ordered matrix structures, may serve physiological functions within luminal compartments in the exocrine pancreas.

[Using an anesthesia information management system (AIMS) for documentation in a day care unit for ambulatory surgery]. / Einsatz eines Anästhesie-Informations-Management-Systems (AIMS) in einer Operativen Tagesklinik.

UNLABELLED: From January 1997 until June 1999, the complete durations of stay of 3152 outpatients were entered into a computerized documentation system. The scope of the data entry went from patient admission to patient release. The objective was to determine the usefulness of the anaesthesia information management system (AIMS) in producing complete and high-quality documentation in the field of outpatient operations. Some aspects and results from routine work are presented here. METHOD: The system was installed in eight bedside computers, in addition to a further client connected to the existing AIMS via Ethernet. Patient medical courses were documented both preoperatively and postoperatively in outpatient bedsides until their discharge or admission. The online documentation software NarkoData (Version 4, Imeso GmbH, Hüttenberg, Germany) was used to document and store patient data in a database. This program contains all relevant information concerning the course of anaesthesia and outpatient duration of stay, including application of drugs, vital signs, observation times, and medical findings as well as the data sets of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), ICD, and ICPM. Data was analyzed by exporting from the database into a statistical program using "structured query language." RESULTS: Data sets of 3152 outpatients were entered into the online documentation software. Most (54.2%) of the ambulatory surgical procedures were performed by the Department of Traumatology. General Surgery followed with 16.0%, and Urology managed 9.5% of the cases. The most frequent ambulatory surgical procedures were: diagnostic arthroscopy (923, 31.2%), removal of osteosynthetic material (410, 13.8%), and circumcision (250, 8.4%). Anesthesia procedures consisted of inhalative (38.6%, n = 1218) and intravenous anesthesia (IVA) (29.9%, n = 938). In 22.6% (713) of the cases, regional anaesthesia was performed. The average postoperative observation time was 289.2 +/- 140.1 minutes. One hundred sixty-nine patients (5.4%) were unexpectedly admitted to overnight care. The decision to admit patients to normal wards took place within the first 3 postoperative hours in 51.9% of the cases. CONCLUSION: The AIMS described above is sufficient in documenting the entire care process of patients in a day care unit. Integration into the existing AIMS was an important prerequisite for the integrity of the documentation chain. This allowed for a sensitive communication with other clinical data processing systems. The quality of documentation and flow of information at the workplaces in the day care unit were increased, similarly to other anaesthesiological workplaces in the hospital. Medical and administrative data and information for analyses of clinical processes are possible with such tools.

[From data entry to data presentation at a clinical workstation--experiences with Anesthesia Information Management Systems (AIMS)]. / Von der Datenerfassung zur Ergebnispräsentation am klinischen Arbeitsplatz--Erfahrungen mit einem Anästhesie-Informations-Management-System (AIMS).

Anesthesia Information Management Systems (AIMS) are required to supply large amounts of data for various purposes such as performance recording, quality assurance, training, operating room management and research. It was our objective to establish an AIMS that enables every member of the department to independently access queries at his/her work station and at the same time allows the presentation of data in a suitable manner in order to increase the transfer of different information to the clinical workstation. Apple Macintosh Clients (Apple Computer, Inc. Cupertino, California) and the file- and database servers were installed into the already partially existing hospital network. The most important components installed on each computer are the anesthesia documenting software NarkoData (ProLogic GmbH, Erkrath), HIS client software and a HTML browser. More than 250 queries for easy evaluation were formulated with the software Voyant (Brossco Systems, Espoo, Finland). Together with the documentation they are the evaluation module of the AIMS. Today, more than 20,000 anesthesia procedures are recorded each year at 112 decentralised workstations with the AIMS. In 1998, 90.8% of the 20,383 performed anesthetic procedures were recorded online and 9.2% entered postopeatively into the system. With a corresponding user access it is possible to receive all available patient data at each single anesthesiological workstation via HIS (diagnoses, laboratory results) anytime. The available information includes previous anesthesia records, statistics and all data available from the hospitals intranet. This additional information is of great advantage in comparison to previous working conditions. The implementation of an AIMS allowed to greatly enhance the quota but also the quality of documentation and an increased flow of information at the anesthesia workstation. The circuit between data entry and the presentation and evaluation of data, statistics and results directly available at the clinical workstation was put into practice.

Clinical and practical requirements of online software for anesthesia documentation an experience report.

The aim of this paper is the presentation of a new version of the anesthesia documentation software, NarkoData, that has been used in routine clinical work in our department as part of an anesthesia information management system (AIMS) since 1995. The performance of this software is presented along with requirements for future development of such a system. The originally used version, NarkoData 3.0, is an online anesthesia documentation software established by the software company ProLogic GmbH. It was primarily developed as a disk-based system for the MacOS operating system (Apple Computer Inc.). Based on our routine experience with the system, a catalogue of requirements was developed that concentrated on improvement in the sequence of work, administration and data management. In 1996, the concepts developed in our department, in close co-operation with medical personnel and the software company, led to a considerable enlargement of the program functions and the subsequent release of a new version of NarkoData. Since 1997, more than 20 000 anesthesia procedures have been recorded annually with this new version at 115 decentralized work stations at our university hospital.

Data processing at the anesthesia workstation: from data entry to data presentation.

Main requirements for an Anesthesia Information Management System (AIMS) are the supply of additional information for the anesthesiologist at his workstation and complete documentation of the anesthetic procedure. With the implementation of an AIMS (NarkoData) and effective user support, the quality of documentation and the information flow at the anesthesia workstation could be increased. Today, more than 20,000 anesthesia procedures are annually recorded with the AIMS at 112 decentralized workstations. The network for data entry and the presentation and evaluation of data, statistics and results directly available at the clinical workstation was made operational.