Cervical cytology quality assurance in Washington State.

The objectives of this study were to establish a profile of cervical cytology laboratories in Washington State, identify quality assurance problems amenable to correction through education or legislation, and describe differences between large and small cytology laboratories. All 43 Washington laboratories that perform cervical cytology were surveyed by mail during 1989. Completed surveys were returned by 37 (86%) of the laboratories. Nearly half (43%) of the respondents reported processing less than 10,000 Papanicolaou smears annually. Only one-third (35%) of the respondents reported participating in relevant proficiency programs. A proportion of smaller cytology laboratories were compensating their cytotechnologists on the basis of the number of slides read and allowing Papanicolaou smears to be read outside the confines of the laboratory. The results of this study suggest that cytotechnologists in some larger Washington laboratories have been exceeding work load limits recommended by professional associations. Recent legislation includes regulations that address cervical cytology quality assurance. However, continued efforts will need to be made to encourage voluntary adoption of quality control measures not addressed by this legislation.     

Classification of cervical smears with discordance between the cytologic and/or histologic ratings

The problems of diagnostic variability between certified cytotechnologists was studied. Three cytology laboratories submitted a total of 28 cervical smears that had a discordance between the cytologic and/or histologic ratings. Eight independent cytotechnologists provided blind readings on each slide, expressed as "absence of cervical intraepithelial neoplasia (CIN)" to "CIN III." The median rating was absence of CIN or CIN I for 8 slides, CIN II for 5 and CIN III for 15. With a kappa value greater than 0 reflecting agreement beyond chance expectation and a value of 0.40 indicating fair agreement, the kappa value for 8 X 28 ratings was 0.36 (P = .0001), with a 90% confidence interval (CI) between 0.34 and 0.37. The kappa value was 0.14 (P = .10), with a 90% CI between 0.10 and 0.18, on a subsample of nine smears with two or more positive cytology diagnoses but a negative histology. Sixteen of the 28 slides represented cases of histologically proven cancer. Treating cytologic diagnoses of CIN II and CIN III as positive, the sensitivity of the cytologist with reference to histology varied between 71% and 86% while the specificity ranged from 18% to 62%. The positive predictive value was 1/2.5 to 1/1 and the negative predictive value was 1/6 to 1/1. The predictive power (true positives/false positives) ranged from 1.0 to 2.2. The cytodiagnosis of these cervical smears from cases of discordance thus exhibited limited reliability. Standardization of the relevant cytologic knowledge and its routine application is needed to improve the level of performance.     

Organisation of cervical cytology screening in Croatia: past, present and future

This presentation highlights strengths and weaknesses of cervical cytology screening in Croatia, with particular reference to the opportunistic screening, the use of conventional Papanicolaou (Pap) test and the analysis of some organizational, educational and performance issues that are associated with it. Its aim is to propose measures to improve the efficacy of cervical cytology screening in order to reduce cervical cancer mortality. Currently, in excess of 450,000 Pap tests/ year are examined at 35 laboratories scattered throughout the country. All of these laboratories use standard operating procedures including internal and external quality control. They employ a total of 68 cytologists and 91 cytotechnologists. The sensitivity of cervical screening in Croatia is 90.0%, specificity 98.6%, positive predictive value 92.3%, negative predictive value 98.1% and overall diagnostic accuracy 97.2%. The high diagnostic accuracy of cervical cytology is attributed to the long-standing tradition of education and training of cytologists (postgraduate MSc course since 1967, independent residency since 1974) and cytotechnologists (since 1968). This tradition spanning more than half a century means that today in Croatia there is a developed network of cytology laboratories staffed by highly competent cytologists and trained cytotechnologists. The high accuracy of cancer detection through Pap tests provides strong evidence in support of cervical cytology screening remaining the basic method of prevention for cervical carcinoma. However, some modifications to the current situation are needed. These relate primarily to opportunistic screening. The current screening coverage rate is 68%, although there is capacity, which would allow for all women at risk, i.e. those aged 25-64, to be screened once in three years. The screening coverage relates mainly to those women visiting gynecological out patient clinics for unrelated conditions. A properly organized and controlled national screening programme should replace this. This should be accompanied by the introduction of alternative, highly sensitive methods of sample collection and preparation, such as are available through the introduction of new technologies, e.g. liquid based cytology.     

