Unacceptable Variability Research Articles

Quality of Life in Oncology: Measuring What Matters for Cancer Patients and Survivors in Europe: The EUonQol Project.

Cancer, in Europe, is the second cause of death. In addition, there is an unacceptable variability in terms of access to innovation, quality of care, and outcomes, within and between countries. The European Union has activated an unprecedented initiative to fight cancer by launching Europe's Beating Cancer Plan and the Cancer Mission. The goals are to reduce mortality, increase survival, and ameliorate quality of life by increasing knowledge, improving quality of care, and reducing inequalities through interventions on actionable determinants of variability. A competitive call was launched with the objective to develop and validate a set of quality of life and patient preference measures for cancer patients and survivors, to be used for routine data collection all over Europe. A consortium, the EUonQoL, was funded, including partners from 41 countries with 55 participants. It will start the activities on January 2023 and rresults are expected by December 2024.

Reliability, Validity, and Comparison of Barbell Velocity Measurement Devices during the Jump Shrug and Hang High Pull.

This study examined the reliability, potential bias, and practical differences between the GymAware Powertool (GA), Tendo Power Analyzer (TENDO), and Push Band 2.0 (PUSH) during the jump shrug (JS) and hang high pull (HHP) performed across a spectrum of loads. Fifteen resistance-trained men performed JS and HHP repetitions with 20, 40, 60, 80, and 100% of their 1RM hang power clean, and mean (MBV) and peak barbell velocity (PBV) were determined by each velocity measurement device. Least-products regression and Bland-Altman plots were used to examine instances of proportional, fixed, and systematic bias between the TENDO and PUSH compared to the GA. Hedge's g effect sizes were also calculated to determine any meaningful differences between devices. The GA and TENDO displayed excellent reliability and acceptable variability during the JS and HHP while the PUSH showed instances of poor-moderate reliability and unacceptable variability at various loads. While the TENDO and PUSH showed instances of various bias, the TENDO device demonstrated greater validity when compared to the GA. Trivial-small differences were shown between the GA and TENDO during the JS and HHP exercises while trivial-moderate differences existed between GA and PUSH during the JS. However, despite trivial-small effects between the GA and PUSH devices at 20 and 40% 1RM during the HHP, practically meaningful differences existed at 60, 80, and 100%, indicating that the PUSH velocity outputs were not accurate. The TENDO appears to be more reliable and valid than the PUSH when measuring MBV and PBV during the JS and HHP.

Thermocapillary Patterning of Highly Uniform Microarrays by Resonant Wavelength Excitation

For decades, researchers have been exploring pattern-forming instabilities in free surface thin films in the hope of developing alternative lithographic techniques for applications only requiring resolution limits in the submicron range. Previous studies have shown how the pitch and shape of elements in an array can be varied by adjusting the magnitude of surface forces and growth time prior to solidification in situ. Since the formations emerge naturally from an initial flat molten film, the final arrays exhibit ultrasmooth interfaces and are therefore ideally suited to beam-shaping applications such as thin-film micro-optics. Progress in this field has stalled, however, due to the very nature of the formation process. Even when great care is taken to ensure that initial films are defect-free, final arrays still exhibit unacceptable variability in pitch, shape, and height due to ubiquitous sources of noise responsible for instability and growth. In this work, we focus on a thermocapillary instability in slender molten films exposed to a very large thermal gradient. We begin with a discussion and demonstration of why this instability inextricably leads to highly disordered arrays even if initialized by a film with very small amplitude surface roughness. We then demonstrate how spatially periodic modulation of the thermal field, implemented in three different ways, can induce synchronous growth of highly uniform periodic arrays despite noisy initial conditions. Results based on linear and weakly nonlinear stability analysis, Bloch wave analysis, and direct numerical simulation of the interface equation reveal how resonant wavelength excitations occurring between the modulation and instability driving fields are responsible for such rapid and coherent growth. An additional benefit is that the modulation field can be selected to yield an array pitch much smaller than in unmodulated systems.

Selection and Validation of Reliable Reference Genes for Gene Expression Studies in Different Genotypes and TRV-Infected Fruits of Peach (Prunus persica L. Batsch) during Ripening.

