Prioritizing Patient Safety and Minimizing Waste: Institutional Review of Cases and a Proposed Process for Designing a Surgical Pathology Gross-Only Examination Policy

OBJECTIVES

Gross-only examination policies vary widely across pathology departments. Several studies-particularly a College of American Pathologists' Q-Probes study-have looked at the variations in gross-only policies, and even more studies have addressed the (in)appropriateness of certain specimen types for gross-only examination. Few, if any, studies have tackled the important task of how to revise and safely implement a new gross-only examination protocol, especially in collaboration with clinical colleagues.

METHODS

We reviewed the grossing protocols from three anatomic pathology centers to identify common gross-only specimen types. We compiled an inclusive list of any specimen types that appeared on one or more centers' lists. We performed a retrospective review of the gross and microscopic diagnoses for those specimen types to determine if any diagnoses of significance would have been missed had that specimen been processed as a gross-only.

RESULTS

We reviewed 940 cases among 13 specimen types. For 7 specimen types, the gross diagnoses provided equivalent information to the microscopic diagnoses. For 6 specimen types, microscopic diagnoses provided clinically meaningful information beyond what was captured in the gross diagnoses.

CONCLUSIONS

To improve the value of care provided, pathology departments should conduct internal reviews and consider transitioning specimen types to gross-only when safe.

Germline mutations of SMARCA4 in small cell carcinoma of the ovary, hypercalcemic type and in SMARCA4-deficient undifferentiated uterine sarcoma: Clinical features of a single family and comparison of large cohorts

OBJECTIVE

Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) and SMARCA4-deficient undifferentiated uterine sarcoma (SMARCA4-DUS) are rare and aggressive tumors, primarily affecting pre- and perimenopausal women. Inactivating SMARCA4 mutations are thought to be the driving molecular events in the majority of these tumors. Here, we report the clinical course of a family with germline SMARCA4 mutation and compare large cohorts of these rare tumor types.

METHODS

We extracted clinico-pathological medical record data for the family with germline SMARCA4 mutation. Clinico-genomic data from SCCOHT and SMARCA4-DUS cohorts were retrospectively extracted from the archives of a large CLIA-certified reference molecular laboratory.

RESULTS

We identified a single family with an inherited germline SMARCA4 mutation, in which two different family members developed either SCCOHT or SMARCA4-DUS, both of whom died within one year of diagnosis, despite aggressive surgical, chemotherapy and immunotherapy treatment. Retrospective comparative analysis of large SCCOHT (n = 48) and SMARCA4-DUS (n = 17) cohorts revealed that SCCOHT patients were younger (median age: 28.5 vs. 49.0) and more likely to have germline SMARCA4 alterations (37.5% vs. 11.8%) than SMARCA4-DUS patients.

CONCLUSIONS

Growing understanding of the role SMARCA4 plays in the pathogenesis of these rare cancers may inform recommended genetic testing and counseling in families with these tumor types.

MEK inhibition and phosphorylation of serine 4 on B23 are two coincident events in mitosis

Previous studies have shown that activation of the Raf/MEK/ERK pathway is necessary for G2/M transition. However, as for the activation state of MEK in mitosis the conclusion is not consistent. Here we show that MEK is inhibited in mitosis. In addition, we identify a multifunctional protein named B23 that strongly cross-reacts with a phospho-MEK antibody in mitotic cells. Sequence homology between the N-terminus surrounding Ser 4 of B23 and the Raf phosphorylation site on MEK suggests a mechanism for cross-reaction of the antibody. Thus, mutation of Ser 4 to alanine abolishes cross-reactivity between B23 and the phospho-MEK antibody. Our findings may explain the discrepancy of results obtained with the use of phospho-MEK antibody regarding the activation state of MEK in mitosis.

Interaction between active Pak1 and Raf-1 is necessary for phosphorylation and activation of Raf-1

Activation of Raf-1 is a complex process in which phosphorylation of Ser(338)-Tyr(341) is a critical step. Previous studies have shown that Pak1/2 is implicated in both Ras-dependent and -independent activation of Raf-1 by phosphorylating Raf Ser(338). The present study explores the structural basis of Raf-1 phosphorylation by Pak1. We found that Pak directly associates with Raf-1 under both physiological and overexpressed conditions. The association is greatly stimulated by 4beta-12-O-tetradecanoylphorbol-13-acetate and nocodazole and by expression of the active mutants of Rac and Ras. The active forms of Pak generated by mutation of Thr(423) to Glu or truncation of the amino-terminal moiety exhibit a greater binding to Raf than the wild type, whereas the kinase-dead mutant Pak barely binds Raf. The extent of binding to Raf-1 is correlated with the ability of Pak to phosphorylate Raf and induce mitogen-activated protein kinase activation. Furthermore, the Raf-1 binding site is defined to the carboxyl terminus of the Pak catalytic domain. In addition, our results suggest that the amino-terminal regulatory region of Raf inhibits the interaction. Taken together, the results indicate that the interaction depends on the active conformations of Pak and Raf. They also argue that Pak1 is a physiological candidate for phosphorylation of Raf Ser(338) during the course of Raf activation.

