Interpretation Of Smears Research Articles

A Pilot Study of Image-associative Teaching Versus Traditional Didactic Teaching for Novice Endosonographers Learning Cytopathology Effectively

Background and AimsInsufficient cytology staff limited the spread of rapid onsite cytology evaluation (ROSE). Therefore, trained endosonographers performing ROSE became an option. To explore the effect of visualization aids for memory in cytology learning, we assessed the impact of image-associative teaching vs traditional didactic teaching of cytopathology for novice endosonographers in a limited time. MethodsEndoscopic ultrasound trainees without previous training in cytopathology were invited to participate in this study. Participants in Period 1 attended traditional didactic learning, and trainees in Period 2 received images-associative teaching. The images in the Period 2 tutorial were cytopathology images combined with their simulation images, whereas in Period 1, cytopathologic images were described in pathological terminology only. After the theoretical study, trainees received a knowledge quiz and an assessment for real smear interpretation. ResultsSeventeen trainees attended traditional didactic learning, whereas the other 8 participated in image-associative learning. In the theory test, the overall correct rate of trainees in Period 2 was higher than that of the trainees in Period 1 (76.92% vs 53.85%). In the evaluation of real smear reviews, the performance of trainees in Period 2 was still better than that of the trainees in Period 1 (the median correct rate 100% vs 75%). ConclusionThe use of image-associative tutorials allows for more efficient use of time and is thus feasible for the study of ROSE.

Impact of Human Papillomavirus Status on the Interpretation of Cervical Papanicolaou Smears

Impact of Human Papillomavirus Status on the Interpretation of Cervical Papanicolaou Smears

Teaching Hematology to Fellows: A Qualitative Study

BACKGROUNDThe Accreditation Council for Graduate Medical Education (ACGME) specifies that ≥18 months of hematology/oncology fellowship training must be dedicated to clinical work evenly divided between hematology and medical oncology, incorporating inpatient and outpatient care, multidisciplinary case conferences, tumor board discussions, and scholarship. Learning styles among fellows necessarily differ from those of medical students or residents, but few studies have examined the impact of such differences on the content and caliber of fellows' educational experiences during training. We performed a qualitative study of senior fellows in an ACGME-accredited hematology/oncology fellowship program to explore their perception of hematology training and elucidate how fellows might best learn hematology. METHODSSenior fellows in the hematology/oncology fellowship program at Yale School of Medicine were invited to participate in this study. Semi-structured interviews were conducted utilizing a standardized set of questions addressing clinical experiences, educational conferences, hematopathology, changes in adult learning styles from medical school through fellowship training, and design and optimization of an ideal curriculum for teaching and mastering hematology. Interviews were recorded, transcribed, and analyzed using the framework method. RESULTSEight 3rd year fellows were enrolled in this study. Four were women; three held dual M.D. and Ph.D. degrees. All were planning on a career in academic medicine; most were doing basic science research with a focus in medical oncology, while one was focused on benign hematology. All fellows completed 6 months of dedicated hematology training that included rotations on inpatient malignant hematology, consultative hematology, laboratory medicine, and hematopathology services. Several common themes emerged from the interviews. Hands-on clinical experience and self-directed learning were identified as central components of effective learning during fellowship. All fellows identified a progression in learning styles from medical school through residency and fellowship. Medical students were viewed as benefiting from didactics and structured educational experiences for foundation-building, while fellows tended to center their learning around patient care experiences and literature reviews and viewed didactics as most effective when occurring after encounters with real cases. Excessive patient volumes and clinical demands were prohibitive to fellows' learning. All fellows viewed mandatory presentations and other fellow-as-teacher opportunities as particularly effective venues for cementing knowledge. Perceptions of weekly tumor board conferences varied according to individual interest and whether fellows had acquired a sufficient knowledge base to follow the conference discussions. A clear distinction was made between benign hematology and all other subsets of the fellowship curriculum, with benign hematology being viewed as more “intellectually difficult,” “complicated,” and “overwhelming” than malignant hematology or medical oncology. All fellows viewed the hematology consult service as the best setting for learning hematopathology, particularly blood smear interpretation due to its incorporation into the clinical decision-making process. DISCUSSIONHematology/Oncology fellows are cognizant of being adult learners who thrive when their education is context-based. Optimal fellowship learning involves devoting the majority of time to direct patient care and centering didactics, conferences, and hematopathology around such patient care experiences. Mandatory presentations and fellow-as-teacher experiences are particularly effective tools for knowledge mastery. Teaching in benign hematology may require more oversight due to the complexity of the material. DisclosuresPodoltsev:CTI biopharma/Baxalta: Consultancy; Alexion: Consultancy; Incyte: Consultancy; Ariad: Consultancy.