Real-time quantitative PCR (RT-qPCR) is a powerful tool to detect and quantify transcription abundance, and the stability of the reference gene determines its success. However, the most suitable reference gene for different genotypes and tobacco rattle virus (TRV) infected fruits was unclear in peach (Prunus persica L. Batsch). In this study, 10 reference genes were selected and gene expression was characterized by RT-qPCR across all samples, including different genotypes and TRV-infected fruits during ripening. Four statistical algorithms (geNorm, NormFinder, BestKeeper, and RefFinder) were used to calculate the stability of 10 reference genes. The geNorm analysis indicated that two suitable reference genes should be used for gene expression normalization. In general, the best combination of reference genes was CYP2 and Tua5 for TRV-infected fruits and CYP2 and Tub1 for different genotypes. In 18S, GADPH, and TEF2, there is an unacceptable variability of gene expression in all experimental conditions. Furthermore, to confirm the validity of the reference genes, the expression levels of PpACO1, PpEIN2, and PpPL were normalized at different fruit storage periods. In summary, our results provide guidelines for selecting reliable reference genes in different genotypes and TRV-infected fruits and lay the foundation for accurate evaluation of gene expression for RT-qPCR analysis in peach.

Effect of Tempering on the Ductile-to-Brittle Transitional Behavior of Ni-Cr-Mo Low-Alloy Steel

About 10 years ago, super-high energy Charpy specimens at the National Institute of Standards and Technology were removed from inventory due to unacceptable variability in absorbed energy, leading to the advent of new methods and materials to reduce the variability and maintain the prescribed energy levels. In this paper, we investigated the ductile-to-brittle transitional behavior of Ni-Cr-Mo low-alloy steel by testing Charpy specimens with side-grooves as a function of the final temper temperature to define the processing conditions for these super-high energy levels. For each temper, absorbed energy and force-displacement data were measured as a function of test temperature; the former was used to assess transition temperature and upper-shelf energy and the latter was used to estimate shear fracture appearance (SFA). From the upper-shelf energy results, it was found that two of the temper conditions yielded energies in the super-high energy range and that side-grooves reduced the variability of the energy by preventing the formation of shear lips. From the SFA data, it was shown that the instrumented striker data and fractography were in excellent agreement, with the minor discrepancies attributed to difficulties with transitional fracture surfaces in the fractography and multiple crack arrest points in the instrumented striker data. In all, the data provided clear evidence that Ni-Cr-Mo low-alloy steel is a good solution for super-high energy Charpy indirect verification specimens.

Abstract P5-02-01: Analytical validation and prognostic potential of an automated digital scoring protocol for Ki67: An International Ki67 Working Group study

