ПАТОЛОГИЯ, ВЫЗВАННАЯ ИМПЛАНТАТОМ: АЛГОРИТМ ОПРЕДЕЛЕНИЯ ЧАСТИЦ ПРИ ГИСТОПАТОЛОГИЧЕСКОМ ИССЛЕДОВАНИИ СИНОВИАЛЬНО-ПОДОБНОЙ ОКОЛОПРОТЕЗНОЙ мембраны (SLIM)

In histopathologic SLIM diagnostic (synovial-like interface membrane, SLIM) apart from diagnosing periprosthetic infection particle identification has an important role to play. The differences in particle pathogenesis and variability of materials in endoprosthetics explain the particle heterogeneity that hampers the diagnostic identification of particles. For this reason, a histopathological particle algorithm has been developed. With minimal methodical complexity this histopathological particle algorithm offers a guide to prosthesis material-particle identification. Light microscopic-morphological as well as enzyme-histochemical characteristics and polarization-optical proporties have set and particles are defined by size (microparticles, macroparticles and supra- macroparticles) and definitely characterized in accordance with a dichotomous principle. Based on these criteria, identification and validation of the particles was carried out in 120 joint endoprosthesis pathological cases. A histopathological particle score (HPS) is proposed that summarizes the most important information for the orthopedist, material scientist and histopathologist concerning particle identification in the SLIM.Важную роль при гистопатологическом исследовании синовиально-подобной околопротезной мембраны (SLIM), наряду с диагностикой околопротезной инфекции, играет идентификация частиц. Различия в патогенезе частиц и разнообразии материалов для эндопротезирования объясняют ту гетерогенность, которая затрудняет диагностическую идентификацию частиц. По этой причине был разработан гистопатологический алгоритм диагностики частиц, который при минимальных методологических сложностях обеспечивает идентификацию частиц материала протеза. Простые микроскопически-морфологические и энзим-гистохимические характеристики, а также поляризационно-оптические свойства позволяют определить размер частиц (микрочастицы, макрочастицы и супер-макрочастицы) и характеризовать их по дихотомическому принципу. На основании этих критериев были выполнены идентификация и аттестация частиц в 120 случаях патологической реакции на эндопротез сустава. Предложена гистопатологическая шкала частиц (HPS), которая суммирует важнейшую информацию для ортопедов, материаловедов и гистопатологов, касающуюся идентификации частиц методом SLIM

Who Is at Risk for Diagnostic Discrepancies? Comparison of Pre- and Postmortal Diagnoses in 1800 Patients of 3 Medical Decades in East and West Berlin

<div><h3>Background</h3><p>Autopsy rates in Western countries consistently decline to an average of <5%, although clinical autopsies represent a reasonable tool for quality control in hospitals, medically and economically. Comparing pre- and postmortal diagnoses, diagnostic discrepancies as uncovered by clinical autopsies supply crucial information on how to improve clinical treatment. The study aimed at analyzing current diagnostic discrepancy rates, investigating their influencing factors and identifying risk profiles of patients that could be affected by a diagnostic discrepancy.</p> <h3>Methods and Findings</h3><p>Of all adult autopsy cases of the Charité Institute of Pathology from the years 1988, 1993, 1998, 2003 and 2008, the pre- and postmortal diagnoses and all demographic data were analyzed retrospectively. Based on power analysis, 1,800 cases were randomly selected to perform discrepancy classification (class I-VI) according to modified Goldman criteria. The rate of discrepancies in major diagnoses (class I) was 10.7% (95% CI: 7.7%–14.7%) in 2008 representing a reduction by 15.1%. Subgroup analysis revealed several influencing factors to significantly correlate with the discrepancy rate. Cardiovascular diseases had the highest frequency among class-I-discrepancies. Comparing the 1988-data of East- and West-Berlin, no significant differences were found in diagnostic discrepancies despite an autopsy rate differing by nearly 50%. A risk profile analysis visualized by intuitive heatmaps revealed a significantly high discrepancy rate in patients treated in low or intermediate care units at community hospitals. In this collective, patients with genitourinary/renal or infectious diseases were at particularly high risk.</p> <h3>Conclusions</h3><p>This is the current largest and most comprehensive study on diagnostic discrepancies worldwide. Our well-powered analysis revealed a significant rate of class-I-discrepancies indicating that autopsies are still of value. The identified risk profiles may aid both pathologists and clinicians to identify patients at increased risk for a discrepant diagnosis and possibly suboptimal treatment intra vitam.</p> </div

Spoiling for a Fight: B Lymphocytes As Initiator and Effector Populations within Tertiary Lymphoid Organs in Autoimmunity and Transplantation.