Blood Storage Conditions Affect Hematological Analysis in Samples From Healthy Donkeys and Donkeys With Experimentally-Induced Endotoxemia.

Preanalytical factors such as storage time and temperature are proved to induce marked artifactual changes in hematological parameters in horses, small animals and humans. These errors can mirror findings typical of endotoxemia, leading to dangerous misdiagnosis. Since donkeys are common in warm climates and remote regions, blood samples from this species can be subjected to long lasting travels from the farm to the nearest laboratory, frequently under suboptimal conditions. Moreover, as other equids, donkeys are prone to suffer endotoxemia. Nonetheless, stability has not been evaluated in samples for hematology in this species. The aim of this study was to characterize the effect of temperature and storage time in hematological parameters from healthy donkeys and donkeys with induced endotoxemia. Blood samples were collected from six healthy female Andalusian donkeys and stored for 6, 12, 24, and 48 h at several temperatures (4, 24, and 35°C). Endotoxemia was induced in the same animals by an intravenous LPS infusion and samples obtained 30 min post-infusion were handled similarly. Hematological analysis was performed using a laser-based analyzer and blood smear examination. Storage at 24°C caused significant neutropenia after 48 h as well as morphological changes typical of endotoxemia in blood from healthy donkeys as soon as 24 h post-storage. Samples kept at 35°C displayed more profound and earlier artifactual variations. Conservation at 4°C did not cause any significant change in blood parameters. Prolonged (48 h) storage of samples from animals with induced endotoxemia at 24 and 35°C accentuated pre-existing leukopenia and neutropenia. These findings highlight that donkey samples should be stored at 4°C, instead of 24°C as recommended for horses. Moreover, blood smear interpretation should be cautious in samples stored for longer than 24 h and could be misleading when blood is kept at 35°C.

P16/Ki-67 Immunostaining in the Triage of Postmenopausal Women With Low-Grade Cytology Results.

The interpretation of postmenopausal smears and the gynecological treatment of these patients can often be difficult. The objective of this study was to assess the performance of p16/Ki-67 dual-stained cytology as a triage of atypical squamous cells of undetermined significance and low-grade intraepithelial lesion cytology results in postmenopausal women. All consecutive atypical squamous cells of undetermined significance and low-grade intraepithelial lesion smears in 1-year period were collected and p16/Ki-67 immunostaining was performed retrospectively. The results were compared with histology results or long-term cytology follow-up in cases with no biopsy. The sensitivity of p16/Ki-67 immunostaining for the detection of cervical intraepithelial neoplasia (CIN) 2 and CIN 3 was 57.1% and 85.0%, respectively. The specificity for the detection of CIN 2 was 94.3% and CIN 3 92.4%. Negative predictive values for the detection of CIN 2 and CIN 3 were 96.3% and 99.6%, respectively. Dual p16/Ki-67 immunostaining is a useful additional method in postmenopausal patients with low-grade cytology. Considering the high specificity and negative predictive value in our study, we believe that it could be helpful in avoiding unnecessary referrals to colposcopy and thus reduce the cost of the program.

A Hematologist-Level Deep Learning Algorithm (BMSNet) for Assessing the Morphologies of Single Nuclear Balls in Bone Marrow Smears: Algorithm Development.

