Lydia Pleotis Howell

Multicenter masked evaluation of AutoCyte PREP thin layers with matched conventional smears. Including initial biopsy results.

OBJECTIVE To compare the performance of liquid-based cell preparations from the AutoCyte PREP system (AutoCyte, Inc., Elon College, North Carolina) with the conventional cervical smear in masked, split-sample, multisite trials. STUDY DESIGN The AutoCyte PREP system utilizes the CytoRich method, which combines liquid preservation, selective reduction of blood and inflammation, thin-layer cell dispersion and discrete staining. In an eight-site multicenter trial, 8,983 cases were evaluated. Parallel AutoCyte PREP slides and matching conventional cervical cytologic smears were screened in a masked fashion, with all abnormals reviewed in a masked, on-site pathologist review. The conventional smear was always prepared first, with the AutoCyte PREP using the residual cells on the collection device. The Bethesda System was used for reporting diagnosis and specimen adequacy. RESULTS Of the cases, 7,805 (86.9%) had the same interpretation. In 8,750 cases (97.4%), there was agreement within one diagnostic category. The AutoCyte PREP demonstrated a statistically significant, 31% overall improvement in the detection of squamous intraepithelial lesion and invasive cancer when evaluating cases with more than one diagnostic class difference. Biopsy correlation of available data supported the improvement observed in the cytology-based comparison. Recovery of infectious organisms and endocervical component was comparable between preparations, especially in light of the split-sample study design. There was a 39% reduction in unsatisfactory slides and 44% fewer satisfactory but limited by reports. CONCLUSION The AutoCyte PREP and CytoRich method produce excellent cellular presentations with standardized quality, superior sensitivity and improved adequacy as compared to the conventional method.

Fine-needle aspiration cytology of sarcoma: Retrospective review of diagnostic utility and specificity

Fine‐needle aspiration cytology (FNA) is useful because of its low cost, quick turn around time, and low incidence of complications. This study investigates the role FNA plays in the evaluation of sarcoma. We reviewed all the pathologic material from patients with sarcoma or a FNA diagnosis suggestive of sarcoma at the University of California‐Davis Medical Center (1985–1994). Fifty‐two of 196 patients identified (26.5%) were evaluated with FNA exhibiting 46 soft tissue and 6 bone lesions located in the extremities (19), trunk (19), head and neck (8), retroperitoneum (3), and abdominal cavity (3). Among 196 patients identified, those evaluated by FNA had soft tissue rather than bone lesions (P < .001) and primary sites other than in the extremities (P < .001). The primary neoplasms for the 52 FNA patients included 47 sarcomas (10 malignant fibrous histiocytomas and 16 other types), I intramuscular myxoma, 2 lymphomas, and 2 spindle cell (sarcomatoid) carcinomas. In 43 patients (22% of total), FNA was used first, before a primary diagnosis. The FNA report showed the correct specific neoplasm in only 20.9%. However, the FNA reports reflected an effective positive diagnosis leading to appropriate diagnostic biopsy in 88.4%, while only 7.0% were misleading (benign or inflammatory) and 4.6% inadequate. Review of FNA slides for 32 of 43 patients in which FNA was used first, in a blinded fashion, exhibited 21.9% specificity for the specific neoplasm, and 88.4% effective positive diagnoses. In 9 patients, FNA was utilized to investigate recurrence. Five out of 5 instances of recurrent sarcoma were identified by FNA. However, FNA misidentified recurrence in 3/4 instances, exhibiting suspicious cells from regenerating skeletal muscle (2) and a traumatic neuroma (I). The specific diagnosis for sarcomas is challenging even with surgical material. FNA usually does not provide a specific diagnosis (only in 20.9% of cases) and review of routinely prepared slides showed the same specificity as reflected by the original FNA report, at times formulated with the benefit of immunohistochemistry or electron microscopy. FNA effectively evaluated lesions in 45 of 52 patients (86.5%), confirming the useful screening role for this technique in sarcomas. Diagn Cytopathol 1996;15:23–32.

