Role of Telemedicine in Multidisciplinary Team Meetings.

We reviewed the role of telemedicine in multidisciplinary team (MDT) meetings, which play an important role in the provision of effective and tailored patient care in diverse clinical settings. This article is based on conducted search in PubMed. Search terms included "telemedicine," "multidisciplinary team," and "(telemedicine) and (multidisciplinary team)." Telemedicine provides an important advantage in the provision of MDT meeting comparing with traditional settings. Those include improved access to and collaboration of medical experts. This resulted in increased levels of medical competence and improved provisions of diagnosis, treatment, and follow-up to patients irrespective of location.

Complete Routine Remote Digital Pathology Services.

BACKGROUND: Validation studies in digital pathology addressed so far diverse aspects of the routine work. We aimed to establish a complete remote digital pathology service. METHODS: Altogether 2295 routine cases (8640 slides) were reported in our studies on digital versus microscopic diagnostics, remote reporting, diagnostic time, fine-needle aspiration cytology (FNAC) clinics, frozen sections, and diagnostic sessions with residents. The same senior pathologist was involved in all studies. Slides were scanned by ScanScope AT Turbo (Aperio). Digital images were accessed through the laboratory system (LS) on either 14" laptops or desktop computers with double 23" displays for the remote and on-site digital reporting. Larger displays were used when available for remote reporting. First diagnosis was either microscopic, digital, or remote digital only (6 months washout period). Both diagnoses were recorded separately and compared. Turnaround was measured from the registration to sign off or scanning to diagnosis. A diagnostic time was measured from the point slides were made available to the point of diagnosis or additional investigations were necessary, recorded independently in minutes/session, and compared. Jabber Video (Cisco) and Lync (Microsoft) were interchangeably used for the secure, video supervision of activities. Mobile phone, broadband, broadband over Wi-Fi, and mobile broadband were tested for internet connections. Nine autopsies were performed remotely involving three staff pathologists, one autopsy technician, and one resident over the secure video link. Remote and on-site pathologists independently interpreted and compared gross findings. Diverse benefits and technical aspects were studied using logs or information recorded in LS. Satisfaction surveys on diverse technical and professional aspects of the studies were conducted. RESULTS: The full concordance between digital and light microscopic diagnosis was 99% (594/600 cases). A minor discordance, without clinical implications, was 1% (6/600 cases). The instant upload of digital images was achieved at 20 Mbps. Deference to microscopic slides and rescanning were under 1%. Average turnaround was shorter and percentage of cases reported up to 3 days higher for remote digital reporting. Larger displays improved the most user experience at magnifications over ×20. A digital diagnostic time was shorter than microscopic in 13 sessions. Four sessions with shorter microscopic diagnostic time included more cases requiring extensive use of magnifications over ×20. Independent interpretations of gross findings between remote and on-site pathologists yielded full agreement in the remote autopsies. Delays in reporting of frozen sections and FNAC due to scanning were clinically insignificant. Satisfaction levels with diverse technical and/or professional aspects of all studies were high. CONCLUSIONS: Complete routine remote digital pathology services are found feasible in hands of experienced staff. The introduction of digital pathology has improved provisions and organizations of our pathology services in histology, cytology, and autopsy including teaching and interdepartmental collaboration.

Correction: Sudden death associated with silent myocardial infarction in a 35-year-old man: a case report.

In the publication of this article [1], there is an error in Table 1 at the Test Ca2+ at the Result. The error in Test Ca2+ Result: '1.24' Should instead read Test Ca2+ Result: '2.24' This has now been included in this erratum.

Remote autopsy services: A feasibility study on nine cases.

Introduction We have conducted a feasibility study on remote autopsy services in order to increase the flexibility of the service with benefits for teaching and interdepartmental collaboration. Methods Three senior staff pathologists, one senior autopsy technician and one junior resident participated in the study. Nine autopsies were performed by the autopsy technician or resident, supervised by the primary pathologist, through the secure, double encrypted video link using Jabber Video (Cisco) with a high-speed broadband connection. The primary pathologist and autopsy room each connected to the secure virtual meeting room using 14″ laptops with in-built cameras (Hewlett-Packard). A portable high-definition web camera (Cisco) was used in the autopsy room. Primary and secondary pathologists independently interpreted and later compared gross findings for the purpose of quality assurance. The video was streamed live only during consultations and interpretation. A satisfaction survey on technical and professional aspects of the study was conducted. Results Independent interpretations of gross findings between primary and secondary pathologists yielded full agreement. A definite cause of death in one complex autopsy was determined following discussions between pathologists and reviews of the clinical notes. Our satisfaction level with the technical and professional aspects of the study was 87% and 97%, respectively. Discussion Remote autopsy services are found to be feasible in the hands of experienced staff, with increased flexibility and interest of autopsy technicians in the service as a result.