Utero-ovarian infection in aged B6C3F1 mice

An unusually high number of ovarian masses and cysts with purulent material were observed in the B6C3F1 mice on 2 year chemical carcinogenicity studies sponsored by the National Cancer Institute-National Toxicology Program. To determine possible etiology, some of these lesions were cultured for bacteria and a majority yielded Klebsiella sp. Necropsy records of 14,029 female mice in 91 chronic studies necropsied from 1979 to 1983 at six toxicology testing laboratories were reviewed to determine the incidence of lesions and distribution of this disease. Animals for these studies were obtained from barrier production colonies of six suppliers. The incidence of this lesion was low in animals less than 14 months of age, increased with age and reached a peak in 24-26 month old mice. Most animals having this lesion either died or were sacrificed in moribund condition, indicating that this is a life shortening disease of aged B6C3F1 mice. The incidence of lesions ranged from less than 1% to 70% in different chronic studies. There was a marked difference in the incidence in mice from different suppliers and the incidence rate was 2.6 to 15% depending on the source of the animals. The incidence of this lesion in some testing laboratories was several-fold higher than in others and ranged from 0.9 to 20%. The proportion of mice with this lesion was low in some laboratories irrespective of the source of the animals, whereas in other laboratories the incidence was several-fold higher with animals from some, but not all suppliers, indicating testing laboratory-supplier interaction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Temporal characteristics of laboratory screening errors in cervical cytology

OBJECTIVE: To explore the temporal characteristics of laboratory false negative reports in cervical cytology. STUDY DESIGN: The temporal characteristics of 198 false negative cervical cytology cases were compared with those of 750,805 control cases. RESULTS: The false negative rate did not vary significantly by month, day of the week or time of day. The false negative rate was lowest for slides that took between 4 and 5 minutes to screen and increased significantly with screening times that were longer than 5 minutes. The false negative rate did not vary by the number of cases already authorized in a given day. After 40 cases had been authorized in a given day, the false negative rate fell for subsequent cases, but this did not reach statistical significance. The false negative rate was higher during periods when prescreening was performed. CONCLUSION: Further studies of the relationship between time and false negative reports are needed. These would provide an evidence base to help promote safe working practices within laboratories and a more objective setting of maximum daily productivity levels for cytotechnologists.     

Quality assurance in cervical smears: 100% rapid rescreening vs. 10% random rescreening

OBJECTIVE: To compare 100% rapid rescreening of cervical smears with 10% random rescreening as a method of quality assurance. STUDY DESIGN: A total of 5215 smears, randomly selected from smears reported as negative by cytotechnologists during routine screening, underwent 100% rapid rescreening by senior cytotechnologists. Ten percent of these smears, selected at random, were rescreened by other senior cytotechnologists. The gold standard was defined by cytopathologists, who rescreened all 5215 smears. After excluding unsatisfactory smears detected by cytopathologists, 4271 were included in the analysis. RESULTS: The 100% rapid rescreening method identified 69.9%, 95.7% and 100%, respectively, of atypical squamous cells of undetermined significance, low grade squamous intraepithelial lesion and high grade squamous intraepithelial lesion cases reported by the cytopathologists. The 100% rapid rescreening method showed a sensitivity of 73.5% and specificity of 98.6%. The 10% rescreening method showed sensitivity of 40.9% and specificity of 98.8%. CONCLUSION: One hundred percent rapid rescreening is an efficient method of internal quality assurance in cervical smear diagnosis. It can reduce the false negative rate and therefore can provide greater certainty to women who have received negative results. Well-trained cytotechnologists are able to identify abnormal smears in 1-minute rapid rescreening.     