BackgroundBone marrow aspiration and biopsy remain the gold standard for the diagnosis of hematological diseases despite the development of flow cytometry (FCM) and molecular and gene analyses. However, the interpretation of the results is laborious and operator dependent. Furthermore, the obtained results exhibit inter- and intravariations among specialists. Therefore, it is important to develop a more objective and automated analysis system. Several deep learning models have been developed and applied in medical image analysis but not in the field of hematological histology, especially for bone marrow smear applications.ObjectiveThe aim of this study was to develop a deep learning model (BMSNet) for assisting hematologists in the interpretation of bone marrow smears for faster diagnosis and disease monitoring.MethodsFrom January 1, 2016, to December 31, 2018, 122 bone marrow smears were photographed and divided into a development cohort (N=42), a validation cohort (N=70), and a competition cohort (N=10). The development cohort included 17,319 annotated cells from 291 high-resolution photos. In total, 20 photos were taken for each patient in the validation cohort and the competition cohort. This study included eight annotation categories: erythroid, blasts, myeloid, lymphoid, plasma cells, monocyte, megakaryocyte, and unable to identify. BMSNet is a convolutional neural network with the YOLO v3 architecture, which detects and classifies single cells in a single model. Six visiting staff members participated in a human-machine competition, and the results from the FCM were regarded as the ground truth.ResultsIn the development cohort, according to 6-fold cross-validation, the average precision of the bounding box prediction without consideration of the classification is 67.4%. After removing the bounding box prediction error, the precision and recall of BMSNet were similar to those of the hematologists in most categories. In detecting more than 5% of blasts in the validation cohort, the area under the curve (AUC) of BMSNet (0.948) was higher than the AUC of the hematologists (0.929) but lower than the AUC of the pathologists (0.985). In detecting more than 20% of blasts, the AUCs of the hematologists (0.981) and pathologists (0.980) were similar and were higher than the AUC of BMSNet (0.942). Further analysis showed that the performance difference could be attributed to the myelodysplastic syndrome cases. In the competition cohort, the mean value of the correlations between BMSNet and FCM was 0.960, and the mean values of the correlations between the visiting staff and FCM ranged between 0.952 and 0.990.ConclusionsOur deep learning model can assist hematologists in interpreting bone marrow smears by facilitating and accelerating the detection of hematopoietic cells. However, a detailed morphological interpretation still requires trained hematologists.

Quantification of Schistocytes from the Peripheral Blood Smear in Thrombotic Thrombocytopenic Purpura (TTP) Compared to Non-TTP Thrombocytopenic Hospitalized Patients

IntroductionThe diagnosis of TTP requires thrombocytopenia without an underlying cause and microangiopathic hemolytic anemia (MAHA)1. TTP is usually confirmed with a low ADAMTS level. However, the turnaround time for an ADAMTS level is several days and treatment for this rare disease cannot be delayed, since it is uniformly fatal if left untreated but highly responsive to plasma exchange therapy. A rapid diagnosis is required and still must be made on clinical findings and peripheral smear morphology. The degree of MAHA that is seen with TTP, though, has not been well defined, or correlated with ADAMTS results. Automated fragmented red cell analyzers are not yet widely available or accepted, so the determination of MAHA still relies on manual smear reviews. Presenting smears from pts with TTP over a 1 ½ year period were reviewed, with manual counting of schistocytes, and were compared to smears from in-patient non-TTP cases of thrombocytopenia where hematology was consulted to rule out TTP.Methods29 cases were identified and peripheral smears from date of presentation were reviewed, initially by a hematologist and experienced special hematology technician, then by 2 medicine residents after they were given a 1 hour tutorial on smear interpretation. All smear reviewers were instructed on schistocyte identification as defined by the International Council for Standardization in Hematology (ICSH)2. The number of schistocytes per 1000 red cells was counted at 1000 power magnification. The blood smears were coded/de-identified and then read “blindly” by the 4 observers. Degree of agreement between the 1st 2 observers was measured (using Pearson correlation coefficient), as was the their average as compared to the average #schistocytes counted between the 2 med residents. Time taken to review smears was also measured.ResultsAve age 54 (19-83); 59% female, 41% male; 62% Caucasian; 35% AA; 3% Hispanic. 9 had TTP and 20 did not. All cases of TTP had a low ADAMTS level (med <3%, range <3-13%) and all but one had a +inhibitor (one had congenital TTP, confirmed by ADAMTS mutation analysis). The non-TTP cases included sepsis (8/20), DIC (3/20), metastatic cancer (2/20), scleroderma crisis (2/20) and single cases of HIT, EtOH, gestational, MPN/MDS and unknown causes for thrombocytopenia. For TTP cases: med plt count was 22k (4-52k); LDH 760 (309-1175); hgb 9.4 (7.1-10.9); creat 1.59mg/dL (0.6-4.85). For non-TTP cases: med plt count was 44k (3-126k); LDH 300 (155-1111); hgb 8.1 (5.9-14.7); creat 1.36mg/dL (0.9-9.1). 3 non-TTP pts had ADAMTS levels sent (med= 69%, 57-100%).The med #schistocytes in TTP cases was 6% (ave 6.3, 1.85-11.95%) compared to 0.625% (ave 1.52%, 0.25-7.5%) in the non-TTP group (p= 0.00002). The R-coefficient for the 1st 2 observers was 0.93 (95% CI 0.85-0.96) and for their average compared to the 2 medicine residents it was 0.82. The average time to read smears overall was 10.5 minutes.Conclusions:This retrospective study showed that manual quantification of schistocytes is feasible, may be done in a timely fashion and with excellent interobserver reproducibility. All pts had some degree of MAHA but the TTP cases, not surprisingly, had a significantly higher percentage of schistocytes/1000 RBCs than non-TTP thrombocytopenic in-pt consult cases (6% vs 0.625%, respectively, p= 0.00002). All cases of low ADAMTS, positive inhibitor confirmed TTP had >2.5% schistocytes, compared to 4/20 non-TTP cases. A larger cohort of acquired TTP should be studied to determine if there is a cut-off % schistocytes which, in the appropriate clinical setting, should warrant urgent plasma exchange while waiting for ADAMTS levels to return.1George JN and Al-Noun ZL. Diagnostic and therapeutic challenges in the TTP and HUS syndromes. ASH Education Book. 2012, p. 604-609.2Zini G et al. ICSH recommendations for identification, diagnostic value, and quantitation of schistocytes. International J of Lab Hematology. 2011; 34: 107-116. DisclosuresNo relevant conflicts of interest to declare.