Relationship of p53 and bcl-2 to Prognosis in Muscle-Invasive Transitional Cell Carcinoma of the Bladder

PURPOSE We examined the presence of the p53 and Bcl-2 oncoproteins, as detected by immunohistochemistry, in muscle-invasive bladder cancer and correlated this with survival. MATERIALS AND METHODS Formalin-fixed cystectomy specimens from 41 consecutive patients with mean follow-up of 52 months were used. Five patients were either lost to follow-up or died of other diseases and were not included in the survival evaluation. RESULTS Eighteen of 36 patients died of metastatic transitional cell carcinoma. p53 immunostaining was found in 61% of patients. In 21 of 23 this staining was homogeneous, with more than 75% of cancer cells staining using a DO-1/DO-7 antibody cocktail. p53 staining was not correlated with stage (p>0.25) or grade (p<0.10) in these invasive cancer specimens. Contrary to recent studies p53 immunostaining was not correlated with disease-specific survival. Bcl-2 immunostaining was found in 28% of patients and was not correlated with grade (p>0.25) or disease-specific survival. No combination of p53 and Bcl-2 staining gave added predictive information. CONCLUSIONS Cytoplasmic Bcl-2 is found in a small percentage of these cancers and does not correlate with prognosis. Further, p53 molecular overexpression is detected in the majority of muscle-invasive bladder tumors as a field defect. However, in patients undergoing cystectomy, it does not correlate with prognosis.

Ultrasound and MR imaging of fibromatosis colli (sternomastoid tumor of infancy)

Abstract The sonographic and CT findings of fibromatosis colli (sternomastoid tumor of infancy) have been described, but the MRI appearance has been reported in only one case in which the mass resolved over time. This case describes the detailed MRI findings in a biopsy-proven case of fibromatosis colli; the signal intensity of the mass on T2-weighted images was slightly less than on gradient-recalled T1-weighted images, consistent with the presence of some fibrous tissue within the muscle mass. The involved portion of the muscle was better defined on MRI than sonography. MRI was helpful in demonstrating the signal characteristics of the mass; localizing the mass to within the sternocleidomastoid muscle; and demonstrating clear surrounding fascial planes with lack of associated lymphadenopathy, airway compression, vascular encasement, bone involvement or intracranial/intraspinal extension associated with other neck masses.

Multigenerational challenges in academic medicine: UCDavis's responses

Academic medicine is a unique work environment, one of the few where members of four different generations regularly interact and where multigenerational teams are key to fulfilling its missions, particularly education. This can lead to increased creativity, but also to intergenerational conflict, since each generation has different values and expectations. The authors describe multigenerational challenges confronted at the University of California, Davis, School of Medicine, and that schools responses to them. These challenges include issues related to work hours, workload, compensation, evaluation for advancement, recruitment and retention, and attendance at required meetings. Awareness of the different generational qualities and values allowed the school of medicine to identify the multigenerational origin of many of these ongoing issues and challenges and to plan appropriate solutions within the Office of Academic Affairs. These include policy changes related to work–life balance, utilizing multiple faculty tracks with different roles, allowing part-time faculty appointments, creating a variety of faculty development programs geared toward different generational needs (which utilize flexible modules, menus of options, and alternative technologies for presentation), defining appropriate reward and incentives through compensations plans, and creating peer-reviewed awards. The authors conclude that these efforts mitigate conflict, promote diversity, and allow multigenerational teams to function more effectively and creatively in education, research, and clinical care. Ongoing evaluation will further refine this approach.

Cervical cytology specimen adequacy: Patient management guidelines and optimizing specimen collection

Objective. To provide updated management guidelines according to cervical cytology specimen adequacy and techniques to optimize adequacy based on literature review and expert opinion. Materials and Methods. Selected members of the American Society for Colposcopy and Cervical Pathology committee and invited experts conducted a literature review and discussed appropriate management and areas for future research emphasis. Results. The guidelines recommend a repeat Pap test in a short interval of 2 to 4 months for most women when the cytology result is unsatisfactory. The preferred follow-up for women with a negative cytology result lacking an endocervical/transformation zone component or showing other quality indicators is a repeat Pap test in 12 months. Indications for an early repeat Pap test in 6 months are provided, and the influence of human papillomavirus testing results on management is discussed. Techniques for optimizing specimen adequacy are provided in detail. Conclusion. The specimen adequacy management guidelines will help promote uniform and optimal follow-up of patients receiving cervical cytology screening. The topics for future research emphasis will be helpful in promoting studies in needed areas.

Diagnostic concordance of telecytology and conventional cytology for evaluating breast aspirates

OBJECTIVE To evaluate the diagnostic concordance between static electronic images versus glass slides for breast fine needle aspiration (FNA) cytology. STUDY DESIGN Nine malignant and 12 benign breast FNA cases were imaged using the Roche Image Manager, at a resolution of 1,024 x 768 pixels. A cytotechnologist or pathology resident selected five to nine representative images per case. Case histories and images were assembled into hypertext documents. Two pathologist blindly made diagnoses for each case based on the images and the clinical history and independently made diagnoses for the glass slides, also evaluating each set of images and glass slides for a list of cellular features. RESULTS The two pathologist had concordance rates of 90.5% and 66.7% between their image and glass diagnoses. For each pathologists discordant cases, 100.0% and 85.7%, respectively, were due chiefly to suspicious rather than definitive diagnoses. CONCLUSION Evaluation of the electronic images indicated that almost all the cellular features were comparable to those viewed though a microscope.

