Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians

BACKGROUND

Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty.

AIM

To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities.

METHODS

A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants.

RESULTS

Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence.

CONCLUSION

The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Does use of the AutoPap assisted primary screener improve cytologic diagnosis?

OBJECTIVE

To correlate the ranked review slides by the AutoPap Assisted Primary Screener with the final cytologic diagnosis and to assess whether the ranking of slides improves diagnostic accuracy.

STUDY DESIGN

A total of 5,865 consecutive conventional and suitable cervical/vaginal smears, including high-risk (HR) cases, were processed by the AutoPap System. All slides designated Review were manually screened by two cytotechnologists using the Ranked Review Report. All abnormal findings and reactive/reparative changes were referred to two attending cytopathologists for a final diagnosis. After screening, the Review slides called Within Normal Limits (WNL) were selected according to rank for a further Quality Control (QC) review by the supervisor. All HR cases not selected by AutoPap for QC review were also rescreened. The final diagnoses of the possibly abnormal/reactive/reparative referred slides were recorded and distributed in five ranks according to the Ranked Review Report assignment.

RESULTS

Of 5,865 slides, 5,120 (87%) qualified for scanning. The AutoPap System designated 3,840 (75%) slides for manual review. One thousand three hundred forty-five slides were assigned for QC review. After elimination of nonqualified slides, 763 remained. Rescreening detected 1 high grade squamous intraepithelial lesion (HSIL), 2 low grade squamous intraepithelial lesions (LSIL), 5 atypical squamous cells of undetermined significance (ASCUS) and 5 Benign Reactive Changes (BRC). QC of 364 HR cases revealed 1 LSIL, 2 ASCUS and 3 BRC. Ultimately, 313 (8.1%) smears were diagnosed as ASCUS or a more severe abnormality, 262 (6.8%) as reactive/reparative changes, 3,259 (84.8%) as WNL and 6 (0.1%) as unsatisfactory. Of 313 abnormal slides, 181 were ranked by the system in the 1st rank, 61 in the 2nd, 38 in the 3rd, 19 in the 4th and 14 in the 5th. No HSIL or more severe lesions occurred in the fourth and fifth ranks.

CONCLUSION

Our study validated the claim by the manufacturer that a significant epithelial abnormality is more likely to be present if a high score is assigned to a slide. The preliminary results support use of the AutoPap Assisted Primary Screener to improve cytologic diagnosis.

Performance of the AutoPap primary screening system at Jefferson University Hospital

OBJECTIVE

To evaluate the performance of the AutoPap System for primary screening of cervical/vaginal cytologic smears at the 25% no review rate at Jefferson University Hospital.

STUDY DESIGN

A total of 5,865 consecutive conventional and suitable cervical/vaginal smears, including high-risk cases, were processed by the AutoPap System. Slides designated "no further review" (NFR) were manually screened by a cytopathologist (rapid screening) and a cytotechnologist (detailed screening) to detect epithelial abnormalities and assess the slide adequacy. The presence of Candida or Trichomonas was noted. Three cytopathologists determined the final diagnosis of all epithelial abnormalities by majority agreement.

RESULTS

Of 5,865 slides, 5,120 (87%) qualified for scanning. The system classified 1,280 slides as NFR (25%) and 3,840 (75%) as review. Manual screening of 1,280 slides classified as NFR revealed 1,252 cases within normal limits, 10 atypical squamous cells of undetermined significance (4, favor low grade squamous intraepithelial lesion, 6 favor reactive) and 18 benign cellular changes. Adequacy assessment discrepancies were detected on 98 (19%) of 515 cases of satisfactory but limited by lack of endocervical component (SBLBLEC) and 15 (14%) of 105 cases on satisfactory but limited by inflammation/obscuration. Twenty-five percent of cases classified as SBLBLEC were vaginal smears. Trichomonas vaginalis was noted in 12 slides and Candida in 29.

CONCLUSION

These preliminary results show that in our patient population, the AutoPap primary screener selected as NFR mostly slides within normal limits. The adequacy assessment discrepancies were comparable to those found in routine laboratory practice.

Utility of the Bard BTA test in detecting upper urinary tract transitional cell carcinoma

OBJECTIVES

The Bard BTA test has been shown in early studies to be useful in diagnosing transitional cell carcinoma (TCC) of the bladder. However, the utility of this test has not been evaluated for TCC of the upper urinary tract. We therefore evaluated the clinical utility of the BTA test for upper urinary TCC.

METHODS

We tested 71 specimens from the ureter and/or renal pelvis in 22 patients with a history or clinical suspicion for TCC and 9 patients with benign disorders.

RESULTS

When compared to cytologic diagnoses, BTA had a sensitivity of 65%, a specificity of 40% (when correlated with clinical history), a false-positive rate of 33%, and a false-negative rate of 62%. The test had a positive predictive value of 83% and a negative predictive value of 32%.

