Leveraging Existing Institutional Resources to Maintain Quality Assurance Practices in Anatomic Pathology in the Era of Social Distancing

Introduction/Objective

Due to the COVID-19 pandemic, hospitals had to adapt practices to incorporate social distancing while maintaining quality assurance (QA) in anatomic pathology (AP). Prior to this, our general surgical pathology (SP) and cytopathology (CP) services held daily consensus conferences (CC) at a multi-headed microscope. Implementing social distancing meant only a few faculty were present onsite and avoidance of interactions at the multi-headed scope. In an effort to preserve QA through CC, faculty exploited the use of web conferencing through our HIPAA-compliant Zoom. We describe the utility of this new practice.

Methods

From 3/25-4/30/20, all SP and CP cases selected for CC were presented by respective pathologists (n=8) in their own offices by using individual microscopes with cameras, image acquisition software, and screen-sharing through Zoom. One pathologist was responsible for sending out a new CC Zoom link daily and recording the consensus diagnosis. All onsite pathologists and those at home participated.

Results

We presented 95 SP and 31 CP cases through Zoom compared to 300 SP and 60 CP cases presented at a similar timeframe prior to social distancing. This 68% and 48% decline could be attributed to elective procedure cancellation. We assigned a consensus diagnosis to all cases, with 77% overall being malignant diagnoses, and breast being the most common SP specimen type (22%). Additionally, all participating pathologists felt comfortable with the new format irrespective of being onsite or at home. Apart from minor audio issues, we did not notice significant lag time or visual disturbances that interfered with diagnostic abilities. Importantly, the transition did not involve investing in new technology.

Conclusion

The new virtual CC allowed our department to maintain QA practices in AP without sacrificing quality and serves as a starting point to investigating the use of this technology to other applications in AP, such as overnight frozen sections.

Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature

Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (<5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find <30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Below-Knee Amputation Resulting from an Arterial Thrombosis from Tourniquet Use in a Patient with Undiagnosed Factor V Leiden: A Case Report

CASE

A 38-year-old woman presented with previously undiagnosed factor V Leiden (FVL), who suffered a complete superficial femoral arterial thrombosis after tourniquet use during the surgical repair of one of her bilateral tibial plafond fractures. This patient's injury eventually resulted in a below-knee amputation.

CONCLUSION

We recommend expanding hypercoagulable screening on patients with risk factors based on a detailed history and physical examination. We also recommend limiting or negating tourniquet use in patients with FVL or other hypercoagulable disorders.

Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments

BACKGROUND

Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures.

METHODS

From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures.

RESULTS

The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively).

CONCLUSIONS

This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments.

LEVEL OF EVIDENCE

Three.

Coronal Plane Deformity Correction in Distal Radius Fracture Fixation With the Volar Locking Plate

The goal of treatment for distal radius fractures is anatomic articular reduction and restoration of coronal and sagittal plane alignment, rotation, and angulation of the metadiaphyseal component of these fractures. This article presents a reproducible technique for restoring coronal plane alignment of the metadiaphyseal component of the fracture using an indirect reduction maneuver leveraging the volar locking plate as an indirect reduction aid. After applying an appropriately sized volar locking plate, the first screw is placed in the center of the shaft of the plate. Next, the distal row of subarticular locking screws is placed to neutralize a reduced articular surface. The shaft screw is subsequently loosened, and two Freer elevators are used to rotate the plate, indirectly translating the distal articular block and achieving improved coronal plane alignment. Last, the remaining diaphyseal screws are applied to appropriately neutralize the fracture. (Journal of Surgical Orthopaedic Advances 27(2):160-163, 2018).

Use of Volar Plate for Indirect Coronal Plane Reduction in an Intraarticular Distal Radius Fracture

Management of intraarticular distal radius fractures requires precise reconstruction of the articular surface to optimize outcomes. Treatment goals also include restoration of alignment, rotation, and angulation in both the coronal and sagittal planes of the metaphyseal component of these fractures. Surgical management with open reduction and internal fixation with a volar plate is often the preferred method of open treatment. However, a variety of different techniques have been described, and the preferred technique may be determined on an individual basis by the fracture characteristics, patient-dependent factors, or surgeon experience.

Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation

BACKGROUND

We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture.

METHODS

We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups.

RESULTS

Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all).

CONCLUSIONS

Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utility of portable monitoring in the diagnosis of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.