Follow‐up of Papanicolaou smears diagnosed as atypical squamous cells of undetermined significance

In the first year since the institution of the Bethesda system at UCDMC, 549/7,388 (7.43%) Papanicolaou (Pap) smears were diagnosed as having an epithelial abnormality. One hundred ninety‐three of the 549 (35.1%) of the abnormal smears received an ASCUS diagnosis, representing 2.61% of the total volume. Follow‐up was obtained on 124/193 (64.2%) and consisted of colposcopy with biopsy in 38.3%, one repeat Pap smear in 51.2%, and two or more repeat Pap smears in 10.5%. Follow‐up revealed a squamous intraepithelial lesion (SIL) in 29.1%, ASCUS in 12.9%, and no evidence of an epithelial lesion in 58.0%. Review of the original ASCUS Pap smear from the group with no epithelial lesion on follow‐up showed increased inflammation plus metaplasia and/or reactive changes in 69.5% and ASCUS in 19.5%.

Generational and Gender Perspectives on Career Flexibility: Ensuring the Faculty Workforce of the Future

There is growing national concern regarding the future adequacy of our physician workforce. The general population aged more than 65 years is predicted to double by 2030, and increased age is commonly accompanied by greater health care needs. The physician population also is aging; 1 in 3 active physicians is currently aged more than 55 years and likely to retire by 2020. A physician shortage is predicted by the Association of American Medical Colleges (AAMC).1 Further affecting the physician workforce is the observation that physicians are choosing to work differently. Many publications in both medical and popular literature describe generational differences toward work. They describe younger workers as placing a higher value on family, career flexibility, and work–life balance than their predecessors.2–10 This difference is likely based on the different roles both sexes assume at work and at home. The Families and Work Institute (FWI) reports that more young men are assuming household and childcare duties than their counterparts 30 years ago, and more women want jobs with responsibilities similar to those of men.11 The inherent challenges of balancing these demanding work and family roles create new stresses and conflicts for both sexes and provide insight into findings from the AAMC National Graduation Questionnaire, which shows a growing trend for medical graduates to choose specialties with more controllable work hours and little or no on-call duties. In addition, the questionnaire revealed more medical graduates opt for careers that do not involve the clinical practice of medicine at all, such as careers in the biotechnology and pharmaceutical industry or as consultants or entrepreneurs.12 Minimizing work–life conflict also is not limited to the younger generation of physicians. Many hospitals and physician practices are finding it difficult to motivate physicians of all ages to take night and weekend call, even when additional compensation is provided for on-call coverage.13,14 This trend among the older generation may reflect concerns about health, ability to meet changing family needs, burnout, or other changes in personal expectations as physicians mature and age. The emerging issues surrounding work and family compound academic medicine’s unique and long-standing challenges in recruitment and retention. In addition to the demands of patient care, which requires long work hours and on-call duties, a career in academic medicine includes considerable teaching demands and high expectations for research accomplishment and productivity. Economic pressures due to declining reimbursement for clinical services, increased competition for research funding, and minimal (if any) compensation for teaching have exacerbated faculty stress, making academic careers seem less appealing to younger generations. A study at a major academic health center found that the average annual turnover of new physician hires was 24%. Even more revealing were findings regarding retention: Only 55% of initial hires were still employed at this center 5 years later.15 Replacing academic physicians is costly. Recruitment, training, and cost of the learning curve as new recruits ramp up their practice over 1 year can total more than

The Women in Medicine and Health Science Program: An Innovative Initiative to Support Female Faculty at the University of California Davis School of Medicine

200,000 per physician.16 It is critical to identify better strategies to improve recruitment, retention, and satisfaction of academic faculty. Other industries and professions also are concerned about attracting and retaining talent. The generations following the baby boomers are smaller in number, and it is becoming harder to fill vacancies due to retirement. Career flexibility has become a common primary recruitment and retention strategy. The Radcliffe Public Policy Center found a work schedule that allows time with family is one of the most important job characteristics to men and women aged 20 to 50 years.17 At Deloitte & Touche, 86% of employees cited flexibility as the major reason for staying with the firm, leading to a savings of