Tertiary lymphoid organs (TLOs) develop at ectopic sites within chronically inflamed tissues, such as in autoimmunity and rejecting organ allografts. TLOs differ structurally from canonical secondary lymphoid organs (SLOs), in that they lack a mantle zone and are not encapsulated, suggesting that they may provide unique immune function. A notable feature of TLOs is the frequent presence of structures typical of germinal centers (GCs). However, little is known about the role of such GCs, and in particular, it is not clear if the B cell response within is autonomous, or whether it synergizes with concurrent responses in SLOs. This review will discuss ectopic lymphoneogenesis and the role of the B cell in TLO formation and subsequent effector output in the context of autoimmunity and transplantation, with particular focus on the contribution of ectopic GCs to affinity maturation in humoral immune responses and to the potential breakdown of self-tolerance and development of humoral autoimmunity

Diagnostic guidelines for the histological particle algorithm in the periprosthetic neo-synovial tissue

Background The identification of implant wear particles and non-implant related particles and the characterization of the inflammatory responses in the periprosthetic neo-synovial membrane, bone, and the synovial-like interface membrane (SLIM) play an important role for the evaluation of clinical outcome, correlation with radiological and implant retrieval studies, and understanding of the biological pathways contributing to implant failures in joint arthroplasty. The purpose of this study is to present a comprehensive histological particle algorithm (HPA) as a practical guide to particle identification at routine light microscopy examination. Methods The cases used for particle analysis were selected retrospectively from the archives of two institutions and were representative of the implant wear and non-implant related particle spectrum. All particle categories were described according to their size, shape, colour and properties observed at light microscopy, under polarized light, and after histochemical stains when necessary. A unified range of particle size, defined as a measure of length only, is proposed for the wear particles with five classes for polyethylene (PE) particles and four classes for conventional and corrosion metallic particles and ceramic particles. Results All implant wear and non-implant related particles were described and illustrated in detail by category. A particle scoring system for the periprosthetic tissue/SLIM is proposed as follows: 1) Wear particle identification at light microscopy with a two-step analysis at low (× 25, × 40, and × 100) and high magnification (× 200 and × 400); 2) Identification of the predominant wear particle type with size determination; 3) The presence of non-implant related endogenous and/or foreign particles. A guide for a comprehensive pathology report is also provided with sections for macroscopic and microscopic description, and diagnosis. Conclusions The HPA should be considered a standard for the histological analysis of periprosthetic neo-synovial membrane, bone, and SLIM. It provides a basic, standardized tool for the identification of implant wear and non-implant related particles at routine light microscopy examination and aims at reducing intra-observer and inter-observer variability to provide a common platform for multicentric implant retrieval/radiological/histological studies and valuable data for the risk assessment of implant performance for regional and national implant registries and government agencies

2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection

The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included

The effect of chewing gum on the impact, pain and breakages associated with fixed orthodontic appliances: a randomized clinical trial

Authors - Benson PE, Razi RM, Al-Bloushi RJ Objectives - To determine if the use of chewing gum reduced the impact and pain of fixed orthodontic appliances. Setting and sample population - The Orthodontic Department of the Charles Clifford Dental Hospital, Sheffield, UK. Fifty-seven patients aged 18 years old or younger and who were about to start fixed orthodontic appliance treatment. Subjects and Methods - A randomized clinical trial with two parallel groups allocated to either receive chewing gum after placement of their appliance or who were asked not to chew gum. The patients completed a previously validated Impact of Fixed Appliances questionnaire at 24hrs and 1wk following each visit up until the placement of the working archwire. A visual analogue scale (VAS) was used to assess the intensity of pain. Appliance breakages were recorded to the end of treatment. Results - The difference between the median Total Impact Score of the two groups at 24hrs was 16, which was significantly different (P=0.031; Mann-Whitney U test). The difference between the median VAS between the two groups at 24 hours was 25 mm, which was significantly different (P=0.038; Mann-Whitney U test). There were no differences at 1 week. None of the risk ratios for appliance breakages were significant. Conclusion - Chewing gum significantly decreased both the impact and pain from the fixed appliances. There was no evidence that chewing gum increased the incidence of appliance breakages

Histopathologischer Osteomyelitis-Evaluationsscore (HOES) - ein innovativer Ansatz zur histopathologischen Diagnostik und Kartierung der Osteomyelitis

