color atlas on bethesda system for reporting thyroid cytologyAshish Jawarkar
this is a color atlas on bethesda system for reporting thyroid cytology. there are nearly 300 images in atlas with explanatory text which will help students and practitioners alike. All images are taken from pap society web atlas.. and entire credit for this work should go to the society.. I have put together images available at one place..
THIS IS A PREVIEW ONLY..ENTIRE DOCUMENT IS AVAILABLE ON SCRIBD.. LINK PROVIDED IN DOCUMENT
color atlas on bethesda system for reporting thyroid cytologyAshish Jawarkar
this is a color atlas on bethesda system for reporting thyroid cytology. there are nearly 300 images in atlas with explanatory text which will help students and practitioners alike. All images are taken from pap society web atlas.. and entire credit for this work should go to the society.. I have put together images available at one place..
THIS IS A PREVIEW ONLY..ENTIRE DOCUMENT IS AVAILABLE ON SCRIBD.. LINK PROVIDED IN DOCUMENT
CytoJournal- Open Access & CMAS on EUS FNA of Pancreasvshidham
This presentation discusses about Open Access Publishing and evolution of CMAS on EUS FNA of pancreatic lesions. A few case studies are also discussed.
02 Presentations Ii Vs (14 4 Mb) (3 30 08)vshidham
Part II of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
03 Presentations III VS (8-47MB)- (3-28-08).ppsvshidham
Part III of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
04 Presentations IV VS (8MB)- (3-28-08) .ppsvshidham
Part IV of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
01 Presentation I VS (8-55MB)- (3-28-08).ppsvshidham
Part I of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
CytoJournal- Open Access & CMAS on EUS FNA of Pancreasvshidham
This presentation discusses about Open Access Publishing and evolution of CMAS on EUS FNA of pancreatic lesions. A few case studies are also discussed.
02 Presentations Ii Vs (14 4 Mb) (3 30 08)vshidham
Part II of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
03 Presentations III VS (8-47MB)- (3-28-08).ppsvshidham
Part III of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
04 Presentations IV VS (8MB)- (3-28-08) .ppsvshidham
Part IV of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
01 Presentation I VS (8-55MB)- (3-28-08).ppsvshidham
Part I of Four part symposium: “Diagnostic Cytopathology of Serous Effusion” on April 19, 2007 at Neenah, WI, USA
(2008 Wisconsin Society of Cytology, 40th Anniversary)
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Potpouri Of Asc H Shidham Et Al (Wk#13 Asc Annual Meeting 2008)
1. A potpourri of ASC-H and related interpretations-
Introduction Problem based learning
(Nov 11, 2008, 1.30 to 1.35)
A potpourri of ASC-H and related interpretations-
Problem based learning
P bl b dl i
Vinod B. Shidham, MD, FRCPath, FIAC
Medical College of Wisconsin,
Milwaukee, WI
Mamatha Chivukula , MD
Magee-Womens Hospital of University of Pittsburgh Medical Center,
Pittsburgh, PA
R. Marshall Austin, MD, PhD
Magee-Womens Hospital of University of Pittsburgh Medical Center,
Pittsburgh, PA
A potpourri of ASC-H and related interpretations-
Problem based learning
Educational objectives
Upon conclusion of this presentation, participants will be able to…
1. Describe cytomorphological spectrum of ASC-H.
2. Define LSIL-H with review of literature.
3. Differential diagnosis of hyperchromatic crowded groups.
4. Discuss application of ancillary tests.
1
2. A potpourri of ASC-H and related interpretations-
Problem based learning
A potpourri of ASC-H and related interpretations-
Problem based learning
P bl b dl i
Shidham VB 1.35 to 2.15 (35 minutes + 5 minutes Q/A)
Morphological Evaluation of Twilight Zone in Cervical Cytology.
