represents a transformative technology that impacts dermatologists and dermatopathologists from residency to academic and private practice. Two concerns are accuracy of interpretation from whole-slide images (WSI) and effect on workflow. Studies of considerably large series involving single-organ systems are lacking.OBJECTIVE To evaluate whether diagnosis from WSI on a digital microscope is inferior to diagnosis of glass slides from traditional microscopy (TM) in a large cohort of dermatopathology cases with attention on image resolution, specifically eosinophils in inflammatory cases and mitotic figures in melanomas, and to measure the workflow efficiency of WSI compared with TM. DESIGN, SETTING, AND PARTICIPANTS Three dermatopathologists established interobserver ground truth consensus (GTC) diagnosis for 499 previously diagnosed cases proportionally representing the spectrum of diagnoses seen in the laboratory. Cases were distributed to 3 different dermatopathologists who diagnosed by WSI and TM with a minimum 30-day washout between methodologies. Intraobserver WSI/TM diagnoses were compared, followed by interobserver comparison with GTC. Concordance, major discrepancies, and minor discrepancies were calculated and analyzed by paired noninferiority testing. We also measured pathologists' read rates to evaluate workflow efficiency between WSI and TM. This retrospective study was caried out in an independent, national, university-affiliated dermatopathology laboratory. MAIN OUTCOMES AND MEASURESIntraobserver concordance of diagnoses between WSI and TM methods and interobserver variance from GTC, following College of American Pathology guidelines.RESULTS Mean intraobserver concordance between WSI and TM was 94%. Mean interobserver concordance was 94% for WSI and GTC and 94% for TM and GTC. Mean interobserver concordance between WSI, TM, and GTC was 91%. Diagnoses from WSI were noninferior to those from TM. Whole-slide image read rates were commensurate with WSI experience, achieving parity with TM by the most experienced user.CONCLUSIONS AND RELEVANCE Diagnosis from WSI was found equivalent to diagnosis from glass slides using TM in this statistically powerful study of 499 dermatopathology cases. This study supports the viability of WSI for primary diagnosis in the clinical setting.

Primary systemic amyloidosis has a varied clinical presentation, making it one of the great masqueraders of other disease entities in clinical medicine. The association of amyloidosis with alopecia is uncommon with at least 22 cases reported in the literature mostly in the setting of systemic amyloidosis. Alopecia in these patients occurs either as the initial presentation of the systemic amyloidosis or it happens during the disease course. The occurrence of amyloid alopecia associated with light chain (LC) restricted plasmacytic infiltrates in the absence of systemic amyloidosis, however, it is not well known. We report 3 cases of LC-associated amyloidosis presenting with alopecia, whereby there was evidence of a systemic plasma cell dyscrasia in 2 of the patients, one of whom developed multiple myeloma. None of the patients had systemic amyloidosis. Skin presentation in the patient with multiple myeloma was characterized by a diffuse form of alopecia affecting the entire scalp, eyebrow, and axillary and pubic hair in contrast to the localized form of alopecia noted in the other 2 patients. The mechanism by which LC-associated amyloidosis eventuates in this pattern of nonscarring alopecia potentially reflects the affinity of this form of amyloid for dermatan sulfate. Dermatan sulfate is found at highest concentrations within the adventitial dermis of the superficial to mid isthmic portions of the anagen hair follicles likely interfering with the hair cycle and induces early hair follicle involution. The result is a pattern of alopecia that can clinically and to some extent pathologically resemble either androgenetic alopecia or alopecia areata.

Objective —There are limited data available in the literature on duplex imaging after axillofemoral bypass grafting. We sought to explore this topic and identify duplex findings predictive of graft failure. Methods —All patients who underwent axillo-femoral or bifemoral prosthetic bypass procedures during an 9-year period and returned for follow-up duplex ultrasound scans (U/S) were included. Protocol based testing included ankle brachial indices, toe pressures, and duplex velocities at proximal anastomosis, mid-axillary graft, and femoral anastomosis sites. Results —Forty-seven patients underwent axillo-femoral bypass prosthetic procedures and returned for follow-up U/S. Mean follow-up was 61 ± 180 months (range, 1–1232) with a mean number of postoperative U/S of 4.5 per person ± 3.6 (range, 1–16). Eight bypass grafts (17%) occluded, i.e., 4 ax-bifemoral segments and 4 femoral-femoral segments. Two of eight occluded patients had not returned for postoperative U/S until occlusion occurred. Of the other 6 patients who underwent postoperative U/S before occlusion, all but one had midgraft peak systolic velocities of <85 cm/sec. Considering all patients evaluated with at least one postoperative examination, midgraft axillary femoral bypass velocities were predictive of future graft failure (p = 0.0001) with occlusion occurring in 66% (5 of 8) of those with velocities <85 cm/sec, and 1 patient (1/37) with velocities >85 cm/sec. Two patients had velocities <85 cm/sec and remained patent. Six patients had abnormal studies (peak systolic velocities >250 cm/sec) but that did not progress to failure at follow-up. One patient had a para-anasatamotic aneurysm that was identified during follow-up that was treated by endovascular grafting. Conclusion —Midgraft axillary femoral bypass velocities are predictive of future graft failure.