Sudden death associated with silent myocardial infarction in a 35-year-old man: a case report.

BACKGROUND: Silent myocardial infarction relates to the absence of symptoms usually associated with myocardial ischemia. It has been estimated that silent myocardial infarction can occur in 2-4 % of young adult asymptomatic men. A majority of patients without an initially apparent cause of sudden death have been found at autopsy to have had significant coronary heart disease, including old, undetected myocardial infarction. Cases of sudden death in young men with unrecognized silent myocardial ischemia seem to be underreported, however. CASE PRESENTATION: A 35-year-old Norwegian man without a previous medical history died suddenly without preceding symptoms of coronary ischemia. Apart from elevated lactate, his laboratory test results were within normal limits. An autopsy revealed advanced coronary artery thrombosis of the left anterior descending branch with an extensive, partly organized myocardial infarction. The results of toxicological examinations of peripheral blood were negative for usual narcotics and alcohol. CONCLUSIONS: Sudden, unexpected death due to myocardial infarction can occur even at a young age in patients without known coronary heart disease.

Diagnostic time in digital pathology: A comparative study on 400 cases.

BACKGROUND: Numerous validation studies in digital pathology confirmed its value as a diagnostic tool. However, a longer time to diagnosis than traditional microscopy has been seen as a significant barrier to the routine use of digital pathology. As a part of our validation study, we compared a digital and microscopic diagnostic time in the routine diagnostic setting. MATERIALS AND METHODS: One senior staff pathologist reported 400 consecutive cases in histology, nongynecological, and fine needle aspiration cytology (20 sessions, 20 cases/session), over 4 weeks. Complex, difficult, and rare cases were excluded from the study to reduce the bias. A primary diagnosis was digital, followed by traditional microscopy, 6 months later, with only request forms available for both. Microscopic slides were scanned at ×20, digital images accessed through the fully integrated laboratory information management system (LIMS) and viewed in the image viewer on double 23" displays. A median broadband speed was 299 Mbps. A diagnostic time was measured from the point slides were made available to the point diagnosis was made or additional investigations were deemed necessary, recorded independently in minutes/session and compared. RESULTS: A digital diagnostic time was 1841 and microscopic 1956 min; digital being shorter than microscopic in 13 sessions. Four sessions with shorter microscopic diagnostic time included more cases requiring extensive use of magnifications over ×20. Diagnostic time was similar in three sessions. CONCLUSIONS: A diagnostic time in digital pathology can be shorter than traditional microscopy in the routine diagnostic setting, with adequate and stable network speeds, fully integrated LIMS and double displays as default parameters. This also related to better ergonomics, larger viewing field, and absence of physical slide handling, with effects on both diagnostic and nondiagnostic time. Differences with previous studies included a design, image size, number of cases, specimen type, network speed, and participant's level of confidence and experience in digital reporting. Further advancements in working stations and gained experience in digital reporting are expected to improve diagnostic time and widen routine applications of digital pathology.

Distance reporting in digital pathology: A study on 950 cases.

BACKGROUND: Increased workload, case complexity, financial constraints, and staffing shortages justify wider implementations of digital pathology. One of its main advantages is distance reporting. AIM: A feasibility study was conducted at our institution in order to achieve comprehensive pathology services available by distance. METHODS: One senior pathologist reported 950 cases (3,650 slides) by distance during 19 weeks. Slides were scanned by ScanScope AT Turbo (Aperio) and digital images accessed through SymPathy (Tieto) on a 14" laptop. Mobile phone, mobile broadband, broadband over Wi-Fi and broadband were used for internet connections along with a virtual private network technology (VPN). Lync (Microsoft) was tested for one case consultation and resident's teaching session. Larger displays were accessed when available. Effects of ergonomics and working flexibility on the user experience were observed. Details on network speed, frequency of technical issues, data usage, scanning, and turnaround, were collected and evaluated. Turnaround was compared to in-office microscopic reporting, measured from the registration to sign off. RESULTS: Network speeds varied 1-80 Mbps (median download speed 8-65 Mbps). 20 Mbps were satisfactory for the instant upload of digital images. VPN, image viewer, and laptop failed on two occasions each. An estimated data usage per digital image was 10 MB (1-50 MB). Two cases (15 slides) were deferred to microscopic slides (0.21/0.41%) due to scanty material and suboptimal slide quality. Additional nine cases (15 slides) needed to be rescanned for various reasons (0.95/0.41%). Average turnaround was shorter, and the percentage of cases reported up to 3 days higher (3.13 days/72.25%) comparing with in-office microscopic reporting (3.90 days/40.56%). Larger displays improved the most user experience at magnifications over ×20. CONCLUSIONS: Existing IT solutions at our institution allow efficient and reliable distance reporting for the core pathology services in histology and cytology. Stable network speeds, fully integrated laboratory information management system, technical reliability, working flexibility, larger displays, and shorter turnaround contributed to the overall satisfaction with distance reporting. A further expansion of our pathology services available by distance, diagnostic and educational, rely on gaining experience in digital reporting and marginal IT investment. Adjustments to the organization of pathology services may follow to fully benefit from the implementation of digital pathology.