Chivukula M 2.15 t 1 55
Chi k l M. 2 15 to 1.55 (35 minutes + 5 minutes Q/A)
i t i t
Study cases and application of two-color immunochemistry
Austin RM. 2.55 to 3.30 (30 minutes + 5 minutes Q/A)
Quality Improvement, Ancillary HPV testing, and Medicolegal aspects
2
3. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning http://bethesda2001.cancer.gov/terminology.html Problem based learning
(Nov 11, 2008, 1.35 to 2.15)
Part I
Morphological Evaluation of
Twilight Zone in Cervical Cytology.
Vinod B. Shidham, MD, FRCPath, FIAC
Professor
Executive editor & co-editor-in-chief, CytoJournal (www.cytojournal.com)
Director- Cytopathology Fellowship Training Program & FNA Service
Department of Pathology
Medical College of Wisconsin
9200 W Wisconsin Av,
Milwaukee, WI 53226, USA
vshidham@mcw.edu
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
EPITHELIAL CELL ABNORMALITIES http://nih.techriver.net/
SQUAMOUS CELL
Atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
Low grade squamous intraepithelial lesion (LSIL) encompassing: HPV/mild dysplasia/CIN 1
High grade squamous intraepithelial lesion (HSIL) encompassing: moderate and severe
dysplasia, CIS/CIN 2 and CIN 3
- with features suspicious for invasion (if invasion is suspected)
Squamous cell carcinoma
GLANDULAR CELL
AGUS
Atypical (NOS)
- endocervical cells (NOS or specify in comments)
- endometrial cells (NOS or specify in comments)
- glandular cells (NOS or specify in comments)
Atypical (favor neoplastic)
- endocervical cells, favor neoplastic
- glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ
Adenocarcinoma
- endocervical, endometrial, extrauterine, and not otherwise specified (NOS)
OTHER MALIGNANT NEOPLASMS: (specify)
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL
Atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
Low grade squamous intraepithelial lesion (LSIL) encompassing: HPV/mild dysplasia/CIN 1 Atypical squamous cells
High grade squamous intraepithelial lesion (HSIL) encompassing: moderate and severe
dysplasia, CIS/CIN 2 and CIN 3
- with features suspicious for invasion (if invasion is suspected)
Squamous cell carcinoma cannot exclude HSIL (ASC-H)
(ASC H)
GLANDULAR CELL
AGUS
Atypical (NOS)
- endocervical cells (NOS or specify in comments)
- endometrial cells (NOS or specify in comments)
- glandular cells (NOS or specify in comments)
Atypical (favor neoplastic)
- endocervical cells, favor neoplastic
- glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ
Adenocarcinoma
- endocervical, endometrial, extrauterine, and not otherwise specified (NOS)
OTHER MALIGNANT NEOPLASMS: (specify)
1
4. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
ASC-H Problem based learning
Normal vs ASC-H Problem based learning
Source: Source:
http://nih.techriver.net/patientImagesHighRes/6322.jpg?content-type=download http://nih.techriver.net/patientImagesHighRes/5568.jpg?content-type=download
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning
ASC-H Problem based learning
Source:
http://nih.techriver.net/patientImagesHighRes/5866.jpg?content-type=download
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning
ASC-H vs HSIL Problem based learning
Source:
http://nih.techriver.net/patientImagesHighRes/2064.jpg?content-type=download
2
5. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
The literature
correlating different
cytomorphological patterns
with
biopsy results??
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
1. “Checker board” MGH – like pattern
Cytomorphological Patterns of ASC-H.
1. MGH-like
2. Repair like - Dark nuclei
3A. Atrophy-like- with single cells - Smudgy chromatin
- Nucleoli.