A Comparative Study of Thyroid Cytology Reporting by Bethesda System and Routine Cytology in a Teaching Institute of Sub Himalayan Region

Introduction: Fine needle aspiration cytology (FNAC) is an important preoperative diagnostic tool for thyroid lesions which are endemic in the Sub-Himalayan belt. But sometimes, the FNAC procedures are unable to guide clinicians for definite management. Bethesda System for Reporting Thyroid Cytology (BSRTC) has been formulated to be more sensitive and specific than routine cytological examination in diagnosis of thyroid swellings and act a better tool than the latter due to its objectivity. It may, thus, improve the clinical management of thyroid diseases and even may prevent unnecessary thyroidectomy. Aims and Objective: The study is aimed to compare the interpretation of thyroid FNAC smears by conventional reporting and by BSRTC in patients of thyroid swellings in the Sub-Himalayan regions. Material and Methods: This observational study was done at the Department of Pathology from July 2015 to June 2016. Total 145 cases of thyroid swellings were included for study and reported by both BSRTC and conventional (routine) reporting system. Each of the reporting system was correlated with the available histopathological findings and statistical assessments were performed. Results: Among the total 145 cases, colloid nodules followed by thyroiditis were most common benign conditions in both the reporting systems and among the malignancies; papillary carcinoma was the most predominant. Statistical assessment showed that sensitivity, specificity as well as positive and negative predictive values was higher in BSRTC compared to the conventional reporting system. Conclusion: BSRTC is more accurate than conventional reporting system for thyroid cytology and its management strategy can help to prevent unnecessary thyroidectomy.

Diagnostic Accuracy and Pitfalls in Fine Needle Aspiration Cytology Of Salivary Gland Lesions.

BACKGROUND : Fine Needle Aspiration cytology (FNAC) is an essential diagnostic method used to evaluate salivary gland lesions. However, at times, diverse morphological patterns and overlapping features between benign and malignant lesions becomes challenging and difficult to give a definitive diagnosis. Aim are to compare the findings of preoperative FNAC with their histopathological types and to discuss the causes for discordancy and identify the potential pitfalls in cytological diagnosis. METHODS: An observational analytical study was carried out over a 4 year period to review the cases of patients with salivary gland lesions who underwent FNAC in a medical college, hospital. Taking histopathological diagnosis as gold standard, the cytological diagnosis of the cases was compared and the causes of discrepancies were evaluated. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value was calculated. RESULTS: In the present study, out of 137 cases, cyto- histological correlation was available in 46 cases. Pleomorphic adenoma was the commonest lesion in the study. The diagnostic value of FNAC was: Sensitivity 66.7%, Specificity 97.4%, Positive Predictive Value 80%, Negative Predictive Value 95% and Diagnostic Accuracy 93.3%. False positive diagnosis was rendered in warthin’s tumor whereas false negative diagnosis was given in mucoepidermoid carcinoma. CONCLUSION: FNAC is useful in the preoperative diagnosis of salivary gland lesions. Pitfalls in cytologic diagnosis were due to errors in sampling, cystic lesions and interpretation of smears . DOI: 10.21276/APALM.1284

