Frank Schneider

Notification of Critical Results A College of American Pathologists Q-Probes Study of 121 Institutions

CONTEXTnHospital accreditors are placing increased emphasis on the timeliness with which critical laboratory results are reported to caregivers.nnnOBJECTIVEnTo measure the speed of critical result notification at a group of laboratories, identify factors associated with faster reporting, and place findings in the context of the time required to transport and test specimens and to correct critical abnormalities.nnnDESIGNnContemporaneous review of 3545 inpatient and emergency department critical result notifications in 121 laboratories enrolled in the College of American Pathologists Q-Probes program.nnnRESULTSnThe median laboratory required a median of 5 minutes for staff to notify someone about a critical result once testing was complete. Laboratories affiliated with smaller institutions (P = .01), rural laboratories (P = .001), and sites that called results before releasing them from the laboratory computer (P = .02) were able to notify caregivers more quickly. There was variation among institutions in the time it took to notify caregivers (interquartile range, 1.5-8 minutes). At the median facility, notification took place 56.5 minutes after the specimen had been collected.nnnCONCLUSIONSnThe time required to notify caregivers of a critical laboratory result is a small proportion of the time taken to collect and test specimens or the time that has been reported for caregivers to correct abnormalities. Although failure to notify caregivers of critical results may represent an important patient safety vulnerability, the timeliness of laboratory notification is a minor contributor to total test turnaround time at most institutions.

Asbestos Fiber Content of Lungs With Diffuse Interstitial Fibrosis: An Analytical Scanning Electron Microscopic Analysis of 249 Cases

CONTEXTnAsbestosis is one of many forms of diffuse interstitial pulmonary fibrosis. Its histologic diagnosis rests on the pattern of fibrosis and the presence of asbestos bodies by light microscopy in lung biopsies.nnnOBJECTIVEnTo determine the asbestos fiber burden in patients with diffuse pulmonary fibrosis (DPF) who had a history of asbestos exposure, but whose biopsies did not meet established criteria for asbestosis, and compare it with the fiber burden in confirmed asbestosis cases.nnnDESIGNnFiber burden analysis was performed using scanning electron microscopy and energy-dispersive x-ray analysis of lung parenchyma from 86 patients with DPF and 163 patients with asbestosis. The correlation of the number of asbestos fibers found for a quantitative degree of fibrosis was analyzed.nnnRESULTSnThe fibrosis scores of the asbestosis cases correlated best with the number of uncoated commercial amphibole fibers. Seven DPF cases fell within the 95% interval of asbestos body count by light microscopy and 3 cases within that of the total commercial amphibole fiber count.nnnCONCLUSIONSnStrict histologic criteria are useful for positive identification of asbestosis among cases of advanced pulmonary fibrosis. Few DPF patients with history of asbestos exposure whose biopsies did not meet the criteria for asbestosis may have asbestos fiber counts in the range seen in asbestosis, and fiber type identification by scanning electron microscopy with energy-dispersive x-ray analysis should be considered in these rare instances to avoid false-positive and false-negative diagnoses of asbestosis.

The pulmonary histopathologic manifestations of the anti-PL7/antithreonyl transfer RNA synthetase syndrome☆

The pulmonary histopathologic manifestations of the antisynthetase syndromes is poorly understood and reported. Eight cases of interstitial lung disease related to the presence of antitheonyl (PL7) transfer RNA synthetase autoantibodies along with a review of biopsy changes reported in the English literature are described. Most patients presented with dyspnea and cough, with myositis, skin changes including mechanics hands, and Raynaud phenomenon. Biopsy patterns of injury included usual interstitial pneumonia (n = 4), organizing pneumonia (n = 2), nonspecific interstitial pneumonia, and lymphoid interstitial pneumonia (n = 1 each), which, in a minority of instances, contrasted with predictions by thoracic radiologists based on high-resolution computed tomographic scans. This study emphasizes the integrated clinical, radiologic, and pathologic approach to interstitial lung disease, especially in connective tissue disorders, and points out the occurrence of usual interstitial pneumonia and organizing pneumonia in this patient group where nonspecific interstitial pneumonia has been the dominant pattern of clinical interest.