Nucleoli
3B At h lik ith
3B. Atrophy-like- with HCG of parabasal cell groups
f b l ll
- Normoblast-like apoptosis
4. ASC-H: NOS confined to the area of nucleus
5. Cyanophilic small atypical parakeratotic cells
6A. HSIL- syncytial
6B. HSIL- Single cell
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
2. “School of fish” Repair – like pattern 3A. Atrophic “ Single-cell” pattern
- Cohesive clusters
-P i t l li
Prominent nucleoli. - Ab d t blue cytoplasm
Abundant bl t l
- Low N/C ratio - Open chromatin
- W/wout nucleoli
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
3
6. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
3B. Atrophic “ Parabasal cell groups” 5. Small Atypical parakeratotic cells
- HCG of small parakeratotic cells
- Sharp angulated cell margins (vs
- HCG of parabasal cells
p round peripheral borders of cells at
- Small dark nuclei periphery of HSIL syncytium)
- Variable, usually scant cytoplasm - Small koilocytes
- Relatively high N/C ratio
- Chromatin may be smudgy
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
6A. “Isolated cell pattern” 6B. “Syncytial cell” pattern
-Groups of atypical cells
- High N/C ratio (without distinct cell borders)
- Hyperchromatic nuclei - Focal single-cell apoptosis
single cell
(with random distribution of apoptotic bodies)
without nucleoli
- Hyperchromatic nuclei
- Coarse chromatin • (without nucleolar prominence)
- Coarse to fine chromatin
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
Cytomorphological Patterns associated with different clinicopathological categories.
Chivukula M, Shidham VB. ASC-H in Pap test- definitive categorization of cytomorphological spectrum.
CytoJournal 2006, 3:14 doi:10.1186/1742-6413-3-14
Free full text is available at: http://www.cytojournal.com/content/3/1/14
PDF at: http://www.cytojournal.com/content/pdf/1742-6413-3-14.pdf
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
4
7. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
1. MGH-like pattern
Shidham VB, Rao RN, Machhi J, Chavan A.
Microglandular Hyperplasia has a cytomorphological spectrum overlappping with Atypical
Squamous Cells- cannot exclude High-grade Squamous Intraepithelial Lesion (ASC-H).
Groups of metaplastic cells arranged in checkerboard like pattern. The dark nuclei may show nucleoli (arrows). (A
& b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained
Diagnostic Cytopathology 2004 ;30:57-61.
section]).
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
2. Repair-like pattern
Shidham et al.
Diagnostic Cytopathology
2004 ;30:57-61. Cohesive groups of cells with ill-defined school of fish pattern with relatively polarized cells with pointed ends
(arrow head) show relatively low N/C ratio. The nuclei show nucleoli (arrows). (a & b- Cervical smear [Papanicolaou
stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]).
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
3A. Atrophy-like pattern 3B. Atrophy-like pattern-
Single cell pattern. HCG 0f Parabasal cell groups
Cohesive hyperchromatic crowded groups of small parabasal cells with high N/C ratio. The nuclei are relatively
Isolated cells with hyperchromatic atypical nuclei with smudgy chromatin). (a & b- Cervical smear [Papanicolaou small and show nucleoli (arrow). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical
stained SurePath™ Preparation]). biopsy [Hematoxylin-eosin stained section]).
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
5
8. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
4. ASC-H: NOS. 5. Cyanophilic Small Atypical parakeratototic cells
Cohesive groups of hyperchromatic cyanophilic small atypical parakeratotic (SAPK) cells with ill-defined cell
Cohesive groups of atypical cells with mostly ill-defined cell borders. The nuclei vary in size with coarse borders, which are straight with angulations better seen at periphery. N/C ratio is higher. Chromatin is smudgy.
chromatin; however, the nuclear details in most are relatively smudgy (arrows). (a & b- Cervical smear Some cells may show koilocytic space around nuclei. (a & b- Cervical smear [Papanicolaou stained SurePath™
[Papanicolaou stained Sure-Path™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]).
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
6A. HSIL pattern)- Syncytial pattern. Problem based learning 6B. HSIL pattern- Problem based learning
Singly scattered (so called 'litigation') cells.
Hyperchromatic crowded groups of cells without distinct cell borders. The hyperchromatic nuclei vary in size and
Scattered, isolated, atypical cells show high N/C ratio. The nuclei have coarse chromatin without nucleoli (arrows).
show coarsely granular chromatin (arrows). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation],
(a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin
c- Cervical biopsy [Hematoxylin-eosin stained section]).
stained section]).
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14 Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
Cytomorphological Patterns of ASC-H.