Peripheral Smear Review and Bone Marrow Biopsy Correlation.

Peripheral Blood Smear (PBS) interpretation is a useful skill for Haematology/Oncology Clinicians (HOC). To explore practice patterns of PBS utilization for all benign haematology diagnosis in a non-simulated environment and to evaluate how it may guide the HOC in determining further work up and whether or not to perform a Bone Marrow Biopsy (BMB). A retrospective review was conducted on 451 outpatient referrals for benign haematology diagnosis. Patient demographics and diagnostic tests were recorded. We further analysed cases in which a blood smear was ordered or reviewed. In cases with PBS review, we recorded testing ordered by the HOC. Records of 451 patients met inclusion criteria. The median age was 55 with males representing 51.9% of the cohort. Distribution of disorders were 50.6% (n = 228) erythrocyte (RBC), 25.5% (n = 114) leukocyte (WBC), 11.3% (n = 51) platelet (PLT), and 12.8% (n = 58) "other." A CBC was ordered in 82.7% of cases (373/451). A PBS was ordered in 47.4% of CBCs obtained (177/373, p<0.001). Of these, documentation occurred in 49.2% (87/177) which led to further testing 41.4% of cases (36/87). A BMB was performed in 11.5% (10/87) of cases in which a PBS was reviewed compared to 4.3% (16/373) of cases where BMB was performed without PBS review (p=.019). Of the 36 cases in which PBS review led to testing, 10 BMBs (27.8%) were performed-all of which led to specific haematologic diagnosis. A specific diagnosis was found in 43.8% (7/16) BMBs performed without prior PBS review. PBS interpretation is an important skill for HOCs. Haematology/Oncology (H/O) training programs should continue to teach this skill to increase proficiency in order to help guide diagnostic evaluation of various haematologic disorders.

An analysis of thyroid cytology reporting in three peripheral hospitals in Sri Lanka

Thyroid cytology is a widely used, cost effective outpatient procedure, which can be easily utilized in resource limited peripheral hospitals, available for preoperative assessment of thyroid nodules. We conducted the following study to analyze thyroid cytology reporting in three peripheral hospitals in Sri Lanka to assess their diagnostic utility, identify the associated problems and make recommendations for further improvement. This was a retrospective study performed on 300 thyroid cytology cases with a histological diagnosis. Thyroid cytology was reported according to BTA/RCP guidelines. Of the cytology diagnosis categories 72.7% were Thy 2, 22.3% were Thy 3, 4.7% were Thy 4 and 0.3% were Thy 5 lesions. Malignancy detection rate for each category were 2.3% for Thy 1, 13.4% for Thy 2, 64.3% for Thy 3 and 100% for Thy 4. The test had a 66.7% sensitivity, 97.7% specificity, 66.8% positive predictive value and 97.7% negative predictive value in diagnosing a malignancy. These parameters are comparable with the published parameters. However, the sensitivity of the test in the three hospitals showed significant variability. Concerted use of clinical and ultrasound findings in the interpretation of smears and multidisciplinary team meetings to discuss equivocal cases can be used to improve the diagnostic utility of thyroid cytology in these hospitals. Furthermore, performance of regular internal audits for each institution to identify problems is important since the study has shown variations in diagnostic parameters in different hospitals.

Introducing a new scoring system for pap smear in the detection of high-grade squamous intraepithelial lesions in pregnancy (The Luebeck Score).

