Rebecca A. Levy

Development of electronic medical record charting for hospital-based transfusion and apheresis medicine services: Early adoption perspectives

Background: Electronic medical records (EMRs) provide universal access to health care information across multidisciplinary lines. In pathology departments, transfusion and apheresis medicine services (TAMS) involved in direct patient care activities produce data and documentation that typically do not enter the EMR. Taking advantage of our institution′s initiative for implementation of a paperless medical record, our TAMS division set out to develop an electronic charting (e-charting) strategy within the EMR. Methods: A focus group of our hospital′s transfusion committee consisting of transfusion medicine specialists, pathologists, residents, nurses, hemapheresis specialists, and information technologists was constituted and charged with the project. The group met periodically to implement e-charting TAMS workflow and produced electronic documents within the EMR (Cerner Millenium) for various service line functions. Results: The interdisciplinary working group developed and implemented electronic versions of various paper-based clinical documentation used by these services. All electronic notes collectively gather and reside within a unique Transfusion Medicine Folder tab in the EMR, available to staff with access to patient charts. E-charting eliminated illegible handwritten notes, resulted in more consistent clinical documentation among staff, and provided greater real-time review/access of hemotherapy practices. No major impediments to workflow or inefficiencies have been encountered. However, minor updates and corrections to documents as well as select work re-designs were required for optimal use of e-charting by these services. Conclusion: Documentation of pathology subspecialty activities such as TAMS can be successfully incorporated into the EMR. E-charting by staff enhances communication and helps promote standardized documentation of patient care within and across service lines. Well-constructed electronic documents in the EMR may also enhance data mining, quality improvement, and biovigilance monitoring activities.

Myeloid sarcoma as the presenting symptom of chronic myelogenous leukemia blast crisis.

Myeloid sarcoma is an extramedullary tumor composed of immature myeloid cells that efface the underlying tissue architecture. It is usually associated with acute myelogenous leukemia, but can be associated with myeloproliferative neoplasms, myelodysplastic disorders, or myeloproliferative/ myelodysplastic syndromes. If it is unrecognized, appropriate chemotherapy may be delayed and survival jeopardized. We present a case of a myeloid sarcoma presenting in an otherwise asymptomatic patient who ultimately was found to have chronic myelogenous leukemia, presenting in blast crisis. We also review the distinct clinical and pathologic features of myeloid sarcoma, as well as treatment of the disease.

The fetal magnetic resonance imaging experience in a large community medical center.

Fetal magnetic resonance imaging (MRI) continues to prove a useful problem solving tool for diagnostic and management decision making issues encountered in the antenatal period. In this paper, we attempt to review basic fetal MRI protocol considerations and demonstrate key imaging findings through multiple modalities, with pathologic correlation in several cases. A study of five fetal MRI cases, from our institution, were selected in order to highlight both the indications for, and benefits obtained from this advanced imaging technique. Fetal MRI proved useful in each case in better defining fetal anomalies, especially where ultrasound (due to drawbacks such as shadowing by pelvic bones) was unable to be completely diagnostic. The more in-depth study made possible by MRI also helped with formulation of disease prognosis and estimation of survival chances of the fetus. Further, MRI as a diagnostic and prognostic tool has become more ubiquitous across the medical community. This imparts tangible benefit to patients, who are now able to find this service within arms reach. Whereas previously these patients were obligatorily referred up to 90 miles away from our centre for further medical work-up, now a large percentage can obtain their prenatal imaging and perinatal care locally. In addition, medical education benefits as new types of cases, those with pathology of the antenatal period, are retained for work-up and management in these large community settings. Cases from our institution exemplify these types of pathologies, from fetal chest masses to a syndromic presentation of bilateral renal agenesis.

Targeting nano drug delivery to cancer cells using tunable, multi-layer, silver-decorated gold nanorods

Multifunctional nanoparticles have high potential as targeting delivery vehicles for cancer chemotherapy. In this study, silver‐decorated gold nanorods (AuNR\Ag) have been successfully used to deliver specific, targeted chemotherapy against breast cancer (MCF7) and prostate carcinoma (PC3) cell lines. Doxorubicin, a commonly used chemotherapy, and anti‐Epithelial cell adhesion molecule (anti‐EpCAM) antibodies were covalently bonded to thiolated polyethylene glycol‐coated AuNR\Ag, and the resultant system was used to deliver the drugs to cancer cells in vitro. Furthermore, these nanoparticles have a unique spectral signature by surface enhanced Raman spectroscopy (SERS), which enables reliable detection and monitoring of the distribution of these chemotherapy constructs inside cells. The development of interest in a plasmonic nano drugs system with unique spectroscopic signatures could result in a clinical approach to the precise targeting and visualization of cells and solid tumors while delivering molecules for the enhanced treatment of cancerous tumors.

