Isolated tibial insert exchange in revision total knee arthroplasty

Aims This study aimed to determine outcomes of isolated tibial insert exchange (ITIE) during revision total knee arthroplasty (TKA). Methods From 1985 to 2016, 270 ITIEs were performed at one institution for instability (55%, n = 148), polyethylene wear (39%, n = 105), insert fracture/dissociation (5%, n = 14), or stiffness (1%, n = 3). Patients with component loosening, implant malposition, infection, and extensor mechanism problems were excluded. Results Survivorship free of any re-revision was 68% at ten years. For the indication of insert wear, survivorship free of any re-revision at ten years was 74%. Re-revisions were more frequent for index diagnoses other than wear (hazard ratio (HR) 1.9; p = 0.013), with ten-year survivorships of 69% for instability and 37% for insert fracture/dissociation. Following ITIE for wear, the most common reason for re-revision was aseptic loosening (33%, n = 7). For other indications, the most common reason for re-revision was recurrence of the original diagnosis. Mean Knee Society Scores improved from 54 (0 to 94) preoperatively to 77 (38 to 94) at ten years. Conclusion After ITIE, the risk and reasons for re-revision correlated with preoperative indications. The best results were for polyethylene wear. For other diagnoses, the re-revision rate was higher and the failure mode was most commonly recurrence of the original indication for the revision TKA. Cite this article: Bone Joint J 2021;103-B(6):1103–1110.

Effect of hypersensitivity pneumonitis guideline on pathologic diagnosis of interstitial pneumonia

Hypersensitivity pneumonitis (HP) and interstitial pneumonia (IP) have several overlapping characteristics, and a high diagnostic concordance rate of HP is rarely obtained. Thus, new guidelines, highly influenced by pathology, were devised for its diagnosis. We attempted to study the impact of the 2020 HP guidelines on pathological diagnosis of previously diagnosed cases of IP. Cases with fibrotic IP diagnosed in 2014 to 2019 were classified according to the 2020 HP guidelines into three categories: typical HP, probable HP, and indeterminate HP. The original pathological diagnosis and categorization based on the HP guidelines were compared. The clinical data including the serum data and the pulmonary function tests were compared among the groups. The study analyzed 247 consecutive cases classified into typical, probable, and indeterminate for HP, and alternative diagnoses. The number of cases that changed from an original diagnosis other than HP to HP based on the guidelines was 56 (23%). The clinical data of these cases bore greater resemblance to cases diagnosed as indeterminate for HP than those cases diagnosed as typical or probable HP. The ratios of typical and probable HP to those of the total cases were significantly low using cryobiopsy. Thus, with the application of the new guidelines, the pathological diagnosis of HP efficiently excluded HP cases but increased the rate of HP diagnosis for cases with fibrotic IP, which may not fit well to an HP diagnosis. Cryobiopsy may not be useful in imparting findings for fibrotic HP diagnosis using the new criteria.

Diagnostic discrepancies in second opinion pathology reviews in a community-based cancer center.

e18650 Background: Tracking diagnostic discrepancies is a common quality indicator in anatomic pathology. Many cases are re-reviewed as care is transferred from one facility to another. Most published data on these discrepancies is from the perspective of the tertiary receiving facility. Disparities in patient access to pathology expertise and technologies in small community hospitals can affect the accuracy of cancer diagnosis and the quality of care. Mary Lanning Healthcare (MLH) is a regional community hospital with a well-established referral pattern to several neighboring health systems. As part of a quality assurance process, we evaluated the diagnostic concordance rate of our cancer related pathology diagnoses with the referred institutions. Methods: Between 2017 and 2020, a cohort of cancer related cases was identified where the initial diagnosis was at MLH, then as part of coordinated care, a second pathologic interpretation was rendered at another instution. Data regarding specimen type, discrepancy in original diagnosis, nature and severity of discrepancy, disagreement in histologic grade, concordance or lack thereof with third party reviewers, and distribution among reviewing pathologists were collected. Results: A total of 521 cancer related cases (890 specimens) were sent to 16 facilities for second opinion. There were 46 (5%) discrepancies. Majority of them 45 (98%) were minor. Third party review of one major discrepancy came back in agreement with our original diagnosis. The most common discrepancy was interobserver variability in findings without strictly defined criteria. A change in histologic grade was the second most frequent deviation with prostate and breast being the most common sites. Upgrades and downgrades to the original diagnoses were nearly evenly split (19 to 21). A total of 33 pathologists were involved. While one reviewing pathologist generated 30% of all discrepancies, 3 other pathologists accounted for 67%. Conclusions: Accurate pathologic diagnoses significantly impact clinical outcomes. Our data which represents a rural community-based cancer program identified an overall discrepancy rate in the range of 0.1 to 1.1% for second opinion review. The vast majority of differences were minor in nature with no change in patient care and could be attributed to expected interobserver variability.[Table: see text]