Isolated diffuse invasive renal aspergillosis in an immunocompromized patient due to longstanding steroid treatment: a case report.

A 53-year-old Indian lady suffered from type 2 diabetes and hypothyroidism and was on longstanding steroid therapy. She was urgently admitted to the hospital with a high white cell count and high creatinine. On imaging no space occupying lesions were shown. In spite of intensive therapy the patient died a week after admission. Post mortem examination revealed markedly enlarged kidneys with areas of necrosis, hemorrhagic infarction, inflammatory response and granulomas related to the widespread glomerular, tubulo-interstitial and vascular involvement by aspergillus. Renal disease may present as bilateral diffuse parenchymal involvement with blood vessel invasion causing organ failure.

Actinomycosis complicating sigmoid diverticular disease: a case report.

A 63-year-old Caucasian woman was admitted to hospital as hypotensive with abdominal tenderness and vaginal discharge. Laboratory investigations showed microcytic anaemia, low albumin and high white cell count. Computerised tomography scans revealed small bowel dilatation, sigmoid diverticula, ascites and pelvic fluid. The endometrial pipelle was positive and vaginal swab was negative for actinomyces. Post mortem examination revealed widespread sigmoid diverticular disease and bowel perforation with an intense inflammation. Actinomycotic granules were noted in the diverticular inflammatory debris, pelvic abscess and lung sections. Clinical course and histomorphological findings favour the perforating sigmoid diverticular actinomycosis as an origin of the systemic infection.

Platelet adhesion onto immobilized fibrinogen under arterial and venous in-vitro flow conditions does not significantly differ between men and women.

BACKGROUND: Gender-related differences in incidence of arterial thrombosis have been a focus of interest for years. The platelet integrin alphaIIbbeta3 is primarily responsible for the interaction between platelets and fibrinogen and consecutive thrombus growth. In this study, we evaluated platelet adhesion onto immobilized fibrinogen under venous and arterial flow conditions in men and women. METHODS: Platelets in whole anticoagulated blood were labelled with the fluorescence dye Mepacrine and perfused through the rectangular flow chamber over glass cover slips coated with fibrinogen (shear rates of 50 s-1, 500 s-1 and 1500 s-1). A fluorescence laser-scan microscope was used for visualisation and quantification of platelet adhesion at 15 seconds, 1 and 5 minutes after the start of perfusion. RESULTS: During perfusion, the platelet adhesion linearly increased in regard to exposition time and shear rate. After five minutes of perfusion the platelet adhesion onto immobilized fibrinogen showed no significant gender related difference, neither at 50 s-1 nor at 500 s-1 and 1500 s-1 (p > 0.05), respectively. No significant difference in platelet adhesion onto immobilized fibrinogen, in regard to the menopausal status, was either observed (p > 0.05). CONCLUSION: In our in vitro experimental system, hormonal differences between men and women did not influence platelet adhesion onto immobilized fibrinogen, neither under venous nor under arterial rheological conditions.

Breast metastasis from a renal cell cancer.

BACKGROUND: Metastases to the breast from extramammary tumours are uncommon, and metastatic renal cell carcinoma to the breast is extremely rare. We report a metastasis to the breast from a renal primary with the radiological and histopathological features. CASE PRESENTATION: An 81-year-old lady was seen in the breast clinic for a right breast mass after sustaining a fall. Clinical examination and investigations revealed a metastatic cancer from a renal primary. She received surgical treatment only and is under regular follow-up in the oncology clinic. CONCLUSION: The treatment strategy for metastatic breast diseases is based on a proper assessment of such cases by surgeons, radiologists and histopathologists.

Antithrombin significantly influences platelet adhesion onto immobilized fibrinogen in an in-vitro system simulating low flow.