Introduction of the Bethesda System to Mainland China with a Web-based tutorial

OBJECTIVE: To validate the use of a Web-based tutorial to introduce the Bethesda System (TBS) to Mainland Chinese laboratories. STUDY DESIGN: Digitized color images of the diagnostic features in 20 Pap smears were displayed on a Web page. Participants were asked to give each smear a diagnosis using the reporting nomenclature employed in their laboratory or one that was familiar to them. This was followed by teaching images of each smear accompanied by text in English and Chinese that highlighted important features for making a diagnosis using TBS. Participants then reviewed the 20 original Pap smears and rendered a diagnosis using TBS. RESULTS: Pathologists and cytotechnologists at 17 laboratories located in 10 cities completed the exercise. The average diagnostic accuracy for the 20 Pap smears before and after the tutorial was 76% and 88%, respectively. CONCLUSION: Web-based tutorials can be used for disseminating cytologic information to widely dispersed laboratories in China and help enhance the practice of cytology, currently an underutilized diagnostic technique. However, such difficulties as lack of Internet connections in the laboratory, outdated computers and a lack of interest in cytology need to be overcome to ensure success.     

Quality assurance in cervical cancer screening

Objectives. to examine the effectiveness of introducing External Quality Assessment (EQA) into all laboratories which undertake gynaecological cytopathology. to assess pathologists and cytotechnologists regularly for their competence to screen cervical smears, regardless of their standing in the laboratory hierarchy or their experience of gynaecological cytopathology.
Methods. Each participant was asked to screen and report on 10 slides during a 2 h period. the assessment was carried out by a facilitator under the direction of a specially appointed EQA Committee. A maximum score of 20 points was awarded for a completely correct set of answers. A minus score was awarded for a missed abnormal smear. Seventeen pathology laboratories in North West Thames Regional Health Authority participated; 146 cytologists were assessed.
Results. A pilot and four rounds of EQA have been completed and a total 5350 smears examined. Out of 2568 dyskaryotic (abnormal) smears screened, 0.7% were not identified correctly. of the 146 cytologists taking part in the assessment, 95% achieved a score of 17 or more. Three participants were identified who did not reach an acceptable level of competence and appropriate remedial action was taken.
Conclusion. the EQA scheme detected unacceptable levels of performance which can be quickly rectified. Participation of 100% has been maintained on a voluntary basis, and 4 years experience of the scheme confirms that a very high standard of screening prevails in the Region. the study illustrates that voluntary self-regulation is acceptable in the NHS, and the introduction of similar EQA schemes on a national scale will go a long way to establishing confidence in the cervical cancer screening programme.     

Imprint cytology of sentinel lymph nodes in breast cancer. Experience with rapid, intraoperative diagnosis and primary screening by cytotechnologists

OBJECTIVE: To evaluate the intraoperative imprint diagnoses of smears from sentinel lymph nodes that had been primary screened by cytotechnologists and to assess the most important causes of false negative (FN) imprint diagnoses. STUDY DESIGN: Material consisted of 429 imprints from sentinel lymph nodes in 211 breast cancer patients that were sent for frozen section examination over 13 months. RESULTS: The mean number of imprints/lymph nodes per patient was 2.02. The mean screening time per imprint was 3.6 minutes. Sixty-six sentinel nodes (16%) from 51 women (24%) were metastatic. Imprints and/or frozen sections were positive in 54 nodes (82%). Imprints were positive in 38 nodes, representing 70% of intraoperative positive nodes and 58% of the total number of positive nodes. Twenty-six of 28 (93%) FN imprints were due to suboptimal sampling. Four of 9 FN macrometastases did not contain diagnostic or suspicious cells/cell groups even on rescreening, whereas a few, and then only 1 diagnostic group were identified in 2/9. There were no false positives. CONCLUSION: Primary screening by experienced cytotechnologists is both rapid and reliable and enabled the diagnosing pathologist to concentrate on the frozen section. The major cause of false negative imprints is sampling, even in macrometastases.     

Quantitative autoradiography of the development of mu opiate binding sites in rat brain

The regional developmental appearance of mu binding sites in rat brain was examined by quantitative autoradiography of 3H-dihydromorphine binding in rats 2, 14, 21, and 28 days old. Labeling with 3H-dihydromorphine was heterogeneous in adult rat brains, as previously reported by other laboratories. Levels of 3H-dihydromorphine binding ranged from approximately 250 nCi/g tissue in the interpeduncular nucleus and 100 nCi/g tissue in the habenula to 40 nCi/g tissue in the hypothalamus and periaqueductal gray. Some areas, particularly white matter regions, had no detectable specific binding. The density of 3H-dihydromorphine binding increased in all regions between 2 and 28 days of age. The increases in 3H-dihydromorphine binding in various regions of rat brain developed at different rates. Maximal densities were seen by 14 days of age in most regions examined, including the caudate, hippocampus, amygdala, and hypothalamus. Binding in the medial thalamus and quadrigeminal plate, however, did not reach maximal levels until 21 days. Although quantitative autoradiography offers major advantages in the examination of the regional distribution of opiate binding sites, variability both between sections from the same brain and between sections from different brains demonstrate some of the difficulties associated with this type of experimental approach.     

