Background Molecular testing (MT) of thyroid fine‐needle aspiration (FNA)‐derived genetic material is commonly used to assess malignancy risk for indeterminate cases. The Bethesda System for Reporting Thyroid Cytopathology (TBS) provides limited guidance for the appropriate use of category III (atypia of undetermined significance [AUS]). The authors combined MT with cytomorphology to monitor AUS diagnoses in a cytopathology laboratory. Methods Neoplasia‐associated genetic alterations (NGAs) were determined by MT of preoperative FNA biopsies or resected malignancies and were categorized as BRAF V600E mutations, RAS‐like mutations (HRAS, NRAS, or KRAS mutations or non‐V600E BRAF mutations), or other mutations. Results Among 7382 thyroid FNA biopsies, the AUS rate was 9.3% overall and ranged from 4.3% to 24.2% among 6 cytopathologists (CPs) who evaluated >150 cases. The ratio of specimens falling into TBS category III to specimens falling into category VI (malignant) (the III:VI ratio) was 2.4 overall (range, 1.1‐8.1), and the ratio of specimens falling into TBS categories III and IV (follicular neoplasm or suspicious for follicular neoplasm) combined (III+IV) to specimens falling into category VI (the [III+IV]:VI ratio) was 2.9 overall (range, 1.4‐9.5). MT was performed on 588 cases from 560 patients (79% women) with a median age of 56 years (range, 8‐89 years). BRAF V600E mutation was the most common (76% of cases) in TBS category VI and was rare (3%) in category III. RAS‐like mutations were most common in TBS categories III (13%), IV (25%), and V (suspicious for malignancy) (17.5%). The NGA rate in AUS cases fell between 5% and 20% for 5 of 6 CPs and did not correlate with the III:VI ratio or the (III+IV):VI ratio. Conclusions Lack of correlation between the NGA rate and easily calculable diagnostic ratios enables the calibration of diagnostic thresholds, even for CPs who have normal metrics. Specifically, calculation of the NGA rate and the III:VI ratio may allow individual CPs to determine whether they are overcalling or undercalling cases that other CPs might otherwise recategorize.

Background The Paris system (TPS) has provided a standardized classification for reporting urinary cytology, specifically high‐grade urothelial carcinoma (HGUC). While hyperchromasia is well described in HGUC, there exists little data on nuclear hypochromasia in HGUC. Our focus was to investigate the incidence of hypochromasia in HGUC and if it should become a criterion for HGUC. Design All cases of HGUC at our institution for a 3‐year interval (2017–2019) using TPS were reviewed. Each case had a single ThinPrep slide and concurrent biopsy or resection specimen to confirm the diagnosis within 30 days. The presence of hypochromasia was evaluated, and cases with hypochromasia were stratified based on the tumor cell percentage. Cases with hypochromasia in 5% or greater of the tumor cells were considered “positively identified” for hypochromasia. Results We reviewed 117 cases of HGUC and identified nuclear hypochromasia in 12 cases (10.2%) within 5% or greater of the tumor cells. These 12 cases were further assessed based on if tumor cells showed hypochromasia in 5%–49% of the sample, or greater than 50% of the sample. Hypochromasia in 5%–49% of tumor cells was present in 8/117 cases (6.8%); whereas in 50% or greater samples 4/117 cases (3.4%) showed hypochromasia. No cases were identified where hypochromasia was noted in less than 5% of the tumor cells. Conclusion TPS and use of hyperchromasia as a feature of HGUC is affirmed. However, hypochromasia, while not diagnostic in isolation, is present in a sub‐set of patients with HGUC (10.2%) and should be considered as a variance noted in the nuclei of HGUC.

Gross room personnel (GRP) work alongside pathologists in grossing, frozen section, and autopsy. We observed that gross room personnel desire follow-up and feedback on the specimens they gross or autopsies they perform. Our goal was to create a sustainable educational program for gross room personnel. Our primary focus was to impact team dynamic, morale, and fulfillment. We assessed the need for an educational program through a preprogram survey, which contained 11 subjective statements scored on a scale from 1 to 10 (1—strongly disagree and 10—strongly agree). These statements assessed topics of current follow-up and team dynamic (core statements), perceived effect of current follow-up, and prospective impact of case follow-up. Core statements received relatively low scores (ie, the perception of being “an integral part in making a diagnosis” received only a mean score of 6.7). In response, we established the Gross-to-Scope educational program hosted by pathology trainees and attendings. This program is comprised of monthly one-hour conferences to discuss/review cases and highlight special topics of interest (ie, “What is a radial margin anyway?”). We distributed the same surveys after the first and fourth conferences and found a statistically significant increase in the mean responses to core statements after the first conference ( P = .041). The trend is similar after four conferences. Overall our program addresses various needs by providing educational opportunities for gross room personnel, which strengthens morale and recognizes hard work, and by fostering a working relationship between gross room personnel and pathologists.

Exertional heat illness, including muscle cramps, heat syncope, heat exhaustion, and heat stroke, occur each year in athletes and military soldiers. Exertional heat stroke, the most concerning type of exertional heat illness, is a life-threatening condition defined clinically by a core body temperature greater than 104° F (40°C) and central nervous system dysfunction. Heat stroke may lead to multiorgan failure and death and is one of the leading causes of nontraumatic death in athletes participating in outdoor activities. Current recommendations are discussed regarding prehospital and first responder care of exertional heat illness, particularly heat stroke, with an emphasis on rapid recognition, assessment, and implementation of cooling and advanced care strategies. This overview is of particular interest to orthopaedic team physicians who often are first responders on the field.

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