Does standardised structured reporting contribute to quality in diagnostic pathology? The importance of evidence-based datasets.

Key quality parameters in diagnostic pathology include timeliness, accuracy, completeness, conformance with current agreed standards, consistency and clarity in communication. In this review, we argue that with worldwide developments in eHealth and big data, generally, there are two further, often overlooked, parameters if our reports are to be fit for purpose. Firstly, population-level studies have clearly demonstrated the value of providing timely structured reporting data in standardised electronic format as part of system-wide quality improvement programmes. Moreover, when combined with multiple health data sources through eHealth and data linkage, structured pathology reports become central to population-level quality monitoring, benchmarking, interventions and benefit analyses in public health management. Secondly, population-level studies, particularly for benchmarking, require a single agreed international and evidence-based standard to ensure interoperability and comparability. This has been taken for granted in tumour classification and staging for many years, yet international standardisation of cancer datasets is only now underway through the International Collaboration on Cancer Reporting (ICCR). In this review, we present evidence supporting the role of structured pathology reporting in quality improvement for both clinical care and population-level health management. Although this review of available evidence largely relates to structured reporting of cancer, it is clear that the same principles can be applied throughout anatomical pathology generally, as they are elsewhere in the health system.

Anoxic encephalopathy: a neurobehavioural study in rehabilitation.

This study examined an operational conditioning paradigm designed to train procedural learning channels in a patient with anoxic encephalopathy. Prior to treatment the patient had been incontinent to bowel and bladder incontinent, minimally participant in daily activities and aggressive toward staff and residents for two years. Previous rehabilitation attempts had been unsuccessful in changing these behaviours. Based on the literature, it was hypothesized that through operant conditioning the patient could be trained on three behaviours: 1) bowel and bladder continence 2) activity level and 3) level of aggression. Results indicated that at a 4 month interval following the initial training, the patient had improved in all areas of functioning.

The Sensory Stimulation Assessment Measure (SSAM): a tool for early evaluation of severely brain-injured patients.

There has been little definitive research ono the efficacy of sensory stimulation, yet many brain-injury rehabilitation programmes offer some form of it as treatment for severely injured patients. In general, however, sensory stimulation programmes and outcome studies alike lack precise definitions of terms, consistent criteria of patient selection, and valid and reliable measures of response to treatment. The Sensory Stimulation Assessment Measure (SSAM) was developed as a neuropsychological approach that provides a reliable and valid measure of responsiveness in patients who can neither communicate nor consistently follow commands. Patient responses are divided into three six-point behavioural scales (Eye Opening, Motor, and Vocalization) that require little evaluator subjectivity or inference. The measure may be used in treatment planning and is designed to address the rigorous demands of scientific research. Validity, reliability, and normative data are presented.

Primary lymphoma of the ampulla of Vater.

A 57-year-old woman was investigated for obstructive jaundice with endoscopic retrograde cholangiopancreaticography that showed a tumor at the ampulla of Vater. A Whipple's procedure was performed. A protuberant tumor was present at the ampulla of Vater in the background of multiple mucosal polyps in the duodenum. Light microscopy revealed a diffuse non-Hodgkin's lymphoma with centrocytelike cells forming lymphoepithelial lesions and infiltrating the sphincter of Oddi. The duodenal polyps were hyperplastic lymphoid follicles with reactive germinal centers. Immunohistochemical staining characterized the tumor as a B-cell neoplasm with IgA heavy-chain and lambda light-chain restrictions. Complete remission of the disease occurred after surgery. The clinical, histologic, and immunohistochemical features of this lymphoma are suggestive of histogenetic derivation from mucosal-associated tissue.

Effects of intensity of treatment and length of stay on rehabilitation outcomes.

The combined effects of intensity of treatment and length of stay during inpatient rehabilitation hospitalization on the outcomes of 95 traumatic brain injury patients were examined. Outcome was assessed using the Rancho Scale and three measures of functional status--physical performance, higher-level cognitive skills, and cognitively mediated physical skills. The effects of intensity of treatment and length of stay were assessed using 2 x 2 analyses of variance with repeated measures. The results showed clearly that both length of stay and intensity of treatment affect outcomes. Patients in the long length of stay group consistently made more progress across all outcome variables than patients in the short length of stay group. However, the greater progress of the long length of stay patients was from a point significantly more disabled than that of the short length of stay patients, with improvement at discharge to the point at which the groups were now equal. The effect of intensity of treatment was significant or closely approached significance for higher-level cognitive skills and Rancho Level. In the long length of stay group, the two intensity groups were initially equivalent, but at discharge the high-intensity group surpassed the low-intensity group. The practical implications of the results are discussed.

Time of rehabilitation admission and severity of trauma: effect on brain injury outcome.

Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.

Sensory stimulation of severely brain-injured patients.