False-negative results in cervical cytologic studies

The appropriate interval between cervical cytologic screening studies is a matter of considerable controversy, with a major consideration being the problem of false-negative results. To determine the rate of false-negative cervical cytologic results in our laboratory and to determine how these failures occur, tissue-proven cases of carcinoma in situ, invasive squamous-cell carcinoma, endocervical adenocarcinoma and lymphoid malignancy involving the cervix with negative Papanicolaou smears obtained within one year prior to the tissue diagnosis were reviewed. Over the four-year period from 1980 through 1983, 339 patients had tissue-proven cervical malignancies. Of these, 66 had false-negative Papanicolaou smears, representing a 20% overall false-negative rate. These false-negative smears were rescreened. For all types of cervical malignancy, the majority of errors were due to sampling. No malignancy was missed disproportionately by either cytotechnologists or cytopathologists. We plan to utilize these data for quality control purposes and for continued review of future performance.     

Diagnostic performance of United States Air Force cytology laboratories. An eight-year experience in central monitoring

Based on experience obtained through review of historical case material, the cytology program of the United States Air Force was regionalized into ten cytocenters, which annually process approximately 375,000 gynecologic cases. In order to assure uniformity and quality of diagnosis to multiple supplying clinics, standardized diagnoses were developed with required central reporting of all abnormal recovery rates. Initial results showed a sign-out abnormal rate (class II or worse) ranging from 1% in two cytocenters to nearly 6% in two others--over a fivefold variation on a demographically similar population. Variation by diagnostic class and follow-up tissue biopsies are reported to validate the higher abnormal rates. Through an applied program over the last seven years of formal education of pathologists and cytotechnologists, consultative visits and sharing of comparative referred statistics, the subsequent abnormal rates were substantialy altered to a range of 3.5% to 7.0%. More recently, required reporting of abnormal rates per technologist appears to be another monitor of laboratory quality, in that a given cytocenter may have a total abnormal rate of 4.5%, but a range among cytotechnolgists of 1.3% to 8.7%. These and other presented statistics may prove valuable for external monitoring (including assessment of quality performance) of individual cytology laboratories.     

Should the laboratory assess the sampling adequacy of cervical smears?

Should the laboratory assess the sampling adequacy of cervical smears? The results of a questionnaire answered by 14 out of the 18 NHS laboratories in Scotland reporting cervical smears showed that, since the publication of Guidelines for Judging the Adequacy of a Cervical Smear, by the British Society for Clinical Cytology (BSCC), rates of unsatisfactory smears had risen from a mean of 3.3% to 6.5%, with some laboratories reporting rates of over 10%. Four laboratories followed the guidelines closely in requiring the presence of two indicators of sampling of the transformation zone, i.e. endocervical cells, metaplastic cells or endocervical mucus. Seven laboratories required one indicator either in all smears or in a subset, whilst three did not require any indicator at all. The laboratories observing the guidelines closely had a higher mean unsatisfactory rate than those partially observing them. The main impediment to the full implementation of the BSCC guidelines appeared to be fear of an unmanageably high unsatisfactory smear rate. The accuracy of the assessment of adequacy is questioned, as is the cost effectiveness of doing so.     

Education and training for cytopathologists. Its role in quality assurance

The role of education and training for cytopathologists in assuring quality in cytology laboratories is discussed, with particular attention given to (1) the problems in the diagnosis of Papanicolaou smears and (2) the contributions of the American Society of Cytology to cytology education. While many people contribute to the success or failure of gynecologic screening programs, poorly trained pathologists can be an especially weak link in the chain given their position in the diagnostic process. Well-formulated residency programs and the use of other educational resources can produce higher-caliber cytopathologists. The problems in Papanicolaou smear screening need to be defined, discussed and resolved by well-trained cytopathologists in conjunction with the clinicians and cytotechnologists involved.     

