Faculty Bibliography

BACKGROUND: The noninvasive encapsulated follicular variant of papillary carcinoma (nEFVPTC) has recently been reclassified to "noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)," removing this entity from the malignant category. This re-categorization has had major implications for clinical management. NIFTP has overlapping cytohistologic features with papillary thyroid carcinoma (PTC) and with follicular adenomas (FA), but sonographic data comparing NIFTP to PTC and FA is lacking. Our study examines the sonographic features of NIFTP as compared with PTC and FA. METHODS: Ultrasound scans and Doppler blood flow from subjects who had pre-surgical sonograms and fine needle aspiration biopsies with final surgical pathology diagnoses of NIFTP/nEFVPTC, classical PTC, and FA between 01/2013-08/2016 were assessed. Sonographic and Doppler features as well as Bethesda System (TBS) diagnoses were recorded and analyzed. RESULTS: 40 NIFTP, 58 classical PTC, and 23 FA cases were included. The most common NIFTP pre-surgical TBS cytology diagnosis was Atypia of Undetermined Significance (AUS/FLUS) (40%). NIFTP cases predominantly displayed wider-than-tall shape (100%), smooth borders (75%), occurrence in multinodular glands (82.5%), heterogeneous echogenicity (50%), both perinodular and intranodular Doppler flow patterns (70%), minimal Doppler flow grade (62.5%), and no calcifications (90%). CONCLUSIONS: Our study demonstrates that NIFTP, PTC, and FA display several distinguishing and overlapping sonographic and Doppler features. Sonographic features appear to complement cytology findings and may help raise pre-operative concern for NIFTP in the proper clinical setting, potentially leading to a more conservative management approach.

Introduction: The success of cell block preparation is crucial for ancillary diagnostic tests in cytology. However, achieving an optimal cell block can be challenging. We observed that cell block cellularity is best in cases with visible blood clots in the fine-needle aspiration (FNA) needle wash solution. Therefore, we hypothesized that the adequacy of cell block preparation will improve if FNA aspirates are allowed to first form a clot in the collection tube. Materials and Methods: We created a modified cell block preparation technique allowing FNA samples to clot in a dry tube prior to addition of any liquid media or further cell block preparation (Figure 1). The clinical data, FNA procedure and the cellularity of cell blocks of the clotting group (37 cases) and the conventional needle wash group (33 cases) were compared. Cellularity was evaluated using a scoring system (0 = acellular, 1Z 10 - 50 cells, 2 = > 50 cells). Results: 28 cases (78%) received a score of 2 in the clotting group compared to 12 (36%) in the conventional needle wash group. 5 (15%) received a score of 1 in the clotting group compared to 3 (9%) in the conventional group; 4 received a score of 0 (11%) in the clotting group versus 18 (55%) in the conventional group. The difference in cell block cellularity between the two methods was statistically significant (p < 0.001) (Figure Presented) (Table 1). Immunohistochemistry (15 cases) and molecular analyses (2 cases) was performed in the clotting group compared to 10 and 1 case, respectively in the conventional group. Conclusions: Our study demonstrates that clotting method is superior to the conventional needle wash method. The clotting method avoids diluting FNA samples in liquid media and maximizes the collection of cellular material by holding the aspirate tightly in a blood clot

Objectives: Differentiating squamous cell carcinoma from adenocarcinoma (ACA) in cytology specimens can be challenging. Recent literature showed p40 had higher specificity than p63 for this purpose. Methods: We identified 190 cytology cases with p40 (polyclonal) and p63 (monoclonal clone 4A4) immunohistochemistry, including specimens from fine-needle aspirations (FNAs) and effusions. Results: ACAs of lung origin stained for p40 and p63 in 21% and 20% of cases, respectively, regardless of specimen site. Among lung FNAs of primary pulmonary ACAs (n = 42), 14% were positive for p40 and 24% were positive for p63. Of the 20 pulmonary ACAs in effusions, more cases showed p40 positivity (40%) compared with FNAs, whereas p63 were positive in 15%. Among metastatic ACAs from other sites (n = 14), more cases were positive for p40 than p63. Conclusions: Polyclonal p40 yields a level of false positivity in ACAs similar to p63, which is highest in effusions and is not limited to lung origin.