Life-stage Analysis of Solvent Induced Fissures under Static Stress in PET Fibers

The paper discusses the impact of drawing poly(ethylene terephthalate) (PET) fibers in the presence of solvents, which consist of the first five homologues of aliphatic primary alcohols, namely methanol to amyl alcohol. The solvent induced deformation under tensile load leads to surface fissures characterized by four stages: fissure formation (birth), incipient draw (neck formation), partial draw, and full draw. This process results in internal void formation in the presence of a propagating neck. A design of experiment (DOE) was performed to screen out the process parameters critical for understanding surface fissure formation. Four process parameters were investigated: initial material properties (orientation); environment of draw (i.e. type of alcohols used as solvent); rate of extension; and amount of extension. The response of solvent induced deformation were characterized by the natural draw force reduction; number of fissures formed at time of birth, fissure width at time of formation, and neck angle. Of all the four process parameters involved, the analysis indicates that the material properties and amount of extension were the best predictors of solvent induced fissure formation. Organic solvents reduce the tension required for draw and create internal voids, a porous network, with possibly the penetrant being “sucked” into the interior of PET fibers drawn in the presence of alcohols.

The effects of sustained delivery of alendronate on the kidney in ovariectomized female rats

Bisphosphonates are indicated for the treatment and prevention of osteoporosis in adults; the treatment and prevention of glucocorticoid-induced osteoporosis; the treatment of Paget’s disease; and the treatment of multiple myeloma in patients with documented bone metastases. Two long-term trials in cancer patients demonstrated an increase in serum creatinine (SCr) when 8 mg of bisphosphonate was administered, prompting a recommendation to reduce the dose to 4 mg. The risk for renal toxicity remains a possibility following chronic administration of bisphosphonate treatment for osteoporosis. The goal of the study was to evaluate the kidney of osteoporotic female rats following chronic administration of alendronate using a drug delivery device for 4 weeks and compare the finding with control non-ovariectomized animals, ovariectomized control animals (OVX), and ovariectomized animals with an empty drug delivery system. The results of the study showed significant increases in body weights in the ovariectomized animals compared with non-ovariectomized animals. The organ wet-weights were not statistically different between the control and treatment groups or the ovariectomized and non-ovariectomized animals. Histological and histomorphometric analysis of the kidney revealed significant changes in the glomerular area on alendronate treated animals at 4 weeks when compared with ovx, ovx-sham and control non-ovariectomized animals. The results indicate chronic use of alendronate for osteoporosis may impair renal function or increase renal related problems in patients with existing kidney disease.

Impaired blood pressure recovery to hemorrhage in obese Zucker rats with orthopedic trauma

We have shown that obese Zucker rats with orthopedic trauma (OZT) exhibit a loss of arteriolar tone in skeletal muscle. We hypothesize that the loss of arteriolar tone in OZT blunts vasoconstrictor responses to hemorrhage, resulting in an impaired blood pressure recovery. Orthopedic trauma was induced with soft tissue injury and local injection of bone components in both hindlimbs in lean (LZT) and OZT (11-13 wk). One day after the orthopedic trauma, blood pressure responses following hemorrhage were measured in conscious control lean, control obese, LZT, and OZT. In another set of experiments, the spinotrapezius muscle of control and trauma animals was prepared for microcirculatory observation. Arteriolar responses to phenylephrine (PE) or hemorrhage were determined. Hemorrhage resulted in similar blood pressure responses in control animals and LZT, but the blood pressure recovery following hemorrhage was blunted in the OZT. In the spinotrapezius, OZT exhibited decreased arteriolar tone and blunted vasoconstrictor responses to PE and hemorrhage. Treatment with glibenclamide improved the blood pressure recovery in the conscious OZT and improved the arteriolar tone, and PE induced vasoconstriction in the spinotrapezius of the OZT. Thus, ATP-dependent K(+) channel-mediated loss of arteriolar tone in OZT blunts the arteriolar constriction to hemorrhage, resulting in impaired blood pressure recovery.

Orthopedic trauma-induced pulmonary injury in the obese Zucker rat

OBJECTIVE

Obese subjects with orthopedic trauma exhibit increased inflammation and an increased risk of pulmonary edema. Prostaglandin E(2) (PGE(2) ) production is elevated during inflammation and associated with increased vascular permeability. We hypothesize that pulmonary edema in obesity following orthopedic trauma is due to elevated PGE(2) and resultant increases in pulmonary permeability.

METHODS

Orthopedic trauma was induced in both hindlimbs in lean (LZ) and obese Zucker rats (OZ). On the following day, plasma interleukin-6 (IL-6) and PGE(2) levels, pulmonary edema, and pulmonary gas exchange capability were compared between groups: LZ, OZ, LZ with trauma (LZT), and OZ with trauma (OZT). Vascular permeability in isolated lungs was measured in LZ and OZ before and after application of PGE(2) .

RESULTS

As compared with the other groups, the OZT exhibited elevated plasma IL-6 and PGE(2) levels, increased lung wet/dry weight ratio and bronchoalveolar protein concentration, and an impaired pulmonary gas exchange. Indomethacin treatment normalized plasma PGE(2) levels and pulmonary edema. Basal pulmonary permeability in isolated lungs was higher in OZ than LZ, with a further increase in permeability following treatment with PGE(2) .