MULTIPLE LABORATORY EVALUATION OF THE REITER PROTEIN COMPLEMENT FIXATION METHOD

Duplicate Reiter protein complement fixation tests were carried out on different days at the UCLA laboratory on 636 specimens entailing diagnostic problems. Results were in agreement in 94.2 per cent of cases.A comparison of the results obtained with the first RPCF test carried out on 639 diagnostic problem specimens submitted to four Los Angeles laboratories showed disagreement ranging from 10 to 13 per cent.Agreement between RPCF and TPI results in each of the four laboratories ranged from 81.2 to 82.7 per cent.A greater correlation was obtained between RPCF and TPI results than between TPI and STS or RPCF and STS.In the presence of nonreactive RPCF tests, from 5.6 to 7.1 per cent of the specimens tested in each laboratory were reactive to VDRL and TPI tests. Nonreactive VDRL and reactive TPI results ranged from 7.2 to 8.3 per cent of the specimens tested.In the presence of reactive TPI and RPCF results, 5.5 to 6.4 per cent of the specimens tested in each laboratory showed nonreactive VDRL tests.Twenty-nine or 4.6 per cent of 625 specimens tested showed nonreactive VDRL, reactive cardiolipin Kolmer and reactive TPI tests.Of the weakly reactive RPCF, VDRL or cardiolipin Kolmer tests, a higher percentage of the RPCF results gave reactive TPI tests than did either the VDRL or cardiolipin Kolmer procedures.The number of specimens showing discrepant RPCF results upon being retested in the four laboratories ranged from 33 to 68. Reactive TPI tests on those specimens ranged from 30.3 per cent to 54.4 per cent.     

Results of the National External Quality Assessment for Toxoplasmosis Serological Testing in China

Background

Toxoplasmosis is typically diagnosed by serologic testing. External quality assessment (EQA) of clinical laboratories could ensure the accuracy and reliability of serological tests. We assessed the quality of toxoplasma serological assays in Chinese clinical laboratories by an EQA performed between 2004 and 2013 by the National Center for Clinical Laboratories.

Methodology and Findings

EQA panels were prepared and shipped at room temperature to participating laboratories that employed toxoplasma IgG and IgM serological detection. By 2013, 5,384 EQA test reports for toxoplasma-specific IgM and 2,666 reports for toxoplasma-specific IgG were collected. Enzyme-linked immunosorbent (ELISA) and chemical immunofluorescent assays were the most commonly used detection methods. The overall coincidence rates of negative samples were better than those of positive samples. The overall EQA score for toxoplasma-specific IgM detection ranged between 84.3% and 99.6%. The ratio of laboratories that achieved correct IgG detection ranged from 61.1% to 99.3%. However, the inter- and intra-assay variabilities were found to be considerable. The most common problem was failure to detect low titers of antibody.

Conclusion

The EQA scheme showed an improvement in toxoplasma serological testing in China. However, further optimization of assay sensitivity to detect challenging samples remains a future challenge.     

Analyses of quality assessment studies using CD45 for gating lymphocytes for CD3(+)4(+)%

BACKGROUND: The purpose of this study was to assess whether laboratories which do not use CD45 for gating lymphocytes with three- (or four-) color flow cytometry (non-CD45 laboratories) for CD3(+)4(+)% and CD3(+)8(+)% do worse on quality assessment (QA) studies than laboratories which do use CD45 (CD45 laboratories). METHODS: Data came from blood specimens donated by 62 donors (50 HIV-positive) assayed over 2 years (November, 1996-October, 1998) by 35 laboratories in the NIAID DAIDS Flow Cytometry QA Program. RESULTS: Non-CD45 laboratories were significantly more likely to be classified as having unacceptable inter-laboratory results (far from the group median) than CD45 laboratories (5.6% vs 1.5%, P = 0.005 for CD3(+)4(+)%; 10.4% vs 5.0%, P = 0.007 for CD3(+)8(+)%). The intra-laboratory range of results on blinded replicates was significantly more likely to be deemed unacceptable (range >4%) in non-CD45 laboratories than in CD45 laboratories for CD3(+)8(+)% (14. 5% vs 3.5%, P = 0.002) but not for CD3(+)4(+)% (2.6% vs 1.5%, P = 0. 62). These differences in favor of CD45 gating were observed even though the non-CD45 laboratories had been doing three-color flow cytometry in the QA program significantly longer (P = 0.05) than the CD45 laboratories, and so would be expected to have fewer problems with the assay. CONCLUSIONS: Laboratories which choose to use a single CD3/CD4/CD8 tube for immunophenotyping may be sacrificing both accuracy and reproducibility.     