In the last decade, there has been renewed interest in three-year MD pathway programs. In 2015, with support from the Josiah Macy Jr., Foundation, eight North American medical schools with three-year accelerated medical pathway programs formed the Consortium of Accelerated Medical Pathway Programs (CAMPP). The schools are two campuses of the Medical College of Wisconsin; McMaster University Michael G. DeGroote School of Medicine; Mercer University School of Medicine; New York University School of Medicine; Penn State College of Medicine; Texas Tech University Health Sciences Center School of Medicine; University of California, Davis School of Medicine; and University of Louisville School of Medicine. These programs vary in size and medical specialty focus but all include the reduction of student debt from savings in tuition costs. Each school's mission to create a three-year pathway program differs; common themes include the ability to train physicians to practice in underserved areas or to allow students for whom the choice of specialty is known to progress more quickly. Compared with McMaster, these programs are small, but most capitalize on training and assessing competency across the undergraduate medical education-graduate medical education continuum and include conditional acceptance into an affiliated residency program. This article includes an overview of each CAMPP school with attention to admissions, curriculum, financial support, and regulatory challenges associated with the design of an accelerated pathway program. These programs are relatively new, with a small number of graduates; this article outlines opportunities and challenges for schools considering the development of accelerated programs.

NEEDS AND OBJECTIVES: To address rising education costs, physician shortages, and the need for educational reform, several medical schools have developed accelerated 3-year MD programs. In 2013, NYU School of Medicine began its new 3-year MD program with guaranteed acceptance into residency upon graduation. Using the AAMC's 13 Core Entrustable Professional Activities for Entry into Residency (CEPAER) framework, we designed an immersive 4-hour simulated "Night on Call" (NOC) experience to compare performance of our first graduating cohort of fifteen 3-year MD students (3A), with third (3T) and fourth year (4T) students in the traditional 4-year MD program. SETTING AND PARTICIPANTS: 73 medical students (39 women, age 26.5 (+2.6) years; 36 '3T', 12 '3A', 25 '4T') completed an IRB-approvedNOC at our simulation center 4 weeks prior to the end of their third or final year of medical school. DESCRIPTION: We developed NOC to measure competence and entrustment across all 13 CEPAERs from the perspective of patients, nurses, and attendings. During the simulation, a medical student rotated through a series of 8 clinical coverage scenarios including: 4 standardized patient (SP) cases with varying degrees of complexity, each of which require answering a call from a standardized nurse (SN), evaluating an SP with the SN in the room, making immediate management decisions and writing a coverage note; a phone call to an experienced clinician to orally present (OP) the case; formulation of a clinical question and finding the most appropriate evidence-based medicine (EBM) answer using digital library resources; a clinical vignette (CV) to test ability to recognize a pre-entrustable peer; and a handoff (HO) of 4 cases to a peer (a senior medical student). CEPAERs assessments based on validated tools included communication, physical exam, patient education and interprofessional teamwork skills assessed by an SP and SN, and clinical reasoning based on notes, OP, EBM, CV, HO. Each rater also provided an entrustment judgment. EVALUATION: Although overall student performance improved across cases and some interesting individual performance patterns emerged, there were no significant differences across the three groups in the core competency and entrustment measures evaluated across various NOC activities. DISCUSSION/REFLECTION/LESSONS LEARNED: The 13 CEPAERs are meant to define what students should be expected to perform (without direct supervision) prior to entering residency. Our results, based on multiple rater perspectives, suggest that our cohort of 3A students is as prepared for residency as their 4T counterparts

BACKGROUND: The Bethesda System uses a two-tiered approach in the diagnosis of cervical squamous intraepithelial lesions (SILs). Occasionally, Papanicolaou (Pap) tests with evident low-grade SIL (LSIL) also have some features suggestive but not diagnostic of high-grade SIL (HSIL). This study reviews our experience with "Low-grade Squamous Intraepithelial Lesion, Cannot Exclude High-grade" (LSIL-H) and discusses the best approach to report such Paps if the LSIL-H interpretation is abandoned. METHODS: Abnormal Paps were identified between January and December 2014 that had surgical follow-up within 6 months. Their biopsy outcomes were compared. Statistical analysis was performed using Pearson's Chi-square and McNemar tests in SPSS software version 23. Statistical significance was defined as P