Naegleria fowleri That Induces Primary Amoebic Meningoencephalitis: Rapid Diagnosis and Rare Case of Survival in a 12-Year-Old Caucasian Girl

Primary amoebic meningoencephalitis (PAM) is a rare and almost always fatal disease that is caused by Naegleria fowleri, a freshwater thermophilic amoeba. Our case involves an adolescent female who presented with fever of unknown origin. A lumbar puncture was performed, and the Wright-Giemsa and Gram stained cerebrospinal fluid (CSF) cytospin slides showed numerous organisms. Experienced medical technologists in the microbiology and hematology laboratories identified the organisms as morphologically consistent with Naegleria species. The laboratory made a rapid diagnosis and alerted emergency department care providers within 75 minutes. The patient was treated for PAM with amphotericin, rifampin, azithromycin, fluconazole and aggressive supportive therapy including dexamethasone. The Centers for Disease Control and Prevention (CDC) was contacted, and miltefosine, an investigational medication, was started. Additional treatment included an intraventricular shunt and controlled hypothermia in order to mitigate potential cerebral edema. Our patient is a rare success story, as she was diagnosed swiftly, successfully treated, and survived PAM.

Naegleria fowleri: Diagnosis, Pathophysiology of Brain Inflammation, and Antimicrobial Treatments

Primary amoebic meningoencephalitis (PAM) is a very rare disease with a high mortality rate. PAM is caused by Naegleria fowleri, an amoeba which resides in freshwater lakes and ponds and can survive in inadequately chlorinated pools ( Lopez, C.; Budge, P.; Chen, J., et al. Primary amebic meningoencephalitis: a case report and literature review . Pediatr. Emerg. Care 2012 , 28 , 272 - 276 ). In the past 50 years, there have been over 130 cases of Naegleria induced PAM in the United States with only three known survivors; one survivor was diagnosed and treated at Arkansas Childrens Hospital. Successful treatment of PAM started with a rapid diagnosis, extensive antimicrobial therapy including an investigational medication miltefosine, supportive care, an intraventricular shunt, and hypothermia. These treatments address different aspects of the disease process. Increased understanding of the diagnosis and treatment of PAM is important especially for patients who present with meningitis-like findings during the summer months.

Smooth muscle neoplasms of the vulva masquerading as Bartholin gland duct cysts.

Smooth muscle neoplasms of the vulva can be mistaken for Bartholin duct cysts, which can lead to a delay in diagnosis. We present a case of vulvar leiomyoma and a case of leiomyosarcoma that clinically mimicked Bartholin duct cysts. Identification of leiomyosarcomas in this region is particularly important; due to the risk of recurrence, patients may need radiation and/or chemotherapy in addition to adequate surgical treatment and appropriate follow up. Prior series have shown that risk of recurrence is related to inadequate resection and not to the size or grade of tumor. It is critical that pathologists recognize smooth muscle tumors of the vulva and communicate to clinicians the importance of clear margins and wide local excision in cases of malignancy.

Cervical polyps: Is histologic evaluation necessary?

OBJECTIVE The aim of this study was to examine a series of clinically identified cervical polyps and determine the incidence of significant histologic and concurrent cytologic findings. METHODS Consecutive cervical polyps from January 2000 through September 2012 were retrieved from the hospital laboratory information system. Histologic evaluation of these polyps was performed, followed by a chart review of clinical findings and correlation with the immediately prior or concurrently collected cervical Papanicolaou (Pap) test results, when available. RESULTS A total of 369 cervical polyps were identified and reviewed. The patient ages ranged from 18 to 87 years (mean 46.5years). Eight polyps demonstrated squamous dysplasia (6 Cervical Intraepithelial Neoplasia/CIN I, and 2 CIN II/III), while 6 had malignant or atypical/potentially malignant features (2 adenosarcoma, 2 atypical polyps concerning for Mullerian adenosarcoma, 1 endometrioid endometrial adenocarcinoma and 1 adenocarcinoma in-situ). An increased incidence of atypical squamous cells of undetermined significance (ASCUS) and atypical glandular cells not otherwise specified (AGC NOS) Pap diagnoses (12.7% and 6.1%, respectively) was found in women with benign polyps on biopsy. DISCUSSION We demonstrated a higher rate of clinically significant histologic findings in cervical polyps (14 of 369 cases, 3.7%) compared to previously reported studies. The increase in ASCUS and AGC Pap results was most likely related to reactive and inflammatory changes present in benign polyps. Our results suggest that removal of all cervical polyps with subsequent histologic review is warranted.

Malt Lymphoma of the Colon: a Rare Occurrence

Non-Hodgkins lymphoma (NHL) is one of the leading causes of cancer in the US. NHL can be seen in the gastrointestinal tract in extralymphatic presentation. Primary GI lymphomas are rare. When present, they are more common in the stomach and small bowel. The most common histologic subtype affecting the gastrointestinal tract and colon is diffuse large B cell lymphoma. These are generally aggressive and are composed of rapidly proliferating cells of B cell origin. The second most common colorectal lymphoma is mucosa-associated lymphoid tissue (MALT)-associated low-grade B cell lymphoma. MALT-associated lymphomas are low-grade tumors arising from B cells associated with mucosal immunity. MALT is predominantly found in the gastrointestinal tract and plays a vital role in immune surveillance, mucosal regeneration, and in carcinogenesis. In the colon, lymphoid tissue consists of isolated lymphoid follicles which are composed mainly of B lymphocytes. These cells occasionally undergo abnormal proliferation and give rise to lymphoma of the MALT type. Colonic MALT lymphoma is a rare entity of increasing recognition, for which no definitive treatment has been established. There are very few case reports of colonic MALT type lymphoma given its uncommon occurrence, thereby lacking sufficient data required in evaluation, management, and treatment of these patients. We describe a rare case of colon marginal-zone B cell lymphoma of MALT (MALT lymphoma) found on routine colonoscopy. Case Presentation