CONCLUSIONS

The BTA does not have any clinical value in detecting upper urinary tract TCC.

Using a CompuCyte Pathfinder to evaluate cytotechnology student diagnostic performance

OBJECTIVE

To determine whether the Pathfinder Cytology System facilitates comparison of initial student diagnoses to rescreener diagnoses; provides a platform for collection, storage and retrieval of data on student screening performance; and generates a student screening "score."

STUDY DESIGN

Using two CompuCyte Pathfinder units networked to a PC server and printer, eight cytotechnology students prescreened 1,224 gynecologic cases and entered their results into the Pathfinder database. Five staff cytotechnologists rescreened the cases and entered their diagnoses. The database containing the initial and rescreen diagnoses were transferred to a modified scoring grid that computed a screening "score" for each of the students.

RESULTS

Student diagnoses matched cytotechnologist target diagnoses in 1,107 to 1,224 total cases (90.4%). Of these 1,107 cases, 996 (81.3%) were reported as "within normal limits" (negative) by both student and cytotechnologist, and 111 (9.1%) were target diagnosed as abnormal (atypical squamous cells of undetermined significance [ASCUS] or above) by both student and cytotechnologist. Of 117 remaining cases, 112 (9.2%) were considered minor discrepancies (one-step discrepancy--e.g., benign cell change-reactive vs. ASCUS--favor reactive), and 5 (0.4%) were considered significant discrepancies (two or more diagnostic categories of difference between student and cytotechnologist-within normal limits vs. low grade squamous intraepithelial lesion). The modified scoring grid developed by CompuCyte for this study was able to compute a numerical score for each student.

CONCLUSION

Our preliminary assessment indicated that Pathfinder will facilitate evaluation of student performance. The system shows potential for eliminating the "paper trail" and manual dotting required for traditional student evaluation and, with the addition of a scoring program, may be standardized for use in both educational and clinical settings.

Single-slide versus double-slide Pap smear: a comparative study

Comparison of the single-slide versus double-slide Pap smear method was performed using ectocervical and endocervical samples taken with the Ayre spatula and Cytobrush and placed together on one slide or on two separate slides. Eight hundred cases were collected by four different physicians in a gynecologic clinic (100 consecutive cases per doctor per method). All samples were evaluated at the Thomas Jefferson University Hospital. Parameters evaluated were: specimen adequacy, quality and detection of disease. Results for the double-slide method were: 352/400 (88%) satisfactory, 48/400 (12%) satisfactory, but limited, and 0% unsatisfactory cases. Results for the single-slide method were: 347/400 (86.7%) satisfactory, 50/400 (12.5%) satisfactory, but limited, and 3/400 (0.75%) unsatisfactory cases. Results regarding detection of disease were 16/400 (4%) CIN 1/400 (0.25%) carcinomas with the double-slide method as compared to 13/400 (3.25%) CIN and no carcinomas with the single-slide method. No statistically significant differences were found regarding specimen adequacy (P = 0.31), quality (P = 1.00), and detection of disease [CIN (P = 0.71) and carcinomas (P = 1.0)]. These preliminary findings suggest that the single-slide method is as efficacious as the double-slide method, although a larger group of patients with a longer follow-up need to be evaluated.

Predictors of human papilloma virus in patients with keratinization

Given the prevalence of human papilloma virus (HPV) infection, an attempt was made to determine whether certain factors such as keratinization and/or squamous atypia are associated with its development. Review of our gynecologic cytology files from 1989 yielded 1,615 specimens showing parakeratosis and/or hyperkeratosis, without cytologic evidence of HPV. Concomitant diagnoses included no atypia [keratinization only (KO)], inflammatory squamous atypia (ISA), and squamous atypia (SA). Morphologic follow-up including repeat cytology or biopsy was available for 916 cases, 92 (10.0%) of which possessed changes of HPV. For any case with both cytologic and biopsy evidence of HPV, only the biopsy result was tabulated. HPV on follow-up examination was detected in 52 (6.7%) of the 764 cases with KO; in 20 (20.8%) of the 96 cases with keratinization and ISA (KISA); and in 20 (35.7%) of the 56 cases with keratinization and SA (KSA). The definitive diagnosis of HPV was based on previously described features (Gupta, In: Comprehensive Cytopathology, Philadelphia: WB Saunders, 1991:133-140) including nuclear enlargement with nuclear membrane irregularities in combination with sharply demarcated paranuclear cytoplasmic clearing. Affected cells have rounded borders. Binucleated cells are not uncommon. The increasing percentage of HPV from KO to KISA to KSA is not necessarily surprising. However, mathematical analysis revealed statistically significant differences in the development of HPV in each of the 3 groups: KISA vs. KO (P < 0.001), KSA vs. KO (P < 0.001), and KSA vs. KISA (P < 0.05). Therefore, a cytologic diagnosis of keratinization with ISA or especially SA should warrant closer follow-up than that of KO.