Milan System for Reporting Salivary Gland Cytopathology - A Two Years’ Experience in a Referral Centre of Western Odisha

BACKGROUND Neoplasms of salivary gland account for 2 - 6.5 % of all head and neck neoplasms. Fine needle aspiration cytology (FNAC) is sufficiently sensitive and relevant to the diagnosis and treatment of salivary gland pathologies for salivary gland lesions. The Milan system for reporting salivary gland cytopathology (MSRSGC) represents a stage for a structured, evidence-based international reporting system for salivary gland fine-needle aspiration (FNA). This system provides a guidance for diagnosis and management according to the risk of malignancy (ROM) in different categories. We wanted to study the various cytomorphological lesions of salivary gland and their cytological categorisation based on the MILAN system of reporting. METHODS A 2-year record-based study (January 2018 to December 2019) was conducted on FNAC of salivary gland lesions in the Department of Pathology, VSSIMSAR (Veer Surendra Sai Institute of Medical Sciences and Research), Burla, Odisha. Based on the classical system, all smears were studied and re-categorized into six groups according to the MILAN classification. Histological correlation was carried out in the available cases. RESULTS A total of 103 FNA cases were examined and 20 different categories were there in the original diagnosis. As per the categorisation based on MILAN System there were six categories, maximum cases were non-neoplastic 34 (33.0 %) followed by benign neoplasms 22 (21.35 %), malignant 14 (13.5 %), non-diagnostic 10 (9.7 %), atypia of undetermined significance 9 (8.7 %), suspicious for malignancy 8 (7.7 %) and neoplasms of uncertain malignant potential 6 (5.8 %). 43 cases (80.4 %) were found to be concordant out of 54 histopathology correlated cases. CONCLUSIONS The Milan system of reporting salivary gland cytopathology provided a uniform system of reporting salivary gland cytomorphology that may increase the effectiveness. KEYWORDS Milan System, Salivary Gland Lesions, FNAC, Risk of Malignancy (ROM)

The Diagnostic Yield of the Multidisciplinary Discussion in Patients With COVID-19 Pneumonia

Purpose: The hypothesis of the study was that a multidisciplinary approach involving experienced specialists in diffuse parenchymal lung disease might improve the diagnosis of patients with COVID-19 pneumonia.Methods: Two pulmonologists, two radiologists, and two pathologists reviewed 27 patients affected by severe COVID-19 pneumonia as the main diagnosis made by non-pulmonologists. To evaluate whether the contribution of specialists, individually and/or in combination, might modify the original diagnosis, a three-step virtual process was planned. The whole lung examination was considered the gold standard for the final diagnosis. The probability of a correct diagnosis was calculated using a model based on generalized estimating equations. The effectiveness of a multidisciplinary diagnosis was obtained by comparing diagnoses made by experienced pulmonologists with those made by non-pulmonologists.Results: In 19% of cases, the diagnosis of COVID-19-related death was mainly incorrect. The probability of a correct diagnosis increased strikingly from an undedicated clinician to an expert specialist. Every single specialist made significantly more correct diagnoses than any non-pulmonologist. The highest level of accuracy was achieved by the combination of 3 expert specialists (p = 0.0003).Conclusion: The dynamic interaction between expert specialists may significantly improve the diagnostic confidence and management of patients with COVID-19 pneumonia.

An Unusual Cause of Facial swelling – Bot Fly Larva in an Infant – A Case Report

‘Myiasis’ is a term used to describe an infestation of humans or animals with dipterous larvae [1]. Due to increased international travel in recent times, health professionals in the UK may encounter these infections more commonly than before. We present a case of a 6 month infant who had been bitten by Dermatobia hominis Bot fly in Brazil and travelled back to the UK. The original diagnosis was of an infected insect bite, which ultimately delayed appropriate management. A detailed travel history is therefore paramount and these types of infections should be considered in differential diagnoses. Management should also involve the infectious diseases team.

Comparative analysis of differences between preoperative endoscopic biopsy and postoperative pathological examination for diagnosis of gastric intraepithelial neoplasia

Objective This study was performed to compare the differences between preoperative endoscopic biopsy (PEB) and postoperative pathological examination (PPE) for diagnosis of gastric intraepithelial neoplasia (GIN). Methods From September 2016 to July 2019, 188 consecutive patients with GIN at Yuyao People’s Hospital were retrospectively analyzed. The 188 patients had 218 GIN lesions. All patients underwent PEB and either endoscopic submucosal dissection or surgical treatment. PPE was performed on pathological tissues that had been surgically removed. Results Among 138 cases of low-grade dysplasia (LGD) diagnosed by PEB, 46 were upgraded to high-grade dysplasia (HGD), 20 were upgraded to early gastric cancer (EGC), and 2 were downgraded to inflammation after PPE. Among 42 cases of HGD, 23 were upgraded to EGC, 2 were downgraded to LGD, and 2 were downgraded to inflammation after PPE. Among 38 cases of EGC, 1 was downgraded to HGD and 2 were downgraded to LGD after PPE. The original diagnosis was maintained after the operation in 120 cases of GIN. Conclusion Biopsy did not fully reflect the lesions of GIN. Biopsy review should be actively performed, and the lesions should be clarified by endoscopic submucosal dissection or surgery.