Reactive In summary,
1. MGH-like our study identified
2. Repair like
p y
3A. Atrophy like- with single cells
g y p g p
a cytomorphologic spectrum
3B. Atrophy like- with HCG of parabasal cell groups related with
Indeterminate
4. ASC-H: NOS ASC-H interpretations,
LSIL which demonstrated
5. Cyanophilic small atypical parakeratotic cells
HSIL an association pattern
6A. HSIL- syncytial with the results of biopsy and HPV test.
6B. HSIL- Single-cell
6
9. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
Other Twilight Zone-
Some unequivocal cases of LSIL
may also be associated some atypical
y yp
cells suspicious for HSIL.
How to evaluate them and
how to report them?
A dilema!!!!!
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
LSIL-H (with CIN2 & HPV in biopsy)
Shidham VB, Kumar N, Narayan R, Brotzman GL.
Should LSIL with ASC-H (LSIL-H) in cervical smears be an independent category? A study on SurePathTM
Cervical smear with unequivocal LSIL in other fields. This field shows rare LSIL (a & c) with some groups of cells
specimens with review of literature.
consistent with ASC-H. The cells have a high N/C ratio with rounder curving cell borders (better seen in 'b'). At 20X
CytoJournal 2007,4:7
(a), the ASC-H cell is difficult to focus because of three dimensional component in liquid based cytology. (a through
Free full text is available at: http://www.cytojournal.com/content/4/1/7
c- Papanicolaou stained SurePathTM preps)
PDF at: http://www.cytojournal.com/content/pdf/1742-6413-4-7.pdf Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
LSIL-H (with only HPV in biopsy)
Biopsy results for LSIL, LSIL-H, ASC-H, and HSIL
Cervical smear (a, b) showed unequivocal LSIL cells in other fields. This field shows rare LSIL (a & b) along with
some groups of cells consistent with ASC-H. The biopsy (c) showed only human papilloma virus cytopathic effect.
Small atypical parakeratotic (SAPK) cells with distinct and sharp angulated cell borders with tinge of cytoplasmic
eosinophilia (arrowhead in b) (see also corresponding area in a) were interpreted as ASC-H component. (a & b-
Papanicolaou stained SurePathTM preps, c- HE stained cervical biopsy Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
section). Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
7
10. A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
LSIL-H as category overlap with LSIL and ASC-H, but was distinct from HSIL.
Biopsy
Keratinizing
CIN 3
Source:
Chivukula M, Shidham V.
CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations- A potpourri of ASC-H and related interpretations-
Problem based learning Problem based learning
Conclusions Suggested Management algorithm of Women with LSIL-H.
LSIL-H as interpretation category is not a unique
biologic entity.
But it correlates with increased risk of high grade
dysplasia on biopsy.
Biopsy results pattern was intermediate between
§Diagnostic excisional
LSIL and ASC-H, but distinct from HSIL. procedure- Sampling of
transformation
zone and endocervical canal
for histological evaluation with
For optimal clinical management a separate group laser conization, cold-knife
conization, loop
of LSIL-H is justified. electrosurgical excision
(LEEP), and loop
electrosurgical conization.
Application of molecular events such as p16 may Source:
Chivukula M, Shidham V.
