In-situ follicular neoplasia: a clinicopathological spectrum.

AIMS: In-situ follicular neoplasia (ISFN) occurs in approximately 2-3% of reactive lymph nodes, and is currently set apart from 'partial involvement by follicular lymphoma' (PFL). ISFN can progress to overt lymphoma, but precise parameters with which to assess this risk and its association with related diseases remain incompletely understood. The aim of this study was to explore these parameters. METHODS AND RESULTS: We reviewed 11 cases of ISFN and one of PFL between 2003 and 2018. Ten patients had ISFN in the lymph nodes, and one had ISFN in the spleen. Haematoxylin and eosin and immunohistochemical stains were reviewed. Involvement of follicles by ISFN was scored with a three-tier scheme. Of five patients with low ISFN scores, one had chronic myelomonocytic leukaemia, one had mycosis fungoides, and three were free of haematopoietic disease. Among them, four are alive and one was lost to follow-up. Of the six ISFN patients with high scores, two had concurrent marginal zone lymphomas, one had concurrent diffuse large B-cell lymphoma (DLBCL), one had Castleman-like disease, one had progressive transformation of germinal centres with IgG4-related disease, and one had no haematopoietic disease; all are alive except for one who died of concurrent DLBCL. The patient with PFL developed DLBCL 7 years after diagnosis. CONCLUSIONS: On the basis of this limited series, we conclude that only cases with high scores are associated with an overt lymphoma or an abnormal lymphoid process, and that scoring may be a useful parameter with which to assess the risk of associated lymphoma, and deserves further study. We also performed a comprehensive review of the literature.

Opening the black box of ethics policy work: evaluating a covert practice.

Hospital ethics committees (HECs) and ethicists generally describe themselves as engaged in four domains of practice: case consultation, research, education, and policy work. Despite the increasing attention to quality indicators, practice standards, and evaluation methods for the other domains, comparatively little is known or published about the policy work of HECs or ethicists. This article attempts to open the "black box" of this health care ethics practice by providing two detailed case examples of ethics policy reviews. We also describe the development and application of an evaluation strategy to assess the quality of ethics policy review work, and to enable continuous improvement of ethics policy review processes. Given the potential for policy work to impact entire patient populations and organizational systems, it is imperative that HECs and ethicists develop clearer roles, responsibilities, procedural standards, and evaluation methods to ensure the delivery of consistent, relevant, and high-quality ethics policy reviews.

Aiming for zero preventable deaths: using death review to improve care and reduce harm.

In 2005, our organization set a goal of zero preventable deaths by 2010--notionally a sound goal but extremely challenging to measure, monitor and evaluate. The development of an interdisciplinary Death and Adverse Event Review process has provided a measure and framework for action to decrease adverse events (AEs) that cause harm. Death and Adverse Event Review is a formal process in which trained reviewers consider patient deaths using a modified Global Trigger Tool to establish the presence of AEs or quality of care issues that may have potentially led to death or harm. When identified, these charts go to second-level review by a physician/interdisciplinary team to determine recommendations for actions to prevent future reoccurrences. Data have provided trending of system influences to patient safety. In 2008-2009, 1,817 deaths were reviewed and AE rates of 12.1% and 16.3% were identified. There were 422 AEs and 114 quality of care issues identified for follow-up. Of the 4.7% and 6.3% referred to the physician/interdisciplinary team for secondary review, 2.3% and 2.6% resulted in recommendations for improvement. In addition to local improvements, many system improvements have occurred as a result of the review, such as proposed minimum standards for physician documentation; a formal review of post-operative guidelines for patients with sleep apnea; and a working group to review nursing documentation, communication/follow-up of vital signs, fluid balance and pain management. The Death and Adverse Event Review process provides a new critical level of detail that supports continuous improvements to our care processes and ongoing progress toward our goal of zero preventable deaths.