Background: Treatment and diagnosis of osteomyelitis are still a challenging problem for surgeons, microbiologists and histopathologists. A direct microbiological detection of bacteria in tissues is still gold standard, but it is not always successful for example in chronic osteomyelitis and/or when an antibiotic treatment has already been started or in cases of low virulent bacteria. The goal of this study was to define diagnostic criteria of osteomyelitis, the inflammatory regression of osteomyelitis ("osteomyelitis score") under specific therapy by the correlation of histopathological and microbiological and clinical standard tests. Methods: In this retrospective analysis patients with medical history and clinically clear signs of bacterial infection and osteomyelitis underwent surgery between 01.01.2013 and 31.12.2012. Their formal consent was given. Tissue samples were taken during surgery according to defined criteria including surgical interventions. Histopathological diagnosis was carried out by conventional techniques based on defined criteria of bacterial infection in connective tissue, peri-implant membrane and bone. These results were carried out in tables by numbers representing the histopathological criteria of acute osteomyelitis (A1 to A3) as well as the chronic criteria (C1 and C2) in a semiquantitative way (scale 0 to 3). On the other hand a notational, graduated histopathological report was performed.Preoperative clinical diagnosis, perioperative macroscopic diagnosis, histopathological and microbiological findings were correlated.Results: Histopathological samples of 52 surgical interventions based on the preoperative diagnosis "osteomyelitis" (AOM, ECOM or COM) were included. 37 times preoperatively signs of a chronic osteomyelitis (COM), 10 times preoperatively acute osteomyelitis (AOM) was diagnosed. Another 5 patients were preoperatively diagnosed as acute exacerbated osteomyelitis (ECOM). The correlation of the histopathological infection including the inflammatory activity and microbiological detection of bacteria was 57%. The correlation between preoperative diagnosis and histopathological findings was 68%.Conclusion: The relatively small 68% correlation between clinical preoperative and histopathological diagnosis and 57% correlation between preoperative clinical diagnosis and microbiological findings indicates: Clinical findings are not sufficient for the diagnosis "osteomyelitis". Clinical findings are not sufficient for the differentiation between AOM, ECOM and COM. Histopathological analysis is the critical factor for the diagnosis ("osteomyelitis") and differential diagnosis (AOM vs. COM). Histopathological analysis represents the basis for further treatment. HOES facilitates the classification of the histopathological findings. HOES is a sufficient tool for the treating physician in order to define the further treatment.Grundlegende Überlegung: Diagnose und Therapie der Osteomyelitis fordern auch heute Chirurgen, Mikrobiologen und Pathologen gleichermaßen. Der direkte mikrobiologische Nachweis des krankheitsverursachenden Erregers stellt einen "Gold Standard" in der Diagnostik der Knocheninfektion dar. Leider gelingt der Keimnachweis nicht in allen Fällen, speziell bei chronischen Krankheitsverläufen, laufender Antibiotikatherapie oder im Falle der "low grade Infektion". Die histopathologische Analyse ist insofern eine Condotio sine qua non. Nur anhand dieser Ergebnisse lässt sich zweifelsfrei das Vorliegen einer Osteomyelitis detektieren und eine Aussage zu ihrer Akuität machen. Ziel dieser Studie ist die Vorstellung eines standardisierten histopathologischen Scores, anhand dessen analog zum TMN-System bei Tumorerkrankungen eine valide Kartierung einer Osteomyelitis möglich ist. Weiterhin wurde die Korrelation zwischen histopathologischen Ergebnissen und der klinischen Diagnose ebenso wie dem positiven Keimnachweis überprüft.Methode: In einer retrospektiven Analyse wurden die histopathologischen und mikrobiologischen Befunde von Patienten mit den eindeutigen klinischen Symptomen einer Osteomyelitis untersucht. Alle in die Studie eingeschlossenen Patienten wurden zwischen dem 01.01.2013 und dem 31.12.2013 operiert. Sämtliche Gewebsproben wurden während der operativen Eingriffe gewonnen. Die histologischen Untersuchungen basierten auf den Standardtechniken für bakterielle Infektionen im Bindegewebe, periimplantär und im Knochen. Die Ergebnisse wurden erfasst: in einer tabellarischen Form durch Zahlen, welche die Ausprägung von akuten (A1 bis A3) und chronischen (C1 und C2) Osteomyelitis-Kriterien semiquantitativ (Scala 0-3) in einer getrennten Form für akute und chronische Veränderungen darstellt (Histopathologischer Osteomyelitis-Evaluationsscore), in einer schriftlichen, abgestuften Form, welche sich durch die Summation der tabellarischen Werte ergibt. Die präoperative und die perioperative Diagnose, das histologische Ergebnis und die Mikrobiologie wurden hinsichtlich ihrer Übereinstimmung korreliert (dabei war nicht die Keimtypisierung, sondern der Keimnachweis an sich relevant). Ergebnisse: 52 chirurgische Proben wurden ausgewertet. Sie alle stammten von Patienten mit der präoperativen Diagnose "Osteomyelitis" (akute Osteomyelitis = AOM; akute Exazerbation einer chronischen Osteomyelitis = ECOM; chronische Osteomyelitis = COM). Es fanden sich: COM n=37, AOM n=10, ECOM n=5. Die Korrelation zwischen dem histopathologischen Bild inklusive der inflammatorischen Reaktion und einem positiven Erregernachweis betrug 57%. Die Korrelation zwischen der präoperativen Diagnose und der histologischen Analyse betrug 68%.Schlussfolgerung: Die relative geringe Übereinstimmung von präoperativer Diagnose, histopathologischem Ergebnis und der Mikrobiologie legt Folgendes nahe: Die klinische Vermutung allein ist nicht ausreichend für die Diagnose "Osteomyelitis". Die klinische Vermutung allein ist nicht ausreichend zur Differenzierung zwischen AOM, ECOM und COM. Die histopathologische Analyse ist das entscheidende Kriterium. Einerseits für die Diagnose "Osteomyelitis" an sich und andererseits für deren Akuität. Die histopathologische Analyse ist die Basis für die Therapie. HOES ist ein brauchbares Instrument zur standardisierten Kartierung der histopathologischen Ergebnisse