be useful in the future. CytoJournal 2006, 3:14
A potpourri of ASC-H and related interpretations-
Problem based learning End
vshidham@mcw.edu Milwaukee Art Museum
8
11. 11/13/2008
Objectives
Study cases and application of
two-
two-color immunochemistry Present real time case studies to
demonstrate the utility of
cytomorphology in interpretation of
y p gy p
Mamatha Chivukula MD, FASCP, FCAP ASC-
ASC-H pap tests
Assistant Professor
Associate Director of
Cytohisto correlation and follow-up
follow-
Immunohistochemistry lab HPV testing
Magee-
Magee-Women’s Hospital of UPMC
Pittsburgh, PA
Cytomorphology of ASC-H
ASC-
Case 1
MGH-like
Repair like 35 year old woman w/ a
Atrophy-like- with single cells
Atrophy-like- with HCG of parabasal
p y p
routine Pap test
cell groups
ASC-H: NOS
Cyanophilic small atypical
parakeratotic cells
HSIL- syncytial
HSIL- Single cell
1
12. 11/13/2008
Groups of atypical cells
(without distinct cell borders)
-
Follow up HPV –DNA test is Positive
for high risk HPV types
Hyperchromatic nuclei
- Coarse to fine chromatin
“Syncytial cell” pattern
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
2
13. 11/13/2008
Case 2
49 year old woman w/ a
routine Pap test
- Abundantblue cytoplasm
-Open chromatin,w/w out nucleoli
Follow up HPV –DNA test is Negative
for high risk HPV types
p16 KI -67
3
14. 11/13/2008
Atrophic “ Single-cell” pattern
Case 3
30 year old woman w/ a
routine Pap test
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:
Cohesive clusters
Follow up HPV –DNA test is Negative
for high risk HPV types
-Prominent nucleoli
P i t l li
- Low N/C ratio
4
15. 11/13/2008
“School of fish” Repair – like pattern
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:14
Case 4
35 year old woman w/ a routine
Pap test
5
16. 11/13/2008
Follow up HPV –DNA test is Positive
for high risk HPV types
“Isolated cell pattern”
Case 5
55 year old woman w/ a
routine Pap test
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:
- HCG of parabasal cells
- Small dark nuclei
- Variable, usually scant
cytoplasm
6
17. 11/13/2008
Follow up HPV –DNA test is Negative
for high risk HPV types
Atrophic “ Parabasal cell groups” Application of two-color
two-
immunochemistry
P16 is over expressed and accumulates in
nucleus and cytoplasm of dysplastic cervical
cells
S di on ASC-US, ASC-H
Studies ASC-US ASC-
Advanced kits for immunostaining cervical
specimens to detect both p16 and ki-67
ki-
simulatneously
Source: Chivukula M, Shidham V. CytoJournal 2006, 3:
State of the art….work in
progress
In a normal cell w/ intact cell cycle,
Simultaneous expression of anti-proliferative
anti-
marker (p16), proliferative marker (ki-67)
(ki-
within the same cell, mutually excludes each
other
Reversely, presence of both p16, ki-67 in
ki-
the same cell, indicates disrupted cell cycle
7
19. 11/13/2008
Multiple Slide Blinded Reviews as a
ASC-H: Quality Improvement Tool
Quality Improvement, Ancillary HPV • Identify Pap tests screened as negative or
testing, and Medicolegal aspects equivocally abnormal preceding subsequent
diagnoses of CIN2/3, AIS, or cervical cancer.
• Insert Pap tests of interest into 10-20 slide
1) Highlight blinded review quality cytology challenge sets
sets.
improvement technique employed at MWH to
enhance ASC-H detection • Ask staff cytotechnologists to rescreen and
2) medicolegal ramifications of disputed interpret all cases on anonymous answer
retrospective ASC-H interpretations. sheets.
3) Unpublished data on the usefulness of • Review rescreening findings with staff along with
HPV testing in the largest series reported to histologic and cytologic follow-up.
date from MWH
Original Review Pap#1
Paps #1 and 2 • Date: 4/7/03
Two Negative Paps Preceding • Diagnosis
CIN2 Biopsy Result – Negative for intraepithelial lesion or
malignancy.
malignancy
– Inflammatory changes.
What do you think?
• Negative
• Cancer
• Suspicious for cancer
• HSIL
• AGC (Atypical glandular cells)
• ASC-H
• LSIL
• ASCUS
1
21. 11/13/2008
Blinded Cytotechnologist
What do you think?