The contribution of CD200 to the diagnostic accuracy of Matutes score in the diagnosis of chronic lymphocytic leukemia in limited resources laboratories

Flow cytometry immunophenotyping has an essential role in distinguishing chronic lymphocytic leukemia from other B-chronic lymphoproliferative disorders. Recently, CD200 is considered as a relatively consistent marker in chronic lymphocytic leukemia. We retrospectively assessed CD200 expression in 252 patients with B chronic lymphoproliferative disorders with four-color flow cytometry. CD200 expression estimation included the proportion of positive cells (≥30%) and the mean fluorescence intensity ratio. Additionally, we have incorporated CD200 into Matutes score, also replaced FMC7 and CD79b in an attempt to improve the score discriminative power. Of 252 patients enrolled, 199(79%) patients were classified as chronic lymphocytic leukemia and 53 (21%) as other B-chronic lymphoproliferative disorders. All chronic lymphocytic leukemia cases and 20 of 53 (37.7%) of other B-chronic lymphoproliferative disorders demonstrated high CD200 expression (≥30%). Further, CD200 (≥30%) revealed a higher accuracy in comparison to other markers in Matutes score (range: 51%–92.5%). Also, CD200 addition to the Matutes score has correctly recognized all 199 chronic lymphocytic leukemia cases including 10 atypical chronic lymphocytic leukemia cases. As for non-CLL cases, 20 of 53 attained a higher score, yet keeping the original diagnosis. Moreover, CD200 enhanced the diagnostic accuracy of Matutes score to 100%, and when included in a simplified 4-markers score, showed an accuracy of 99.8% compared to 99.4% of Matutes score. In conclusion, CD200 is an accurate diagnostic marker for chronic lymphocytic leukemia, and can refine the modified Matutes score accuracy when added with other markers.

Rapid Validation of Whole-Slide Imaging for Primary Histopathology Diagnosis

Objectives The ongoing global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic necessitates adaptations in the practice of surgical pathology at scale. Primary diagnosis by whole-slide imaging (WSI) is a key component that would aid departments in providing uninterrupted histopathology diagnosis and maintaining revenue streams from disruption. We sought to perform rapid validation of the use of WSI in primary diagnosis meeting recommendations of the College of American Pathologists guidelines. Methods Glass slides from clinically reported cases from 5 participating pathologists with a preset washout period were digitally scanned and reviewed in settings identical to typical reporting. Cases were classified as concordant or with minor or major disagreement with the original diagnosis. Randomized subsampling was performed, and mean concordance rates were calculated. Results In total, 171 cases were included and distributed equally among participants. For the group as a whole, the mean concordance rate in sampled cases (n = 90) was 83.6% counting all discrepancies and 94.6% counting only major disagreements. The mean pathologist concordance rate in sampled cases (n = 18) ranged from 90.49% to 97%. Conclusions We describe a novel double-blinded method for rapid validation of WSI for primary diagnosis. Our findings highlight the occurrence of a range of diagnostic reproducibility when deploying digital methods.

Primary Breast Extranodal Marginal Zone Lymphoma in Primary Sjögren Syndrome: Case Presentation and Relevant Literature

The association between autoimmune diseases, mostly rheumatoid arthritis, systemic lupus erythematous, celiac disease and Sjögren syndrome, and lymphoma has been widely demonstrated by several epidemiologic studies. By a not yet entirely elucidated mechanism, chronic activation/stimulation of the immune system, along with the administration of specific treatments, may lead to persistent stimulation of both of B- and T-cells, and to the onset of different types of lymphoma in such patients. Specifically, patients affected by may develop lymphomas may years after the original diagnosis. Several epidemiologic, hematologic and histological factors may anticipate the progression from Sjögren syndrome into lymphoma but, to the best of our knowledge, a definite pathogenetic mechanism for such progression is still missing. In fact, while the association between Sjögren syndrome and non-Hodgkin lymphoma, mostly diffuse large B-cell and extranodal marginal zone lymphomas is well established, many other variables, such as time of onset, gender predilection, sites of occurrence, subtype of lymphoma and predictive factors still remain unclear. We report on a rare case of primary breast lymphoma occurring three years after the diagnosis of Sjögren syndrome in a 57 y.o. patient. The diagnostic work-up, including radiograms, core needle biopsy and histological examination are discussed, along with emerging data from the recent literature, thus highlighting the usefulness of breast surveillance in Sjögren syndrome patients.