BACKGROUND: Adhesion of platelets onto immobilized fibrinogen is of importance in initiation and development of thrombosis. According to a recent increase in evidence of a multiple biological property of antithrombin, we evaluated the influence of antithrombin on platelet adhesion onto immobilized fibrinogen using an in-vitro flow system. METHODS: Platelets in anticoagulated whole blood (29 healthy blood donors) were labelled with fluorescence dye and perfused through a rectangular flow chamber (shear rates of 13 s-1 to 1500 s-1). Platelet adhesion onto fibrinogen-coated slips was assessed using a fluorescence laser-scan microscope and compared to the plasma antithrombin activity. Additionally the effect of supraphysiological AT supplementation on platelets adhesion rate was evaluated. RESULTS: Within a first minute of perfusion, an inverse correlation between platelet adhesion and plasma antithrombin were observed at 13 s-1 and 50 s-1 (r = -0.48 and r = -0.7, p < 0.05, respectively). Significant differences in platelet adhesion related to low (92 +/- 3.3%) and high (117 +/- 4.1%) antithrombin activity (1786 +/- 516 U vs. 823 +/- 331 U, p < 0.05) at low flow rate (13 s-1, within first minute) have been found. An in-vitro supplementation of whole blood with antithrombin increased the antithrombin activity up to 280% and platelet adhesion rate reached about 65% related to the adhesion rate in a non-supplemented blood (1.25 +/- 0.17 vs. 1.95 +/- 0.4 p = 0.008, respectively). CONCLUSION: It appears that antithrombin in a low flow system suppresses platelet adhesion onto immobilized fibrinogen independently from its antithrombin activity. A supraphysiological substitution of blood with antithrombin significantly reduces platelet adhesion rate. This inhibitory effect might be of clinical relevance.

Fine needle aspiration cytology of primary thyroid paraganglioma. Report of a case with cytologic, histologic and immunohistochemical features and differential diagnostic considerations.

BACKGROUND: Thyroid paraganglioma is a rare tumor and can cause diagnostic difficulties when using fine needle aspiration cytology (FNAC), especially when associated with some cytologic atypia. This case report appears to be the first on FNAC of primary thyroid paraganglioma. CASE: FNAC of a thyroid nodule situated in the right lobe was performed on a 46-year-old female. FNAC showed single cells and loose clusters of large, oval cells with round to oval nuclei, evenly dispersed chromatin, focally discrete nucleoli, moderate anisocytosis and anisonucleosis. A few larger cells showing irregular nuclei and coarser chromatin. The tumorous appearance of the lesion and some cytologic atypia led to a right lobe thyroidectomy, revealing a primary thyroid paraganglioma associated with capsular invasion; slight, focal cytologic atypia; and no vascular invasion. CONCLUSION: The atypia probably originated in the area of capsular invasion. To avoid misdiagnosing these tumors as malignancies, paraganglioma should be added to the differential diagnosis list when dealing with thyroid FNAC showing some atypia.

Cerebellar granular layer aplasia in congenital hydrocephalus.

An unusual case of cerebellar granular layer aplasia is reported. A 5-year-old boy was born with hydrocephalus and a peritoneal drainage shunt was placed after the delivery. Symptoms of cerebral paralysis, impaired mental function and cerebellar ataxia had developed gradually. Patient's karyotype was 46,XY. Laboratory tests for cytomegalovirus, Herpes simplex virus, Toxoplasma gondii, human immunodeficiency virus, rubella and hepatitis B virus were negative. Further laboratory investigation showed no signs of Tay-Sachs disease, Niemann-Pick disease, Gaucher disease, phenylketonuria, galactosemia or glycogen storage disease. No congenital malformations were traced in other family members for three generations. Radiation exposure and infections during the pregnancy were refuted.

Bladder-washing cytology of metastatic ovarian granulosa cell tumor.

An 86-year-old Caucasian female presented with two weeks history of discomfort discharging urine, occasional hematuria, and suprapubic pain. The patient had a history of left salpingo-oophorectomy for an ovarian tumor, performed four years earlier. Ultrasound showed a solid mass surrounding the orifice of the left ureter. Bladder washing cytology yielded single, loosely cohesive syncytial aggregates of rather uniform cells. A few discretely grooved nuclei ("coffee bean nuclei") were seen. Histologic examination revealed muscular tissue infiltrated by oval to round cells, arranged in solid and follicular structures. The tumor cells were immunoreactive for estrogen receptor, inhibin, vimentin, and calretinin. The use of antibodies to pancytokeratin, inhibin, estrogen receptor, S-100, calretinin, and chromagranin could help confirm granulosa cell tumor. To my knowledge, there was no previous report on bladder washing cytology of metastatic granulosa cell tumor.