Use of 111In-Capromab Pendetide Immunoscintigraphy to Image Localized Prostate Cancer Foci Within the Prostate Gland

PURPOSEnWe compared the results of a preoperative (111)In-capromab pendetide scan co-registered with computerized tomography with pathological findings in the surgically excised prostate to determine whether the scan can efficiently detect cancer in the prostate.nnnMATERIALS AND METHODSnThis prospective trial included 25 hormone naïve men with clinically localized prostate cancer who underwent (111)In-capromab pendetide single photon emission computerized tomography/computerized tomography as part of the preoperative evaluation. In addition to routine histological analysis, representative prostate sections were stained for prostate specific membrane antigen using the same antibody used in the scan. A pathologist and a radiologist were blinded to pathology and imaging findings, respectively. Prostate specific membrane antigen immunohistochemistry was correlated with the 3-dimensional location of the prostate specific membrane antigen signal detected by scan.nnnRESULTSnScan sensitivity was 37% to 87% for 4 quadrants (right vs left and apical vs basal) with 0% to 50% specificity, as validated by final pathological assessment of the same quadrants. Stratifying positive scan signal strength did not statistically improve specificity (p = 0.35). There was no significant correlation between prostate specific membrane antigen over expression and tumor stage distribution (p = 0.23).nnnCONCLUSIONSnThe scan did not localize prostate cancer to a particular quadrant based on comparison with radical prostatectomy specimen pathology. The antibody used has affinity for benign and malignant prostatic glands in excised, formalin fixed prostate tissue, which may contribute to low scan specificity in vivo. The scan cannot be used to reliably detect or image cancer foci in the prostate.

Crocidolite and Mesothelioma

This study reports changes in the frequency of detection of various asbestos fiber types between 1982 and 2005. Crocidolite is increasingly detected in U.S. mesothelioma patients. The percentage of crocidolite fibers detected in lung tissue has risen from 4 to 10%, and the percentage of cases in which crocidolite was detected increased from 19 to 37%. Meanwhile, the frequency of detection of amosite and chrysotile has decreased. The authors performed a detailed analysis of cases in which crocidolite was identified in the absence of amosite. Most of such cases were identified in recent years, a finding of concern since crocidolite is considered the most potent fiber type with respect to the pathogenesis of mesothelioma.

Nonspecific interstitial pneumonia: a study of 6 patients with progressive disease.

This study describes the clinical presentations and histology of surgical biopsy-proven nonspecific interstitial pneumonia (NSIP) in 6 patients with clinical and radiologic progression, resulting in the need for rebiopsy or lung transplantation. The majority of patients were middle-aged women (F/M=5) with shortness of breath, dyspnea on exertion, and dry cough. Three had evidence of autoimmune disease/phenomena. High-resolution computerized tomographic scans revealed bilateral ground-glass infiltrates without honeycomb change in 4 of 6 cases; over time (16 to 115 mo), 5 of the 6 cases developed subpleural honeycomb change. Histologic examination of the initial biopsy showed fibrotic variant NSIP in 5 cases and cellular variant NSIP in 1 case. At repeat biopsy and/or transplantation, the 5 cases of fibrotic NSIP showed morphologic features of usual interstitial pneumonia, whereas the cellular case showed fibrotic variant NSIP. The potential pathophysiologic explanation for such a change is discussed.

Benchmarking Laboratory Quality

Proficiency testing is the oldest form of laboratory benchmarking. Today, laboratory managers can compare local laboratory quality to industry averages in many domains. This review discusses practical aspects of benchmarking laboratory quality—when benchmarking is a good idea, common misunderstandings about what benchmarking can tell us, and examples of quality benchmarks that are widely used in the clinical laboratory industry.