To construct a scoring system for pap smears to objectify cytological appraisal and to enhance the accuracy and comparability of pap smear interpretation in pregnancy. For development of a scoring system for cell appraisal of pap smears the style of the Modified Masood's Scoring Index for appraisal of cells from fine needle aspirations of breast lesions was used. Cohort analysis of n=54 dysplastic pap smears for polymorphology of cells, anisonucleosis, structure of the nucleus, signs of tissue destruction, nucleus/plasma relation and signs of tumordiathesis. Each criteria was classified into three stages: The first with little evidence for dysplasia (one point), second stage with sporadic evidence (two points) or third stage with frequent evidence (three points). To further evaluate if pregnancy associated cells changes interfere with this scoring system we compared the results of pregnant and non-pregnant women. Histological result was used as an indicator of correctness of the score. Statistical analysis showed a good correlation of the scoring system with histological results. Especially in pregnancy statistical analysis shows promising results (sensitivity 86.67%, Specificity 100%, receiver operating characteristic analysis p≤0.05). The Luebeck Score seems to be a useful approach for appraisal of pap smears in pregnancy. Further studies containing high numbers of cases are needed for further evaluation of potential benefits of the scoring system compared to conventional evaluation of pap smears.

Concordance in the Interpretation of Cervical Cytology for the Early Diagnosis of Cervical Cancer

Objective: To identify the diagnostic concordance in the interpretation of cervical smears. Material and Methods: Cross-sectional study from October 2011 to January 2013. 50 samples were read by every 4 cyto-technologists who are the total staffs that read and interpret cytological specimens from a public health institution of the city of San Luis Potosi, Mexico. The cytological diagnosis was confirmed by a certified pathologist. Checklist was developed to determine the quality of the interpretation composed of three sections: adequate sample, inadequate sample and cytological diagnosis. The diagnostic report was made by Bethesda System 2001 classification. Diagnostic concordance was measured through the Kappa coefficient. To establish the differences in cytological diagnosis between each cyto-technologist, chi square test was applied. Results: The concordance is acceptable in the classification of samples as inadequate (k = 0.66). The negative diagnosis was a significant concordance between each cytotechnologist and pathologist; however, no case had very good concordance. In the epithelial abnormalities, only the cytotechnologist 2 had significant concordance with the pathologist, however, its concordance is low. In the case of glandular abnormalities, only cytotechnologist 1 had no significant concordance with the pathologist. The percentage of true negatives was 30%, true positives 20%, false negatives 50% and false positives 0 %. There are significant differences between the readings of cyto-technologist 1 and 2 (p < 0.008), between 1 to 4 (p < 0.001), between 2 and 3 (p < 0.05), and finally between 3 and 4 (p < 0.003). Conclusions: The concordance between cyto-technologists and pathologists is below the required minimum level set by national and international standards.

La mucificación superficial de la vagina humana

Se demuestra la existencia de una mucificación superficial en el epitelio de la vagina. Esta mucificación es, por lo tanto, paralela a la que se observa en algunos animales de experimentación. Esta mucificación superficial motiva que las células descamadas en la vagina sean principalmente células conteniendo mucina, sobre todo en la segunda mitad del intermenstruo. El polisacárido de las células superficiales de la vagina, demostrable tanto en los cortes como en los extendidos, no es por lo tanto, como se creía, el glucógeno, sino esta otra sustancia. El glucógeno existe en la vagina, pero se deposita en células más profundas, por lo que no es de esperar que frotis de alto nivel cariopicnótico, contengan cantidades elevadas de glucógeno; antes al contrario es cuando el nivel de estrógenos comienza a descender, cuando el contenido glucogénico del descamado es mayor. La importancia de estos hallazgos en la fisiopatología y en la interpretación de los frotis, debe ser subrayada.

Use of BRAF v600e immunocytochemistry on FNA direct smears of papillary thyroid carcinoma.

