Intraoperative pathology consultation: error, cause and impact.

BACKGROUND: Correlation of intraoperative frozen section diagnosis with final diagnosis can be an important component of an institution's quality assurance process. METHODS: We performed a quality assurance review of 1207 frozen section diagnoses from 812 surgical cases performed in the Hamilton Regional Laboratory Medicine Programme during a 6-month period in 2007. We reviewed the frozen section and permanent slides from all potentially discordant cases using a multiheaded microscope to arrive at a consensus pertaining to the type and reason for error. We reviewed the clinical record to determine whether there had been a potential adverse impact on immediate clinical management. RESULTS: Frozen sections were most commonly requested for head and neck, nervous system and female genital tract specimens. Twenty-eight frozen sections (3%) were deferred. We identified 24 discordant diagnoses involving 3% of cases and 2% of specimens. The organ systems showing the greatest frequency of discordance relative to the total number from that system were the nervous system, head and neck, and the lungs. Of the errors identified, most occurred owing to diagnostic misinterpretation, followed by problems related to tissue sampling. There was a potential adverse impact on immediate clinical management in 14 cases. CONCLUSION: Our results add to the Canadian data on the correlation between frozen sections and permanent sections; we note comparability to the concordance rates reported in the literature.

CONTEXTE: La corrélation entre le diagnostic fondé sur une analyse peropératoire des coupes congelées et le diagnostic final pourrait être un élément important du processus d'assurance qualité dans les établissements de santé. MÉTHODES: À des fins d'examen de l'assurance qualité, le Programme régional de médecine de laboratoire d'Hamilton a procédé à une revue de 1207 diagnostics fondés sur l'analyse de coupes congelées prélevées lors de 812 interventions chirurgicales au cours d'une période de 6 mois en 2007. Nous avons analysé les coupes congelées et les spécimens fixés pour tous les cas potentiellement discordants à l'aide d'un microscope multitête, dans la recherche d'un consensus quant au type d'erreur et à la raison de celle-ci. Nous avons passé en revue les dossiers cliniques pour mesurer, le cas échéant, un quelconque impact négatif sur la prise en charge clinique immédiate. RÉSULTANTS: Les coupes congelées ont le plus souvent été demandées pour des spécimens de tissu de la tête et du cou, du système nerveux et des voies génitales féminines. Vingt-huit coupes congelées (3 %) ont été écartées. Nous avons relevé 24 diagnostics discordants concernant 3 % des cas et 2 % des spécimens. Les systèmes et organes pour lesquels la fréquence de la discordance a été la plus élevée par rapport au nombre total de spécimens du même type, ont été le système nerveux, la tête et le cou et les poumons. Parmi les erreurs relevées, la plupart ont été attribuables à une mauvaise interprétation diagnostique, suivie de problèmes relatifs au prélèvement tissulaire. Dans 14 cas, l'erreur a pu exercer un impact négatif sur la prise en charge clinique immédiate. CONCLUSIONS: Nos résultats viennent étayer les données canadiennes sur la corrélation entre les coupes congelées et les lames adhérentes; nous notons que nos taux de concordance sont comparables à ceux qui sont cités dans la littérature.

Urothelial carcinoma involving the distal penis.

Urothelial carcinoma (UC) rarely metastasizes to the penis and skin. We report the case of a 73-year-old man with UC metastases to the corpus spongiosum and dermis of the distal penis. We also review the clinicopathologic characteristics and management options for UC metastasizing to the penis. The patient presented with priapism and edema of the genital region. This follows a 5-year history of urothelial carcinoma in situ that progressed to invasive cancer despite intravesical immunotherapy. Seventeen months prior to presentation, the patient underwent a radical cystectomy with adjuvant chemotherapy. The cystectomy specimen demonstrated a pT4a N2 M0 G3 UC and margins were positive for carcinoma in situ. Follow-up had been negative for recurrence until his presentation with priapism. Incisional biopsy of the glans revealed UC and radical penectomy was performed with negative margins. The penile specimen demonstrated extensive involvement of the corpus spongiosum by UC with lymphovascular invasion and subepidermal involvement. Three months after penectomy, the patient presented with inguinal nodal recurrence. Palliative radiotherapy was administered and the patient passed away eight months after surgery.