Abstract Background: The nuclear proliferation biomarker Ki67 has multiple potential roles in breast cancer, including aiding decisions based on prognosis, but has unacceptable between-laboratory variability. Here we tested an open source and calibrated automated digital image analysis (DIA) platform to: (i) Assess inter-laboratory reproducibility of automated Ki67 measurement among 17 participating labs and compare those with standardized pathologist-based visual scoring. (ii) Investigate the comparability of Ki67 measurement across corresponding core biopsy and whole section cases. (iii) Test prognostic potential of the built Ki67 scoring algorithms on an independent cohort. Methods: Two sets of 60 previously stained slides containing 30 core-cut biopsy and 30 corresponding whole tumor sections from 30 ER+ breast cancer cases were sent to 17 participating labs for automated assessment of average Ki67 expression. The blocks were centrally cut and stained for Ki67 using the Mib-1 antibody. The QuPath (open-source software) DIA platform was used to evaluate tumoral Ki67 expression. Calibration of the DIA method was performed in our previous study (Acs et al, Lab Invest 2019). A detailed guideline for building an automated Ki67 scoring algorithm was sent to the participating labs. Visual scoring of average Ki67 expression was performed by pathologists according to published standardized methods (Leung et al, NPJ Br Cancer 2016; Leung et al, Histopath 2019). Locked down DIA Ki67 scoring algorithms were applied to a validation cohort: 222 breast cancer cases from the Karolinska University Hospital in whole section format. Sufficient reproducibility to declare analytical validity was defined as an Intra Class Correlation (ICC) with lower limit of 95% credible interval (CI) >0.80. Markov Chain Monte Carlo routines for generalized linear mixed models were used to estimate ICCs and calculate corresponding CIs. Results: The same-section ICC was 0.902 (CI: 0.852-0.949) across 17 labs using calibrated DIA platform on core biopsy slides and 0.845 (CI: 0.778-0.912) on whole sections. The different-section ICC across the 17 labs was 0.873 (CI: 0.806-0.932) scoring on core biopsy slides and 0.777 (CI: 0.670-0.874) on whole sections. The pathologist-based visual Ki67 scoring showed ICC of 0.860 for all comparisons, respectively (CI: 0.795-0.927). Similar to what was observed for visual Ki67 scoring, the DIA scores are higher for core biopsy slides compared to paired whole sections (p≤0.001; median difference: 5.31%; IQR: 11.50%). Ki67 scores of all locked down DIA algorithms correlates significantly (p≤0.023) with outcome on the validation cohort (observed hazard ratios range: 2.518-2.922). Conclusions: Automated Ki67 evaluation using a calibrated, open-source DIA platform (QuPath) met the pre-specified criterion of success on core biopsies but not on whole sections in the multi-institutional setting. The systematic discrepancy between core biopsy and corresponding whole sections was likely due to pre-analytical factors (tissue handling, fixation) and intratumor heterogeneity. We found that different algorithms built according to calibrated DIA methods had similar prognostic potential. Assessment of clinical utility is planned. Citation Format: Balazs Acs, Samuel C.Y. Leung, Kelley M. Kidwell, Indu Arun, Renaldas Augulis, Sunil S. Badve, Yalai Bai, Anita L. Bane, John M.S. Bartlett, Jane Bayani, Gilbert Bigras, Annika Blank, Signe Borgquist, Henk Buikema, Martin C. Chang, Robin L. Dietz, Andrew Dodson, Anna Ehinger, Susan Fineberg, Cornelia M. Focke, Dongxia Gao, Allen M. Gown, Carolina Gutierrez, Johan Hartman, Judith C. Hugh, Zuzana Kos, Anne-Vibeke Lænkholm, Arvydas Laurinavicius, Richard M. Levenson, Rustin Mahboubi-Ardakani, Mauro G. Mastropasqua, Takuya Moriya, Sharon Nofech-Mozes, C. Kent Osborne, Liron Pantanowitz, Frédérique M. Penault-Llorca, Tammy Piper, Mary Anne Quintayo, Tilman T. Rau, Stefan Reinhard, Stephanie Robertson, Takashi Sakatani, Roberto Salgado, Melanie Spears, Jane Starczynski, Tomoharu Sugie, Bert van der Vegt, Giuseppe Viale, Shakeel Virk, Lila A. Zabaglo, Daniel F. Hayes, Mitch Dowsett, Torsten O. Nielsen, David L. Rimm, International Ki67 in Breast Cancer Working Group, BIG-NABCG. Analytical validation and prognostic potential of an automated digital scoring protocol for Ki67: An International Ki67 Working Group study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-02-01.

A Step in the Right Direction: Body Location Determines Activity Tracking Device Accuracy in Total Knee and Hip Arthroplasty Patients.