Mutations of v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) are identified in almost half of all papillary thyroid carcinomas (PTCs). These mutations are specific for PTC and may confer a worse prognosis. An immunohistochemical (IHC) stain for BRAF is commercially available and has been validated in surgical specimens. Fine-needle aspiration (FNA) is frequently used as a diagnostic tool for risk stratification of thyroid nodules. Therefore, the authors evaluated the performance of immunostaining with the anti-BRAF antibody VE1 on FNA direct smears. The authors identified 51 FNA specimens that had subsequent surgical resection specimens with a diagnosis of PTC. BRAF VE1 IHC was performed on the surgical specimens to determine their mutation status. The corresponding direct smears were then stained using the same VE1 stain to assess correlation. Twenty-two of the 46 included surgical specimens were positive for BRAF mutations (47.8%) by IHC, consistent with the published rates. The paired cytologic smears from these cases revealed 65.3% concordance. The overall sensitivity of BRAF staining on cytologic smears was 63.6%, and the specificity was 58.3%. Concordance rates were highest in specimens that were diagnosed as malignant or suspicious for malignancy (75% and 85.7%, respectively). The negative predictive value increased to 77.8% when suspicious for follicular neoplasm/suspicious cases were combined. Specimens that were malignant or suspicious on FNA were most likely to be BRAF concordant. Limitations to the interpretation of smears included low cellularity and obscuring blood, macrophages, or colloid. With further refinement, it is possible that BRAF immunocytochemistry can be applied prospectively to thyroid FNAs for risk stratification and to reduce false-negative rates.

Correlation of peripheral blood smear review and bone marrow biopsies for benign hematology Outpatient referrals.

e17668 Background: Peripheral blood smear (PBS) interpretation is an important diagnostic skill for Hem/Onc clinicians (HOC). We explored practice patterns of PBS utilization and how it may guide t...

Efficacy of a real time optoelectronic device (TruScreen™) in detecting cervical intraepithelial pathologies: a prospective observational study.

To assess the effect of TruScreen™ (an objective optoelectronic cervical screening device) in improving the sensitivity of cervical screening programs either alone or in combination with Papanicolaou (PAP) smear or human papilloma virus (HPV) DNA screening. Our study was performed in 285 patients with abnormal Pap test results. TruScreen™ and HPV screening methods were performed in all participants. Consistency and differences between the tests were compared with cervical biopsy results. TruScreen™ was found to be an approach method in the determination of cervical pathologies (ROC curve area underlined=0.606) and with an 89.5% negative predictive value. HPV screening remains a counterpart to TruScreen™ with a 0.620 area underlined in the ROC curve and an 83% negative predictive value. As determined in our study, TruScreen™ with a sensitivity of 86.1% can be used as a screening test with instant and not professional dependent results for cervical cancer screening. Avoiding from subjectivity in interpretation of Pap smears and requirement for pathologists, TruScreen™ can be a used for cervical cancer screening especially in countries with a low socio-economic status. The combination of TruScreen™ and HPV screening was not able to demonstrate a significant rise of effectiveness in screening.

Peripheral Blood Smear Utilization within a Military Hematology/Oncology Fellowship Program