Multitasking a telemedicine training unit in earthquake disaster response: paraplegic rehabilitation assessment.

The objective of this work was to provide computer and telecommunications skill training for paraplegics using a telemedicine training center in a curriculum that would support connectivity and offer new skills for career applications in the rehabilitation phase and beyond. This was a hospital-based, cross-sectional study. The study was conducted from October 10, 2005 to May 10, 2006 in the hospitals of Rawalpindi Medical College and the Melody Rehabilitation Center, Rawalpindi, Pakistan. These centers provided care for casualties of the October 2005 earthquake in Pakistan. One hundred and ninety four (194) paraplegics were admitted to Rawalpindi Medical College allied hospitals after injuries in the rural mountains near the epicenter. Surveys assessed the education level of the patients, and a sample of 12 patients was enrolled in computer training classes. Of the 194 patients, 144 were female and 50 were male. The majority, 78% (151) were 16-39 years of age. Although only 60% were literate, the overall literacy rate of Pakistan is just 48.7%. Telephone service at home was available after discharge for 40% of patients. Only 8% of patients had basic computer skills. All patients participated in the survey and sought to take the course. All the enrolled patients demonstrated full competency in the skills taught. The social disruption of disaster plus the new challenge of a neurological deficit in paraplegia did not deter a remarkable number of patients from a rural area from engaging in computer and telemedicine training. This study demonstrated the feasibility of educating rural paraplegics in computer skills for telemedicine. The telemedicine training center was used for this task without special equipment or personnel, thereby increasing the utilization of the facility.

Complications in patients with spinal cord injuries sustained in an earthquake in Northern Pakistan.

BACKGROUND: Spinal cord injury (SCI) is a devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. METHODS: The cross-sectional retrospective study covering a 2-month period was conducted on 194 patients admitted to the surgical/neurosurgical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. RESULTS: The male-to-female ratio was approximately 1:3 (n = 50 [26%] and n = 144 [74%], respectively). The majority (78% [n = 151]) were 16 to 39 years of age; 62% (n = 120) had lumbar-level injuries, 25% (n = 48) had thoracic-level injuries, 9% (n = 18) had thoracolumbar-level injuries, and a few had cervical- or sacral-level injuries. Forty-six percent (n = 90) had American Spinal Injury Association type A injuries; 4% (n = 8) were graded B, 11% (n = 21) were graded C, 9% (n = 18) were graded D, and 14% (n = 27) were graded E. Twenty percent (n = 39) developed pressure ulcers, of which 38% (n = 15) had grade 1, 36% (n = 14) had grade 2, 23% (n = 9) had grade 3, and 3% (n = 1) had grade 4. All patients developed urinary tract infections; 15% (n = 30) had bowel complaints; 2% (n = 3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n = 1) developed wound infection. CONCLUSION: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning.

Complications in Patients with Spinal Cord Injuries Sustained in an Earthquake in Northern Pakistan

Background: Spinal cord injury (SCI) is devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. Methods: The cross-sectional restrospective study covering a 2-month perido was conducted on 194 patients admitted to the surgical/neurosugical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. Results: The male-to-male ratio was approximately 1:3 (n=50 [26%] and n=144 [74%], respectivily). The majority (78% [ n=151]) were 16 to 39 years of age; 62% (n=120) had lumbar-injuries, 25% (n=48) had thoracic-level-injuries, 9% (n=18) had thoracolumbar-level injuries, and a few had cervical - or sacral-level-injuries. Forty six percent (n=90) had American Spinal Injury Association type A injuries; 4% (n=8) were graded B, 11% (n=21) were graded C, 95 (n=18) were graded D, and 14% (n=27) were graded E. Twenty percent (n=39) developed pressure ulcers, of which 38% (n=15) had grade, 1, 36% (n=14) had grade 2, 23% (n=29) had grade 3, and 3% (n=1) had grade 4. All patients developed urinary tract infections; 15% (n=30) had bowel complaints; 2% (n=3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n=1) developed wound infection. Conclusion: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning. (AU)