Review Results
• Negative • Negative: 9
• Cancer • ASC-US: 4
• Suspicious for cancer
• HSIL
• AGC (Atypical glandular cells) Retro-review Diagnosis knowing outcome:
• ASC-H Atypical Squamous Cells cannot exclude
• LSIL HSIL (ASC-H)
• ASCUS
Subsequent Surgical
Pathology Result
Paps #3 and 4
• Date: 1/4/07
• Diagnosis: Two Negative Paps Preceding
– Cervical intraepithelial neoplasia 2 (CIN 2) CIN2 Biopsy Result
3
22. 11/13/2008
Original Review Pap #3
• Date: 4/21/05
• Diagnosis
– Negative for intraepithelial lesion or
malignancy
malignancy.
– Repair.
Blinded Cytotechnologist
What do you think?
Review Results
• Negative • Negative: 8
• Cancer • Atypical glandular cells: 1
• Suspicious for cancer
• ASC-H: 2
• HSIL
• ASC-US: 2
• AGC (Atypical glandular cells)
• ASC-H
Retro-review Diagnosis knowing outcome:
• LSIL
Atypical Squamous Cells cannot exclude HSIL (ASC-H)
• ASCUS
4
23. 11/13/2008
Original Review Pap #4
• Date: 6/1/06
• Diagnosis
– Negative for intraepithelial lesion or
malignancy.
malignancy
– Adequate with cocci partially obscuring 50-
75% of epithelial cells.
5
24. 11/13/2008
Blinded Cytotechnologist
What do you think?
Review Results
• Negative • Negative: 2
• Cancer • HSIL: 4
• Suspicious for cancer • ASC-H: 5
• HSIL • ASC-US: 2
• AGC (Atypical glandular cells)
• ASC-H
Retro-review Diagnosis knowing outcome:
• LSIL
• ASCUS High-grade squamous intraepithelial lesion
(HSIL)
Subsequent Surgical Multiple Slide Blinded Review
Pathology Result (MSBR) Conclusions
• Difficult to diagnose ASC-H cases may be
• Date: 1/4/07 best recognized only with the hindsight bias
• Diagnosis: of later known histologic outcome.
– Cervical intraepithelial neoplasia 2 (CIN 2) • Standard of practice- what a reasonable peer
who do under similar circumstances
circumstances-
is different from hindsight bias-influenced
retrospective review.
• ASC Pap Litigation Guidelines state that a
violation of the standard of practice can
ONLY be confirmed with MSBR.
6
25. 11/13/2008
ASC-H and HPV Testing
Atypical squamous cells, cannot exclude HSIL
MWH Experience
p (ASC-H) subcategory was introduced in the 2001
Bethesda System.
-“Atypical (immature) Metaplasia” : small cells
with high N/C ratios.
-“Crowded Sheet Pattern”
Background Background
• Mimics:
• Atrophy • Incidence of ASC-H: 0.22% - 1.09%
• Reactive/reparative change
• Naked nuclei • Reported rate of CIN 2/3 on histologic follow-
•P k t i
Parakeratosis up: 12 2% - 68 2%
12.2% 68.2%
• Immature metaplastic cells
• Reported rates of high-risk HPV + in ASC-H:
33.3% - 85.6%
Background Background on ALTS
• All patients had previous ASC-US or LSIL
• 2006 Consensus Follow-up Guidelines pap on conventional smears based on
from the American Society for Colposcopy 1991 Bethesda terminology.
and Cervical Pathology (ASCCP)
• Participants had liquid-based Pap and
– ASC H
ASC-H go to colposcopy
HPV testing.
– Based on data from the ASCUS / LSIL Triage
Study (ALTS) • Diagnosis was made by 4 pathologists
• 110 ASC-H cases; 84% + hrHPV
• Younger than average patient population.
- Median age 24 years old.
7
26. 11/13/2008
Background GOALS
• 2001 ASCCP guidelines for ASC-US • Evaluate:
recommend “reflex” HPV DNA testing when – ASC-H paps
liquid-based cytology is used. – High-risk HPV (hrHPV) DNA test results
– ~ 85% of ASC-US paps get reflex HPV testing.