Myositis-associated usual interstitial pneumonia has a better survival than idiopathic pulmonary fibrosis

Objective. To compare the survival outcomes between myositis-associated usual interstitial pneumonia (MA-UIP) and idiopathic pulmonary fibrosis (IPF-UIP). Methods. Adult MA-UIP and IPF-UIP patients were identified using CTD and IPF registries. The MA-UIP cohort included myositis or anti-synthetase syndrome patients with interstitial lung disease while manifesting UIP on high-resolution CT chest and/or a lung biopsy revealing UIP histology. IPF subjects met American Thoracic Society criteria and similarly had UIP histopathology. Kaplan–Meier survival curves compared cumulative and pulmonary event-free survival (event = transplant or death) between (i) all MA-UIP and IPF-UIP subjects, (ii) MA-UIP with biopsy proven UIP (n = 25) vs IPF-UIP subjects matched for age, gender and baseline forced vital capacity (±10%). Cox proportional hazards ratios compared the survival controlling for co-variates. Results. Eighty-one IPF-UIP and 43 MA-UIP subjects were identified. The median cumulative and event-free survival time in IPF vs MA-UIP was 5.25/1.8 years vs 16.2/10.8 years, respectively. Cumulative and event-free survival was significantly worse in IPF-UIP vs MA-UIP [hazards ratio of IPF-UIP was 2.9 (95% CI: 1.5, 5.6) and 5.0 (95% CI: 2.8, 8.7) (P < 0.001), respectively]. IPF-UIP event-free survival (but not cumulative) remained significantly worse than MA-UIP with a hazards ratio of 6.4 (95% CI: 3.0, 13.8) after controlling for age at interstitial lung disease diagnosis, gender, ethnicity and baseline forced vital capacity%. Respiratory failure was the most common cause of death in both groups. A sub-analysis of 25 biopsy-proven MA-UIP subjects showed similar results. Conclusion. MA-UIP patients demonstrated a significant survival advantage over a matched IPF cohort, suggesting that despite similar histological and radiographic findings at presentation, the prognosis of MA-UIP is superior to that of IPF-UIP.

The Pulmonary Histopathology of Anti-KS Transfer RNA Synthetase Syndrome

CONTEXTnThe clinical spectrum of the antisynthetase syndromes (AS) has been poorly defined, although some frequently present with pulmonary manifestations. The anti-KS anti-asparaginyl-transfer RNA synthetase syndrome is one in which pulmonary interstitial lung disease is almost always present and yet the histopathologic spectrum is not well described.nnnOBJECTIVEnTo define the morphologic manifestations of pulmonary disease in those patients with anti-KS antiasparaginyl syndrome.nnnDESIGNnWe reviewed the connective tissue disorder registry of the University of Pittsburgh and identified those patients with anti-KS autoantibodies who presented with interstitial lung disease and had surgical lung biopsies.nnnRESULTSnThe 5 patients with anti-KS antisynthetase syndrome were usually women presenting with dyspnea and without myositis, but with mechanics hands (60%) and Raynaud phenomenon (40%). They most often presented with a usual interstitial pneumonia pattern of fibrosis (80%), with the final patient displaying organizing pneumonia.nnnCONCLUSIONSnPulmonary interstitial lung disease is a common presentation in patients with the anti-KS-antisynthetase syndrome, who are often women with rather subtle or subclinical connective tissue disease, whereas the literature emphasizes the nonspecific interstitial pneumonia pattern often diagnosed clinically. Usual interstitial pneumonia and organizing pneumonia patterns of interstitial injury need to be added to this clinical differential diagnosis.

Document control practices in 120 clinical laboratories

CONTEXTnA variety of document control practices are required of clinical laboratories by US regulation, laboratory accreditors, and standard-setting organizations.nnnOBJECTIVEnTo determine how faithfully document control is being implemented in practice and whether particular approaches to document control result in better levels of compliance.nnnDESIGNnContemporaneous, structured audit of 8814 documents used in 120 laboratories for conformance with 6 generally accepted document control requirements: available, authorized, current, reviewed by management, reviewed by staff, and archived.nnnRESULTSnOf the 8814 documents, 3113 (35%) fulfilled all 6 document control requirements. The requirement fulfilled most frequently was availability of the document at all shifts and locations (8564 documents; 97%). Only 4407 (50%) of documents fulfilled Clinical Laboratory Improvement Amendment requirements for being properly archived after updating or discontinuation. Policies and procedures were more likely to fulfill document control requirements than forms and work aids. Documents tended to be better controlled in some laboratory sections (eg, transfusion service) than in others (eg, microbiology and client services). We could not identify document control practices significantly associated with higher compliance rates.nnnCONCLUSIONSnMost laboratories are not meeting regulatory and accreditation requirements related to control of documents. It is not clear whether control failures have any impact on the quality of laboratory results or patient outcomes.