Raf-1/MEK/MAPK pathway is necessary for the G2/M transition induced by nocodazole

The dynamic balance between polymerization and depolymerization of microtubules is critical for cells to enter and exit mitosis, and drugs that disrupt this balance, such as taxol, colchicine, and nocodazole, arrest the cell cycle in mitosis. Although the Raf/MEK/MAPK pathway can be activated by these drugs, its role in mitosis has not been addressed. Here, we characterize activation of Raf/MEK/MAPK by nocodazole when mitosis is induced. We find that at early time points (up to 3 h) in nocodazole induction, Raf/MEK/MAPK is activated, and inhibition of MAPK activation by a MEK inhibitor, PD98059 or U0126, reduces the number of cells entering mitosis by creating a block at G(2). At later time points and in mitosis, activation of MEK/MAPK is severely inhibited, even though Raf-1 activity remains high and can be further increased by growth factor. This inhibition is reversed when cells are released from metaphase and enter G(0)/G(1) phase. In addition, we find that binding of Raf-1 to 14-3-3 is progressively induced by nocodazole, reaching a maximum in mitosis, and that this binding is necessary to maintain mitotic Raf-1 activity. Our present study indicates that activation of the Raf/MEK/MAPK pathway is necessary for the G(2)/M progression.

Substantial superiority of semiflexed (MTP) views in knee osteoarthritis: a comparative radiographic study, without fluoroscopy, of standing extended, semiflexed (MTP), and schuss views

OBJECTIVE

To improve the radiographic assessment of cartilage loss, as measured by joint space width (JSW) in patients with osteoarthritis (OA) of the knees required to detect the effect of structure modifying drugs in OA trials. This was achieved by determining which of 3 nonfluoroscopic radiographic views--standing extended, semiflexed, and schuss--produced the most accurate radioanatomic positioning of the joint and greater reproducibility in joint repositioning and JSW measurement.

METHODS

Knees from 74 patients with OA of the knees who had medial tibiofemoral compartment JSW > or =2 mm in all views were studied. For all 3 radiographic views, accuracy in the radioanatomic positioning of the knee was determined for both joint rotation and flexion. Reproducibility in joint repositioning and JSW measurement were determined from the difference between repeat examinations taken within 2 h.

RESULTS

About 86% of knees in the 3 views had accurate rotational position of the joint at each visit. Radioanatomically, knees in the semiflexed view were significantly more accurately positioned in regard to knee flexion (p<0.0005) than in the schuss view, which in turn was better (p<0.014) than in the extended knee view. Joint repositioning was significantly more reproducible in the semiflexed (p<0.0001) than in the extended knee, which was better (p<0.013) than in the schuss position. JSW measurement was significantly more reproducible in the semiflexed (p<0.014) than both schuss and extended knee positions, which were not significantly different from each other.

CONCLUSION

Protocols defining the nonfluoroscopic radiographic procedures for the semiflexed view provide the most accurate radioanatomic joint positioning, and the most reproducible joint repositioning and JSW measurement. Using this method significantly fewer knees would be required to detect significant JSW changes in a structure modifying drug trial compared to the schuss and the extended knee positions.

Replicated factor structure of the Beck Depression Inventory

The factor structure of the Beck Depression Inventory (BDI) was examined in an initial sample of 407 patients and replicated in a sample of 370 patients, using principal components analysis and varimax rotation. The entire sample was 98% male, with ages ranging from 22 to 88 years. The incidence of alcoholism was 72%, and the incidence of major mental illnesses was 17%. The stable dominant first factor (cognitive) accounted for 67 to 81% of the common variance, with a correlation of .94 between the factor loadings in the initial and replication analyses. The unstable second factor (vegetative) accounted for 15% to 19% of the common variance, with a correlation of .58 in item loadings. Consequently, the BDI appears to measure the cognitive aspects of depressive severity in a global fashion, as Beck originally intended. Approximately half of the items contribute very little useful predictive information. The fact that BDI total scores are not strongly related to the traditional vegetative symptoms of depression used in psychiatry is an artifact of the original method used to construct the test and is not a statement about the fundamental characteristics of depression.

A focus of Lyme disease in Monmouth County, New Jersey

An endemic focus of Lyme disease is present in Colt's Neck, Howell, Freehold, and Wall Townships in Monmouth County, New Jersey. Cases of Lyme disease have occurred in this area from 1978 to 1982. Fifty-seven of the 117 persons (49%) who acquired their infection in New Jersey from 1978 to 1982 live or work in these four townships, whose population of 82,491 is only 1.1% of the population of the entire state. Thirty persons who contracted Lyme disease were exposed to ticks at the Naval Weapons Station, Earle, which is located within Colt's Neck and Howell Townships. The annual incidence rate for persons stationed at or working on this military facility in 1981 and 1982 was about 1%. At Naval Weapons Station, Earle, persons working outdoors in 1981-1982 were at higher risk than those working indoors.

Clinical manifestations and descriptive epidemiology of Lyme disease in New Jersey, 1978 to 1982

Clinical manifestations and epidemiologic characteristics of 117 cases (31 children and 86 adults) of Lyme disease in New Jersey from 1978 to 1982 are summarized. The male-female sex ratio was 1.9:1. An endemic focus in Monmouth County has been recognized. Erythema chronicum migrans was present in 93% of cases and was the only clinical manifestation in 25% of patients. Nonspecific febrile syndrome, in addition to erythema chronicum migrans, was present in 45% of cases; 26% had arthritis. The proportion of cases with arthritis in 1982 (7/56) was less than for 1978 to 1981 (24/61) probably because of better recognition of milder cases by physicians and earlier antibiotic treatment, which may have reduced late complications. Meningitis (10%) and cranial nerve palsies (8%) were the most frequent neurological manifestations. As medical personnel and the public become more aware of the disease, Lyme disease is being recognized with increased frequency in central and southern New Jersey.