ASC US – Histologic follow up
follow-up
• Some studies suggest that HPV testing may – Presence or absence of endocervical/
help triage ASC-H patients and reduce the transformation zone (EC / TZ)
number of colposcopies. • Affect on detection of CIN
• Affect on hrHPV detection
Materials and Methods Materials and Methods
• July 1, 2005 – December 31, 2007 • Histologic follow-up
• ThinPrep Imaging System (TIS) was used – Endocervical curettage
– ASC-H called when small, rounded, squamous cells with dense
– Cervical biopsy
limited cytoplasm, enlarged and euchromatic or hyperchromatic – Cervical conization (loop or cold knife cone)
nuclei and some degree of nuclear membrane irregularities were
identified
• Two surgical pathologists confirmed CIN
– EC/TZ status based on Bethesda 2001. diagnoses.
• High-risk HPV DNA testing via Hybrid – CIN1
Capture II (HC2) – CIN 2 or higher (CIN2/3)
– Ordered by clinicians as reflex for ASC pap, women > 30 y.o., or • Stratified according to age and EC/TZ
HPV regardless. status.
Results
• ASC-H interpretations
– 1646 (1619 ThinPrep, 27 conventional)
– 0.59% of all paps
• 0.60% in TP, 0.38% in conv.
– 1187 (of TP) 73.3% had hrHPV testing done
• Presence or absence of EC/TZ made no
difference with regard to hrHPV DNA
detection or detection of CIN 2/3
8
27. 11/13/2008
Results Results
926 with ASC-H &
hrHPV testing
421 No histology 505 w/ at least 1
cervical bx*
bx
257 (50.9%) hrHPV + 248 (49.1%) hrHPV -
The difference in hrHPV + was significant
between women <40 y.o. and women >40 y.o.
*101 women had two or more biopsies
Results Results
257 (50.9%) HPV + 248 (49.1%) HPV -
160 (62.3%) CIN 35 (14.1%) CIN
• Cumulative CIN detection rate was 38.6% (195/505)
• CIN 2/3 in 87 (17.2%) of 505 ASC-H & hrHPV tested
patients
Results Results (Table 4)
• Statistical difference (P < .001) between hrHPV+
w/ CIN 2/3 and hrHPV – w/ CIN 2/3.
• Women 30 -39 y.o. w/ + hrHPV had the greatest
• 35.8% of HPV+ women < 40 y.o. had CIN 2/3;
risk.
• 20.8% of HPV+ women > 40 y.o. had CIN 2/3
• 4 women had AIS; all were hrHPV +
9
28. 11/13/2008
Results ASC-H w/ reflex hrHPV Testing
• ASC-H PPV of CIN2/3 = 17.2% < 40 y.o. <40 y.o.
Sensitivity 96.1% 100%
• ASC-H and + hrHPV PPV of CIN2/3 = 32.7% Specificity 54% 68.4%
PPV 35 8%
35.8% 20.8%
20 8%
• ASC-H and – hrHPV NPV of no CIN2/3 = NPV 98.1% 100%
98.8%
Comment Comment
• Some abstracts report increased ASC-H
reporting with the use of the ThinPrep
Imaging System (TIS)
– Decreased detection of hr HPV
– Decreased detection of CIN 2/3
CAP interlaboratory comparison program
Comment Why so much variability in hrHPV
detection rates?
• Differences in cytologic interpretation
threshold for ASC-H
ALTS
• Undercalling of HSIL
• Overcalling of ASC-H as HSIL
ASC H
• Overcalling metaplastic cells as ASC-H
• Different patient populations
– Rate of hrHPV + varies from 2.9% (current study) -
32.7% (ALTS)
– ALTS median age 24 y.o.; this study median age 30
y.o.
10
29. 11/13/2008
Summary of this study Conclusions
• Significant difference in detection of CIN in
+ hrHPV than negative. • Using both Pap test and high-risk HPV
DNA testing allows for effective risk
stratification of patients:
• The negative predictive value of – hrHPV
in ASC-H
i ASC H was 100% i women > 40 y.o.
in – HPV + to colposcopy
– HPV – to follow-up with regular Pap and
hrHPV testing.
• Highest CIN 2/3 detection rate was in
women 30-39 y.o. with ASC-H and +
hrHPV
11