CONCLUSIONS

These results suggest that pulmonary edema in OZ following orthopedic trauma is due to an elevated PGE(2) and resultant increases in pulmonary permeability.

Use of demineralized bone matrix protein in osteoporotic rats: a histological evaluation - biomed 2009

Osteoporosis is a disease characterized by structural deterioration of bone tissue, leading to fragile bone with an increased risk for fractures. Bone morphogenetic proteins (BMPs) are supplemental bone graft materials that have osteoconductive properties of serving as a scaffold for bone to grow on and osteoinductive capability of stimulating the patient's own stem cells and growth factors to grow new bone. Osteoblast cells in osteoporotic bone have the ability to produce BMPs and other factors needed for adequate bone formation when activated, demonstrating that there are factors that can serve as stimulus for fracture repair in osteoporosis. The objective of this study was to deliver a cascade of growth factors from demineralized bone (DBM), a rich composite of BMP-2, BMP-4, and BMP-7, to the fracture defect site in an effort to enhance osteoporotic fracture healing. 72 female ovariectomized (OVX) rats were divided into six treatment groups: intact control, OVX control, intact + drill defect (sham), OVX + drill defect (sham), intact + drill defect + DBM, and OVX + drill defect + DBM. Ovariectomy induced osteoporosis. DBM was delivered in a sustained manner via a novel local drug delivery device, tricalcium phosphate combined with lysine (TCPL). At 2 and 4 weeks post implantation, animals in each group were sacrificed, the femurs were retrieved and underwent histological analysis. Other surrounding and vital organs were also harvested and analyzed to study the systemic effects of DBM. The results suggest that DBM was effective in increasing osteocyte number en route to restoring periosteal and endosteal area in both intact and OVX animal populations.

Analysis of tobramycin release from beta tricalcium phosphate drug delivery system

The purpose of this pilot study was to determine the in-vitro release properties of tobramycin by tricalcium phosphate (TCP) delivery capsules. In addition, two different forms of TCP capsules, matrix and reservoir, were characterized. Three types of TCP ceramic capsules were constructed: six sham matrix capsules (Group A), six tobramycin loaded matrix capsules (Group B), and four hollow tobramycin loaded reservoir capsules (Group C). The capsules were submerged in PBS and 1 mL of elutant was collected, centrifuged, and analyzed via spectrometry for 14 days. In addition, elutant from selected capsules was bleached onto bacterial discs and placed on confluent Staphylococcus aureus agar plates to evaluate zones of inhibition. Their was a statistically significant difference in the concentration of tobramycin released between Group A versus Group B and Group C capsules and a statistically significant difference in the concentration of tobramycin released between Group B and Group C capsules over a 14 day period. Bacterial discs containing Group A elutant did not have a visible zone of inhibition, while both Groups B and C elutant discs had an appreciable zone of inhibition for the duration of the study. Group A sham capsules eluted no antibiotics implying that TCP by itself lacks antibacterial properties. Group B matrix and Group C reservoir capsules eluted sustained tobramycin concentrations that were bactericidal for the duration of the study. The data from this study demonstrates that the sustained release property of tobramycin loaded TCP matrix and reservoir capsules make them a suitable mode for local antibiotic delivery.

Suture plication, thermal shrinkage, and sclerosing agents: effects on rat patellar tendon length and biomechanical strength

BACKGROUND

Shortening or tightening of dense, collagenous tissues is often desirable in the treatment of laxity.

PURPOSE

To compare the effect of stress-protection suture, radiofrequency thermal shrinkage combined with stress-protection suture, and a 5% sodium morrhuate sclerosing injection on the length and biomechanical strength of the rat patellar tendon.

HYPOTHESIS

Sclerosing agents will increase tendon mechanical strength. Thermal shrinkage combined with stress-protection suture and stress-protection suture only will cause a short-term decrease in tendon strength. All 3 methods will produce equivalent shortening of the tendon.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-six female retired breeder rats were split into 4 groups, each receiving 1 of the 3 aforementioned treatments plus a control group that received a saline injection. After 4 weeks' survival, the length and biomechanical properties of the patellar tendons were measured and compared to the contralateral untreated tendon.

RESULTS

Rats treated with stress-protection suture had shorter tendons. Radiofrequency thermal shrinkage combined with stress-protection suture yielded tendons that were both shorter and stronger than were the untreated contralateral tendons. The sodium morrhuate-injected tendons were stronger whereas the saline-treated tendons were weaker than were their respective untreated contralateral tendons.

CONCLUSION

Surgical stress-protection suture without radiofrequency shrinkage is most effective at shortening the length of the rat patellar tendon, whereas radiofrequency thermal shrinkage combined with stress-protection suture as well as sodium morrhuate are effective at increasing the strength of rat patellar tendons.

CLINICAL RELEVANCE

Judicious use of thermal shrinkage in combination with stress protection may improve ligament strength and decrease laxity.