Step counts measured by activity monitoring devices (AMDs) and smartphones (SPs) can objectively measure a patient's activity levels after total hip and knee arthroplasty (total joint arthroplasty [TJA]). This study investigated the use and optimal body location of AMDs and SPs to measure step counts in the postoperative period. This was a two-armed, prospective, observational study of TJA inpatients (n = 24) and 2-week status after TJA (n = 25) completing a 100-ft walk. Observer-counted steps were compared with those measured by AMDs (wrist and ankle) and SPs (hip and neck). Acceptable error was defined as <30%. Error rates were treated as both dichotomous and continuous variables. AMD and SP step counts had overall unacceptable error in TJA inpatients. AMDs on the contralateral ankle and SPs on the contralateral hip had error rates less than 30% at 2 weeks postoperatively. Two-week postoperative patients required lower levels of assist (11/25 walker; 4/25 no assist), and significant improvements in stride length (total hip arthroplasty 1.27 versus 1.83 ft/step; total knee arthroplasty 1.42 versus 1.83 ft/step) and cadence (total hip arthroplasty 74.6 versus 166.0 steps/min; total knee arthroplasty 73.5 versus 144.4 steps/min) were seen between inpatient and postoperative patients. Regression analysis found that increases in postoperative day and cadence led to a decrease in device error. In inpatients with TJA, AMDs and SPs have unacceptable variability and limited utility for step counting when using a walker. As gait normalizes and the level of ambulatory assist decreases, AMDs on the contralateral ankle and SPs on the contralateral hip demonstrated low error rates. These devices offer a novel method for measurement of objective outcomes and potential for remote monitoring of patient progress after TJA. Level II, prospective, three-armed study, prognostic study.

New artificial intelligence system: first validation study versus experienced endoscopists for colorectal polyp detection

To improve colorectal polyp detection, a new artificial intelligence (AI) system (GI-Genius, Medtronic) was trained and validated on a dataset of white-light endoscopy videos from a high-quality randomised controlled trial...

Quantitative Analysis of Lactate and Other Organic Acids in Plasma: Preanalytical Challenges

Abstract Background and Objectives We developed a gas chromatography–mass spectrometry (GC-MS) method for the analysis of organic acids (OAs) in plasma using liquid-liquid extraction with acidified methanol. This method allows for the simultaneous analysis of several metabolites associated with energy metabolism, including lactic and pyruvic acids. Here, we evaluated the effect of different preanalytical variables (anticoagulants, delayed plasma separation, fasting vs nonfasting status) on plasma organic acid quantitation. Methods Nine organic acids (lactic, pyruvic, 3-hydroxybutyric, acetoacetic, 2-ketoisovaleric, 2-keto-3-methylvaleric, 2-ketoisocaproic, succinic, and glutaric) were extracted by deproteinizing with acidified methanol, oximated to preserve ketoacids, converted to volatile trimethylsilyl derivatives, and detected by GC-MS. Compound identification was obtained by retention time and fragmentation spectra using Agilent MassHunter software. We performed several comparison studies using blood collected from self-reported healthy participants (24-60 years of age; 14 females, 13 males). The effect of fasting/nonfasting status was evaluated in 14 participants by comparing samples collected after overnight fasting and 4 hours after meal. Paired t test was used for the statistical analysis of results. Results When compared to the preferred sample type, sodium heparin (green top) plasma EDTA plasma (purple top, n = 9) and serum (red top or serum separator tube; n = 5) displayed an unacceptable variability for several analytes. The biggest differences were observed for lactic and pyruvic acids. Lactic acid was significantly lower in EDTA plasma (9%-35% decrease; P = .0001), but higher in serum (4%-63% increase; P = .014), while pyruvic acid was significantly higher in EDTA plasma (4%-145% increase; P = .0002). The measurements of lactic and pyruvic acids were also affected by delayed separation of plasma in samples kept at room temperature. We observed a marked increase in lactate and decrease in pyruvate levels (+42% and –43% mean change, respectively) in plasma separated from whole blood after 2 hours of collection compared to samples processed within 30 minutes. Plasma separated 1 hour postcollection was acceptable. Overnight fasting (12-14 hours) did not have a significant impact on ketones (3-hydroxybutyric and acetoacetic acids) or branched-chain ketoacids (2-keto-3-methylvaleric, 2-ketoisocaproic, 2-ketoisovaleric acids). In contrast, fasting samples displayed higher lactic acid concentrations compared to nonfasting samples (24% increase on average, P = .0072), although in most fasting samples (13 out of 14), lactate concentrations were still within established normal range (600-2,600 µmol/L). Conclusions We identified several preanalytical factors influencing plasma organic acid quantitation, particularly lactic and pyruvic acids. Since those are critical analytes, suggestive of primary or secondary metabolic acidosis, appropriate steps should be taken to ensure sample quality during collection and processing.