The research reported here consisted of a series of three studies of the use of a sensory stimulation protocol and assessment scale with brain-injured patients at either Level II or Level III on the Ranchos Los Amigos Cognitive Scale. In the first study, a pilot project with six patients addressed the hypotheses that: (1) immediate changes in responsiveness occur as a result of sensory stimulation; (2) variables such as positioning and level of contact have an effect on responsiveness; and (3) these changes can be measured. The second study established acceptable concurrent validity (n = 20), test-retest (n = 20) reliability and inter-rater reliability (n = 19) values for the procedures. The third study assessed whether change in responsiveness occurs over time secondary to sensory stimulation. General Responsiveness measures for 19 patients were obtained and then remeasured after 3 months. No significant differences in mean General Responsiveness values were found using the t-test for related measures procedure. Relationships were reviewed between General Responsiveness and amount of treatment per day, frequency of family visits, pre-morbid education, age, time since injury and neurological status. No differences were found between those patients who improved and those who did not improve.

Activated killer cell lymphoma: an erythrophagocytic syndrome simulating histiocytic medullary histiocytosis.

We report a detailed analysis of a lymphoma-induced erythrophagocytic syndrome mimicking histiocytic medullary reticulosis. Phenotypic analysis of cell surface molecules demonstrated a T cell-like phenotype. However, more extensive analysis showed that this phenotype was not typical of any element of the normal T cell lineage. The markers were consistent with a subset of natural killer cells, the lymphokine-activated killer (LAK) cell. The lymphoma cells, like normal LAK cells, were shown to be capable of non-specific cytotoxicity. Moreover, consistent with the reported regulatory effects of certain non-specific killer cells on hemopoiesis, the lymphoma cells were able to suppress in-vitro hemopoiesis, especially maturation of erythroid precursors, although a soluble factor could not be directly demonstrated. Both of these activities were blocked by a monoclonal antibody (9.IC3) which inhibits NK cell function. These findings imply that this tumour is a neoplastic counterpart of the cell identifiable in vitro as an LAK cell.

Nesidioblastosis and multifocal pancreatic islet cell hyperplasia in an adult. Clinicopathologic features and in vitro pancreatic studies.

The clinicopathologic features of an adult with insulinoma and pancreatic islet cell hyperplasia, who presented with hyperinsulinemic hypoglycemia are reported, together with in vitro studies on the patient's pancreatic islets. Islet cell hyperplasia with ductal proliferation and budding and beta cell degranulation was demonstrated by immunochemical means. The in vitro studies of cultured hyperplastic islet cells support the clinicopathologic features. Thus, in comparison with control islets maintained in culture for up to 14 days, hyperplastic islets could be cultured for up to 60 days, during which time cell overgrowth required subculture on three occasions. Furthermore, in contrast to control islets the release of both insulin and somatostatin from cultured hyperplastic islets was refractory to glucose, glucagon, and tolbutamide; theophylline was the only secretagogue to stimulate insulin and somatostatin release from hyperplastic islets in vitro. Indirect immunofluorescence revealed the presence of islet cell surface autoantibodies in the plasma of this patient reactive with both normal human islets and a rat insulinoma line (RIN-m5F). These studies demonstrate the proliferative capacity and relatively undifferentiated functional state of hyperplastic islets in vitro. They provide further evidence that islet cell division is capable of being stimulated in adult life. The pathogenic significance of islet cell surface autoantibodies in hyperplastic islet cell disease and insulinoma warrants further investigation.

Psychological functioning after severe closed head injury.

The residual effects of severe closed head injury on psychological functioning, as determined by data from the Rorschach test, were examined. Thirty-five young adult patients with severe closed head injury were compared to a nonpatient, non-head injured matched group sample of 36 subjects. The utility of the Rorschach test in distinguishing the characteristic psychological functioning of inpatients who have suffered from severe closed head injury was outlined. The apperceptive disturbance, affective/cognitive problems, and interpersonal difficulties were discussed.

Multiple immunoperoxidase markers in benign hyperplasia and adenocarcinoma of the prostate.

A series of 60 cases of prostatic adenocarcinoma and 34 cases of benign prostatic hyperplasia were examined quantitatively after immunoperoxidase staining for prostate-specific antigen (PSA), prostate-specific acid phosphatase (PSAP), carcino-embryonic antigen (CEA), epithelial membrane antigen (EMA), alpha fetoprotein (AFP), and human chorionic gonadotrophin (HCG). The tumors were graded I to IV according to the MDAH grading system recently proposed. Fifty-nine of the 60 tumors were positive for PSA and 58 were positive for PSAP. The one PSA and PSAP negative case was CEA negative and weakly EMA positive. Grade I to III tumors stained more tumor cells and more diffusely for PSA and PSAP than grade IV tumors. There was no significant difference in the intensity or extent of staining between grade I and grade II-III tumors for PSA and PSAP. A comparison of PSA and PSAP showed that PSA stained more intensely and more extensively than PSAP. Benign prostatic tissue and low-grade prostatic tumors did not stain for CEA but three of the 20 grade IV tumors and one of the 23 grade II-III tumors did. Staining for EMA was focal and showed no relation to tumor grade. Benign and malignant lesions failed to stain for AFP and HCG.

Extracellular dextran hydrolase from Streptococcus mutans strain 6715.

Streptococcus mutans strain 6715 was shown to produce an extracellular dextramase with endohydrolytic alpha-(1 leads to 6)-glucan-6-glucanohydrolase activity. The enzyme degraded soluble polymers produced by some oral streptococci but did not disperse the streptococcal plaques tested. Enzyme levels in the culture supernatant were elevated in sucrose and sucrose plus glucose cultures but remained at basal levels in glucose and dextran plus glucose cultures.