Background: The practice of peripheral blood smear (PBS) interpretation is considered an important diagnostic skill in Hematology/Oncology (HO). The Accreditation Council of Graduate Medical Education (ACGME) requires trainees to become proficient in the preparation and interpretation of blood smears. We explored practice patterns of PBS utilization in a tertiary care, military medical center HO fellowship program.Methods: A retrospective chart review was conducted on 350 consecutive outpatient referrals for benign hematology diagnoses (ICD-9 codes 280-289) in a military medical center, from August 2011 to March 2012. Data obtained from the electronic medical records (EMR) included patient demographics, pertinent medical history, labs ordered, and provider status (resident, fellow, or staff). We also recorded HO ordering patterns for complete blood counts (CBC) and PBS and documentation of PBS findings. For those encounters in which the findings were documented, we reported any further diagnostic studies ordered. The practices of PBS review by HO clinicians and hematopathologists (HP) were also compared.Results: 334 of 350 records reviewed met inclusion criteria for the study. Of the 16 records excluded, one was due to age > 85, 11 due to malignant oncology diagnoses, and 4 were unavailable within the EMR. The median age was 52.5 with males representing 52% of the cohort. 43.8% were self-reported as Caucasian, 23.6% African-American, and 32.6% “Other.” The distribution of diagnoses were 52.7% (n = 176) erythrocyte (RBC) disorders, 23.0% (n = 77) leukocyte (WBC) disorders, 10.2% (n = 34) platelet (PLT) disorders, and 14.1% (n = 47) falling into the category of “other.” The five most common diagnoses were anemia, unspecified (n = 74, 19.3%), iron deficiency anemia (n = 53, 13.8%), leukocytosis, unspecified (n = 37, 9.6%), thrombocytopenia, unspecified (n = 31, 8.1%), and leukopenia, unspecified (n = 16, 4.2%) corresponding to ICD-9 codes 285.9, 280.9, 288.6, 287.5, and 288.5, respectively.A CBC was ordered in 82.9% encounters (n = 277/334, 95% confidence interval [CI], 78.9%-87%) A PBS was ordered in 52.3% of cases in which a CBC was ordered (n = 145/277, 95% CI, p < 0.001). There was no statistical significance between the rates at which residents, fellows, or staff ordered PBS with percentages of 40% (n = 18/45), 43.6% (n = 89/204), and 44.7% (n = 38/85), respectively. A HP reviewed 5.7% (n=19/334) of the CBC’s obtained.If a PBS was ordered, findings were documented in the EMR for 49% of cases (71/145). In the 71 encounters that had PBS documentation, only 7 had HP review (9.9%). Examination of PBS led to further evaluation in 40.8% (29/71) of cases, which represented 8.7% (29/334) of the entire cohort. Of these 29, there was one consult to Gastroenterology, one imaging study ordered (ultrasound for splenomegaly), 9 bone marrow biopsies (12.7%), and lab work in all 29. Of the labs ordered, 8 (27.6%) were studies for hemolysis (DAT, LDH, haptoglobin), 10 (34.5%) were studies for myeloproliferative disease (Jak2, BCR-ABL), and 5 (17.2%) were peripheral flow cytometry.A PBS was more likely to be ordered for WBC disorders (71.9%, CI 95%: 61.9%-81.9%; p ≤ 0.001), followed by PLT (61.3%, CI 95%: 44.2%-78.4%; p = 0.076) and RBC disorders (38.7%, CI 95%: 30.9%-46.5%; p ≤ 0.001), respectively. Of the 29 cases in which PBS findings were documented and further studies ordered, 8 (27.6%) were RBC disorders, 10 (34.5%) were WBC disorders, 6 (20.7%) were PLT disorders, and 5 (17.2%) fell into the category of “other.” In the “other” category, 2 were other specified disease of blood and blood-forming organs (289.89), and the remaining 3 were splenomegaly (789.2) polyclonal hypergammaglobulinemia (273), and monoclonal paraproteinemia (273.1).Discussion: The practice of interpreting the PBS is considered an important diagnostic skill for HO providers. In a military HO training program, PBS were ordered in about half of new benign hematologic outpatient referrals. When PBS were ordered, findings were documented in 49% of cases. While diagnoses could be made without getting PBS in a majority of cases, close to 10% of all benign hematology referrals had documented PBS fidings that led to further diagnostic evaluation. DisclosuresNo relevant conflicts of interest to declare.

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Small-group sessions are 3 hour sessions that include case-based experience in decision making. Practicals include basic ophthalmic surgery and blood smear interpretation.

Cytomorphologic spectrum of Hashimoto's thyroiditis and its clinical correlation: A retrospective study of 52 patients.

Background:Hashimoto's thyroiditis (HT) is an autoimmune disease and it is more prevalent in Asians. The incidence of HT seems to be increasing in the recent times. It is one of the most common cause of hypothyroidism. The purpose of this study is to review the cytomorphologic spectrum of HT and correlate it with clinical findings including thyroid function and antibody profile.Materials and Methods:We retrospectively analyzed the fine-needle aspiration (FNA) features of 52 HT patients. Based on cytomorphologic features patients were categorized into three groups. Clinical findings including thyroid function and thyroid peroxidase (TPO) antibody profile were correlated with cytomorphologic features in all three groups.Results:Majority of the patients were females and in 2nd, 3rd and 4th decades. Diffuse goiter and thyroid hypofunction were the common findings. Significant number of patients had thyroid hyperfunction. Increased lymphocytes on the background and lymphocytic infiltration of thyroid follicular cell clusters in cytology smears were diagnostic of HT. The 32 patients showed elevated titers of TPO antibodies. In the early stages and mild form of the disease, results of thyroid function and anti TPO antibodies are quite variable.Conclusions:HT is a disease of young and middle age and mostly occur in females. Clinical findings alone may not be adequate for definitive diagnosis. FNA is the gold standard for diagnosis. In the presence of abundant colloid, follicular hyperplasia or co-existing neoplasm, careful interpretation of cytology smears should be done. Aspiration from more than one site minimizes the diagnostic pitfalls.