Acellular Biologic Scaffolds in Regenerative Medicine: Unacceptable Variability with Acceptable Results

The innovation of regenerative medicine in health care is matched only by the challenges in regulating such products to ensure safety and efficacy for patients. The variability that is inherent within each step of product development, including the fidelity of basic science test methods, the relevance of preclinical models, the often-non-traditional manufacturing methods, the clinical trials, and the variability that exists within the composition of the products themselves, are unavoidable when attempting to create complex tissues and organs from biologic components that, by design, have variability as a constructive and positive attribute. Nonetheless, the control of variability has long been considered a requirement for product quality and consistency. Herein is a discussion regarding the regulation of regenerative medicine products and examples of products, especially biologic scaffold materials, that have unacceptable variability by current standards but are associated with more-than-acceptable clinical outcomes. Future considerations are suggested for the regulation of regenerative medicine products to allow for and incentivize creativity, innovation, and the commercialization of heretofore unrealized regenerative medicine solutions for unmet medical needs while also assuring safety. Surgical mesh and topical wound care products composed of extracellular matrix (ECM) are safe and effective. However, by their very nature, the composition of ECM products is more variable than synthetic materials, and the methods of preparation vary markedly from one product to the next. Further, the mechanism(s) by which ECM influences the host response to affect clinical outcomes is multimodal and only partially understood. The conundrum of acceptable clinical results in the face of typically unacceptable variability in raw material composition and biologic activity presents regulatory challenges. There is a need to reevaluate the suitability of existing guidelines for regulation of ECM-based products.

A Simplified, Fully Defined Differentiation Scheme for Producing Blood-Brain Barrier Endothelial Cells from Human iPSCs.

SummaryHuman induced pluripotent stem cell (iPSC)-derived developmental lineages are key tools for in vitro mechanistic interrogations, drug discovery, and disease modeling. iPSCs have previously been differentiated to endothelial cells with blood-brain barrier (BBB) properties, as defined by high transendothelial electrical resistance (TEER), low passive permeability, and active transporter functions. Typical protocols use undefined components, which impart unacceptable variability on the differentiation process. We demonstrate that replacement of serum with fully defined components, from common medium supplements to a simple mixture of insulin, transferrin, and selenium, yields BBB endothelium with TEER in the range of 2,000–8,000 Ω × cm2 across multiple iPSC lines, with appropriate marker expression and active transporters. The use of a fully defined medium vastly improves the consistency of differentiation, and co-culture of BBB endothelium with iPSC-derived astrocytes produces a robust in vitro neurovascular model. This defined differentiation scheme should broadly enable the use of human BBB endothelium for diverse applications.

An international multicenter study to evaluate reproducibility of automated scoring for assessment of Ki67 in breast cancer

The nuclear proliferation biomarker Ki67 has potential prognostic, predictive, and monitoring roles in breast cancer. Unacceptable between-laboratory variability has limited its clinical value. The International Ki67 in Breast Cancer Working Group investigated whether Ki67 immunohistochemistry can be analytically validated and standardized across laboratories using automated machine-based scoring. Sets of pre-stained core-cut biopsy sections of 30 breast tumors were circulated to 14 laboratories for scanning and automated assessment of the average and maximum percentage of tumor cells positive for Ki67. Seven unique scanners and 10 software platforms were involved in this study. Pre-specified analyses included evaluation of reproducibility between all laboratories (primary) as well as among those using scanners from a single vendor (secondary). The primary reproducibility metric was intraclass correlation coefficient between laboratories, with success considered to be intraclass correlation coefficient >0.80. Intraclass correlation coefficient for automated average scores across 16 operators was 0.83 (95% credible interval: 0.73–0.91) and intraclass correlation coefficient for maximum scores across 10 operators was 0.63 (95% credible interval: 0.44–0.80). For the laboratories using scanners from a single vendor (8 score sets), intraclass correlation coefficient for average automated scores was 0.89 (95% credible interval: 0.81–0.96), which was similar to the intraclass correlation coefficient of 0.87 (95% credible interval: 0.81–0.93) achieved using these same slides in a prior visual-reading reproducibility study. Automated machine assessment of average Ki67 has the potential to achieve between-laboratory reproducibility similar to that for a rigorously standardized pathologist-based visual assessment of Ki67. The observed intraclass correlation coefficient was worse for maximum compared to average scoring methods, suggesting that maximum score methods may be suboptimal for consistent measurement of proliferation. Automated average scoring methods show promise for assessment of Ki67 scoring, but requires further standardization and subsequent clinical validation.