Determination of ochratoxin A in liquorice products using HPLC based analytical methods. Part I: proficiency test of methods commonly used by the confectionary industry

A European proficiency test series was accomplished on behalf of the CAOBISCO (Association of the Chocolate, Biscuit and Confectionery Industries of the EU) expert group on ochratoxin A to assess the performance of laboratories in measuring ochratoxin A in samples of various liquorice products. In addition, the impact of the extraction type (mainly with or without the use of halogenated solvents) was to be evaluated. Four different test samples (two liquorice powders and two liquorice pastes) were tested for sufficient homogeneity and distributed to 15 laboratories in 8 countries in Europe. The results were analysed using standard proficiency testing statistical procedures and laboratories were awarded z-scores on the basis of their reported results. The overall evaluation of the results shows a distinct variation between the participating laboratories. Based on a target standard deviation (σ-value) taken from the Horwitz equation, of the 14 laboratories that reported results, satisfactory results (z-score: |Z| ≤ 2.0) were obtained by 60% and 27% of the laboratories, respectively, for the two liquorice powders and by 93% and 53% of the laboratories, respectively, for the two liquorice pastes. Approximately equal numbers of laboratories used extraction types with and without the use of halogenated solvents. ANOVA testing of the results indicates there was no evident trend using different extraction solvents.     

Simultaneous measurement of pazufloxacin,ciprofloxacin, and levofloxacin in human serum by high-performance liquid chromatography with fluorescence detection

In this study, three fluoroquinolones, pazufloxacin, ciprofloxacin and levofloxacin, were simultaneously determined in spiked human serum by high-performance liquid chromatography (HPLC) method with fluorescence detection. Chromatography was performed using a C₈ column with an isocratic mobile phase consisting of 1% triethylamine (pH 3.0)/acetonitrile (86/14, v/v). Protein precipitation was conducted using perchloric acid and methanol. The calibration curves for the three fluoroquinolones were linear over concentrations ranging from 0.1 to 20.0 μg/mL. The within-day and between-day coefficients of variation obtained from three fluoroquinolones were less than 7%, and relative errors ranged from −1.6% to 9.3%. Mean recoveries of pazufloxacin, ciprofloxacin, and levofloxacin from spiked human serum were 97%, 88%, and 90%, respectively. The proposed method proved to be simple and reliable for the determination of three fluoroquinolones.     

Vesiculation induced by amphiphiles in erythrocytes

The ability of shape-transforming cationic, anionic, zwitterionic, and nonionic amphiphiles to induce vesiculation in human erythrocytes was studied. At concentrations where they exhibit maximum protection against hypotonic haemolysis (CAHmax) echinocytogenic amphiphiles induced a rapid release of exovesicles. Following 5 min of incubation, the vesicle release (acetylcholinesterase release) amounted from 4% (sodium alkyl sulphates) to 13% (zwittergents) of the total acetylcholinesterase activity of the erythrocytes. At concentrations corresponding to CAH50 the vesicle release was less than 15% of that released at CAHmax. The size and the appearance of the vesicles varied with the type of amphiphile. Stomatocytogenic amphiphiles which do not pass the erythrocytes through echinocytic stages, did not induce release of exovesicles. Electron and fluorescence microscopic observations of erythrocytes treated with stomatocytogenic amphiphiles strongly indicated that an endovesiculation had occurred. Amphiphiles which pass the erythrocytes through echinocytic stages before stomatocytic shapes are attained, induced a release of both exo- and endovesicles.