Molecular Diagnosis of Rejection Phenotypes in Lung Transplant Biopsies: Initial Findings of the INTERLUNG Study

Histologic assessment of T-cell mediated rejection (TCMR) in lung transplant (LTx) transbronchial biopsies (TBB) has unacceptable interobserver variability (intrinsic errors), and cannot assess antibody mediated rejection (ABMR). Molecular phenotyping of biopsies with microarrays has been successful in kidney and heart transplants. We sought to standardize its use in TBB.

Molecular Detection of Rejection-like Changes in Proximal Bronchial Mucosal Lung Transplant Biopsies: Initial Findings of the INTERLUNG Study

Histologic assessment of rejection in transbronchial biopsies (TBB) from lung transplant recipients (LTxR) has unacceptable interobserver variability and poses risk that excludes the sickest patients. Mucosal biopsies (MB) are safer, but cannot be interpreted by histology. Based on success in kidney and heart transplants, we evaluated a molecular system for assessing rejection-like changes in MB.

Automatic delineation of functional lung volumes with 68Ga-ventilation/perfusion PET/CT

BackgroundFunctional volumes computed from 68Ga-ventilation/perfusion (V/Q) PET/CT, which we have shown to correlate with pulmonary function test parameters (PFTs), have potential diagnostic utility in a variety of clinical applications, including radiotherapy planning. An automatic segmentation method would facilitate delineation of such volumes. The aim of this study was to develop an automated threshold-based approach to delineate functional volumes that best correlates with manual delineation.Thirty lung cancer patients undergoing both V/Q PET/CT and PFTs were analyzed. Images were acquired following inhalation of Galligas and, subsequently, intravenous administration of 68Ga-macroaggreted-albumin (MAA). Using visually defined manual contours as the reference standard, various cutoff values, expressed as a percentage of the maximal pixel value, were applied. The average volume difference and Dice similarity coefficient (DSC) were calculated, measuring the similarity of the automatic segmentation and the reference standard. Pearson’s correlation was also calculated to compare automated volumes with manual volumes, and automated volumes optimized to PFT indices.ResultsFor ventilation volumes, mean volume difference was lowest (− 0.4%) using a 15%max threshold with Pearson’s coefficient of 0.71. Applying this cutoff, median DSC was 0.93 (0.87–0.95). Nevertheless, limits of agreement in volume differences were large (− 31.0 and 30.2%) with differences ranging from − 40.4 to + 33.0%.For perfusion volumes, mean volume difference was lowest and Pearson’s coefficient was highest using a 15%max threshold (3.3% and 0.81, respectively). Applying this cutoff, median DSC was 0.93 (0.88–0.93). Nevertheless, limits of agreement were again large (− 21.1 and 27.8%) with volume differences ranging from − 18.6 to + 35.5%.Using the 15%max threshold, moderate correlation was demonstrated with FEV1/FVC (r = 0.48 and r = 0.46 for ventilation and perfusion images, respectively). No correlation was found between other PFT indices.ConclusionsTo automatically delineate functional volumes with 68Ga-V/Q PET/CT, the most appropriate cutoff was 15%max for both ventilation and perfusion images. However, using this unique threshold systematically provided unacceptable variability compared to the reference volume and relatively poor correlation with PFT parameters. Accordingly, a visually adapted semi-automatic method is favored, enabling rapid and quantitative delineation of lung functional volumes with 68Ga-V/Q PET/CT.

Assessing the expansion of wadeable benthic macroinvertebrate collection methods in large semiwadeable rivers

AbstractBenthic macroinvertebrates are used commonly as water-quality indicators in wadeable streams and rivers. However, increased depth and overall complexity of large rivers may cause inaccessibility or unacceptable index and metric variability when attempting a single wadeable method. Significant increases in sampling effort and time expenditure have been recommended to compensate for the increased variability when assessing large rivers. However, the transition between wadeable streams and nonwadeable rivers is not well defined, especially for free-flowing systems. We evaluated the utility of a modified wadeable-stream collection method for sampling large and complex semiwadeable rivers. Our results suggest that water-quality measurements across the width of a river can be used to identify influences of multiple water sources. This spatial information and a single-habitat (e.g., riffle–run) approach could be used with a modest increase in sampling effort to reduce metric variability and provide impor...

Interobserver reproducibility of The Paris System for Reporting Urinary Cytology.

Background:The Paris System for Reporting Urinary Cytology represents a significant improvement in classification of urinary specimens. The system acknowledges the difficulty in cytologically diagnosing low-grade urothelial carcinomas and has developed categories to deal with this issue. The system uses six categories: unsatisfactory, negative for high-grade urothelial carcinoma (NHGUC), atypical urothelial cells, suspicious for high-grade urothelial carcinoma, high-grade urothelial carcinoma, other malignancies and a seventh subcategory (low-grade urothelial neoplasm).Methods:Three hundred and fifty-seven urine specimens were independently reviewed by four cytopathologists unaware of the previous diagnoses. Each cytopathologist rendered a diagnosis according to the Paris System categories. Agreement was assessed using absolute agreement and weighted chance-corrected agreement (kappa). Disagreements were classified as low impact and high impact based on the potential impact of a misclassification on clinical management.Results:The average absolute agreement was 65% with an average expected agreement of 44%. The average chance-corrected agreement (kappa) was 0.32. Nine hundred and ninety-nine of 1902 comparisons between rater pairs were in agreement, but 12% of comparisons differed by two or more categories for the category NHGUC. Approximately 15% of the disagreements were classified as high clinical impact.Conclusions:Our findings indicated that the scheme recommended by the Paris System shows adequate precision for the category NHGUC, but the other categories demonstrated unacceptable interobserver variability. This low level of diagnostic precision may negatively impact the applicability of the Paris System for widespread clinical application.

Abstract P1-03-01: An international multicenter study to evaluate reproducibility of automated scoring methods for assessment of Ki67 in breast cancer

Abstract Background: The nuclear proliferation biomarker Ki67 has multiple potential roles in breast cancer, including prognosis-based decisions, but unacceptable between-laboratory variability has limited its clinical value. The International Ki67 Working Group (IKWG) has undertaken a systematic program to determine whether Ki67 immunohistochemistry can be analytically validated and standardized across laboratories. Technological advances and broader availability of devices for automated assessment of stained slides raise the possibility that these machines may improve on reproducibility of traditional pathologist-based visual Ki67 assessment. Aims: To characterize reproducibility of automated machine-measured Ki67 expression using slides previously analyzed in the IKWG phase 3 study that evaluated reproducibility of visual Ki67 assessment. Methods: Two sets of 30 previously stained slides containing core-cut biopsy sections of breast tumors were circulated to 14 laboratories for scanning and automated assessment of Ki67 expression. Sites were instructed to return average and maximum percentage of tumor cells positive for Ki67 for each slide, where maximum is designed to reflect “hot spot” analysis. Two laboratories returned scores from 2 operators; not all laboratories reported values for maximum Ki67 scores. Different operators were treated as distinct laboratories in analyses. Sixteen and 10 score sets were available for average and maximum Ki67 analyses, respectively, encompassing 7 unique scanner and 10 software platforms. Pre-specified analyses included evaluation of reproducibility across all laboratories as well as within a subgroup limited to those using Aperio scanners. The primary reproducibility metric was intraclass correlation coefficient between laboratories (ICC), regardless of device platform or software. Results: Geometric means across 30 cases for 16 operators ranged from 11.06% to 38.11% with overall mean 16.75% (95% CI:14.45-19.42) for average scores. Geometric means for 10 operators ranged from 16.44% to 68.73% with overall mean 25.16% (95% CI: 18.71-33.84) for maximum scores. ICC for automated average scores across 16 operators was 0.83 (95% CI: 0.73-0.91) and ICC for maximum scores across 10 operators was 0.63 (95% CI: 0.44-0.80) although one outlier lab dramatically affected results. For the laboratories using the Aperio platform (8 score sets), ICC for automated average scores was 0.89 (95% CI; 0.81-0.96). These results are similar to ICC of 0.87 (95%CI; 0.81-0.93) reported using these same slides in the Phase 3 visual assessment reproducibility study in which observers counted 500 cells per slide (Leung et al, NPJBrCancer, in press). Conclusions: Between-laboratory reproducibility for automated machine assessment of average Ki67 is similar to that for pathologist-based visual assessment of Ki67. However, the observed ICC was markedly numerically lower for the maximum score method compared to the average method, suggesting that the maximum score may not be useful as a reproducible measure of proliferation. Automated average scoring methods show promise for standardization of Ki67 scoring, supporting future studies to clinically validate Ki67. Citation Format: Rimm DL, McShane LM, Leung SCY, Bai Y, Bane AL, Bartlett JMS, Bayani J, Chang MC, Dean M, Denkert C, Enwere E, Galderisi C, Gholap A, Hugh JC, Jadhav A, Kornaga E, Laurinavicius A, Levenson R, Lima J, Miller K, Pantanowitz L, Piper T, Ruan J, Srinivasan M, Virk S, Wu Y, Yang H, Hayes DF, Nielsen TO, Dowsett M. An international multicenter study to evaluate reproducibility of automated scoring methods for assessment of Ki67 in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-03-01.

Shear Wave Elastography of the Spleen in Healthy Subjects

To evaluate spleen stiffness (SS) value measured by shear wave elastography (SWE) in healthy population. Sixty-eight healthy subjects who underwent donor workup (US including SWE and CT) for adult-to-adult living donor liver transplantation were included in this study. SWE of liver and spleen was performed on a Toshiba Aplio 500 unit by board certified radiologists, through right/left intercostal examination. SWE values were obtained the three measurements and the average in each organ, and we also measured the distance from skin to organic capsule. To determine the normal range of SS and spleen/liver stiffness ratio (SLSR), 2.5∼97.5 percentile values as well as mean and standard deviation were obtained. CT volumetry was performed to assess the liver and spleen volumes and liver/spleen volume ratio (LSVR). We evaluated the relationship between SS or SLSR and spleen volume or LSVR. On SWE, technical failure or unacceptable variability (coefficient of variability=SD/Mean ≥ 0.3) occurred more commonly for SS (n=26, 89.7%) than liver stiffness (LS, n=9, 31.0%) measurement. There was a significant difference in distance of skin-to-capsule between technical success and failure groups (p< 0.05). Among 31 subjects in whom both SS and LS measurements were successful, mean, SD, 2.5 percentile, and 97.5 percentile values were 16.0, 3.6, 8.2, and 24.5 kPa for SS, 5.7, 1.1, 4.1, and 8.6 kPa for LS, and 2.9, 0.8, 1.3, and 4.0 for SLSR.The SS and SLSR correlated significantly with spleen volume and liver/spleen volume ratio (p< 0.05, respectively). SS and SLSR measured by SWE in healthy population ranged from 8.2 to 24.5 kPa and 1.3 to 4.0 (2.5∼97.5 percentiles), and may be associated with spleen volume and liver/spleen volume ratio.

Modern Approach to Brain Death.

People die either when their heart and respiration stop or when their brain irreversibly stops functioning. This latter mode of death by neurologic criteria (also called brain death) emerged after the development of ventilators and intensive care units in the late 1950s and 1960s. Brain death is universally accepted as a modern entity, but the complex process for declaring a patient brain dead is not uniformly followed across country and state lines or even hospital policies, creating unacceptable variability and risks for falsely pronouncing a patient dead. If, however, the declaring physician has expertise and diligently follows the steps that have been published in guidelines, this risk is mitigated. In this article, the authors describe the steps for brain death declaration, discuss how to avoid pitfalls, and examine the modern controversies regarding this medical reality.