Does how much a resident teaches impact performance? A comparison of preclinical teaching hours to pathology residents' in-service examination scores

BACKGROUND

While others have studied the effects of resident teaching on medical student performance, few have examined the benefits to the resident educator. Our study compared the quantity of pathology residents' didactic teaching with their performance on in-service examinations.

METHODS

The academic records of anatomic/clinical pathology residents over 10 years were reviewed. Scores on step I of the United States Medical Licensing Examination (USMLE(®)), the annual percentile on the in-service examination, and preclinical teaching hours for each resident were obtained.

RESULTS

Average annual teaching hours showed a weak positive correlation with mean in-service examination performance. Those below the 50th percentile had a lower number of teaching hours (average 7.8) than above the 50th percentile (mean 10.4, P=0.01). The incremental positive association between the two metrics increased by year in training and was strongest among senior residents, even controlling for USMLE performance (P<0.01).

CONCLUSION

There is an association between the amount of pathology residents' preclinical educational activity and their mean performance on in-service examinations.

Visual memory effects on intraoperator study design: determining a minimum time gap between case reviews to reduce recall bias

OBJECTIVES

The objective of this research was to determine test intervals between intraoperator case reviews to minimize the impact of recall.

METHODS

Three pathologists were presented with a group of 120 slides and subsequently challenged with a study set of 120 slides after 2-week and 4-week intervals. The challenge set consisted of 60 slides seen during the initial review and 60 slides previously unseen within the study. Pathologists rendered a diagnosis for each slide and indicated whether they recalled seeing the slide previously (yes/no).

RESULTS

Two weeks after having been shown 60 cases from a challenge set of 120 cases, the pathologists correctly remembered 26, 22, and 24 cases or 40% overall. After 4 weeks, the pathologists correctly recalled 31% of cases previously seen.

CONCLUSIONS

Pathologists were capable of recalling from memory cases seen previously at 2 and 4 weeks. Recall rates may be sufficiently high to affect intraobserver study design.

Stromal tumor of uncertain malignant potential of the prostate

Stromal tumor of uncertain malignant potential (STUMP) of the prostate is a rare tumor with a variable and unpredictable clinical course. Many STUMPs are diagnosed incidentally and never progress, while others may invade locally and rapidly recur after surgical intervention, and yet others may lead to distant metastasis and death. A wide array of histologic patterns is encompassed by STUMP, and distinguishing these tumors from prostatic stromal sarcoma or other causes of stromal expansion often proves difficult. Owing to the rarity of this tumor, there is not yet a consensus on appropriate management. However, owing to the possibility of aggressive behavior, close management and consideration of definitive resection is warranted.

The eAutopsy: an effective virtual tool for exposing medical students to the postmortem examination

OBJECTIVES

One reason for declining autopsy numbers is clinicians' lack of familiarity with the practice. We developed an online tool used in place of attending postmortem examinations and aimed to determine if the experience was as effective in affecting medical students' attitudes toward the procedure.

METHODS

The eAutopsy was a part of a unit consisting of a mixture of a didactic lecture, readings, and online discussion board. A class of second-year medical students was randomly distributed between autopsy attendance and the eAutopsy, afterward completing a Likert-type attitudinal survey. Responses were compared with previous students receiving only a lecture.

RESULTS

Thirty students attended a "live" autopsy, 90 completed the eAutopsy, and 47 students from the prior year completed the survey. Responses between all three were statistically similar for all but one item. The live and eAutopsy groups would be significantly more comfortable asking for an autopsy in the future. Narrative responses indicated that while the eAutopsy was effective in delivering information, some noticed the lack of emotional impact.

CONCLUSIONS

The two forms of autopsy exposure performed similarly on a Likert-type survey assessing certain attitudes related to the procedure. However, the emotional impact of the live experience may be longer lasting.

Intestinal transplantation in children with multiple intestinal atresias and immunodeficiency

GVHD has been reported in 8-10% of children after small bowel transplant (SBTx). Immunodeficient children may be predisposed to aggressive, steroid-resistant GVHD. There exists a unique association of immunodeficiency in children with MIA (MIAI). We report on our SBTx experience in patients with the diagnosis of MIAI, their high incidence of GVHD, and the possible role of stem cell transplantation in these patients. We performed a review of records from children that underwent SBTx or that we evaluated for SBTx at our institution. We focused on the diagnoses of atresia, multiple intestinal atresia, immunodeficiency, and GVHD in our patient population. Children with MIAI are likely to experience severe GVHD following SBTx. MIAI correlated with a 100% incidence of GVHD in these patients. Of the five patients with MIAI that underwent SBTx, three succumbed to severe GVHD within 1-6 months after SBTx. One patient received stem cell transplant prior to SBTx and did not develop severe GVHD, but died from influenza nine months after SBTx. Our unique patient survives long-term, with engraftment of donor γ δ T cells. He has mild, persistent chronic GVHD. Atresia is a common referral diagnosis for SBTx. Patients with multiple atresias, especially MIAI, are at significant risk for the complication of GVHD following SBTx. We recommend careful immunologic assessment and antecedent stem cell transplant in children with MIAI prior to SBTx.

Increased hepatic stiffness as consequence of high hepatic afterload in the Fontan circulation: a vascular Doppler and elastography study

Hepatic dysfunction is a recognized complication after Fontan palliation of congenital heart disease. We sought to quantitatively measure hepatic stiffness and vascular Doppler indices using ultrasound (US) and shear wave elastography (SWE) in a Fontan cohort. Subjects were prospectively recruited for echocardiography and real-time hepatic duplex US with SWE for hepatic stiffness (kPa). Doppler peak velocities, velocity time integral, resistive, pulsatility, acceleration indices (RI, PI, AI), and flow volume were measured in celiac artery, superior mesenteric artery, and main portal vein (MPV). A subset underwent cardiac catheterizations with liver biopsy. Correlations were explored between SWE, duplex, hemodynamic, and histopathologic data. In all, 106 subjects were studied including 41 patients with Fontan physiology (age 13.8 ± 6 years, weight 45.4 ± 23 kg) and 65 controls (age 15.0 ± 8.4 years, weight 47.9 ± 22 kg). Patients with Fontan physiology had significantly higher hepatic stiffness (15.6 versus 5.5 kPa, P < 0.0001), higher celiac RI (0.78 versus 0.73, P = 0.04) superior mesenteric artery RI (0.89 versus 0.84, P = 0.005), and celiac PI (1.87 versus 1.6, P = 0.034); while MPV flow volume (287 versus 420 mL/min in controls, P = 0.007) and SMA AI (829 versus 1100, P = 0.002) were lower. Significant correlation was seen for stiffness with ventricular end-diastolic pressure (P = 0.001) and pulmonary artery wedge pressure (P = 0.009). Greater stiffness correlated with greater degrees of histopathologic fibrosis. No significant change was seen in stiffness or other duplex indices with age, gender, time since Fontan, or ventricular morphology.

CONCLUSION

Elevated hepatic afterload in Fontan, manifested by high ventricular end-diastolic pressures and pulmonary arterial wedge pressures, is associated with remarkably increased hepatic stiffness, abnormal vascular flow patterns, and fibrotic histologic changes. The MPV is dilated and carries decreased flow volume, while the celiac and superior mesenteric arterial RI is increased. SWE is feasible in this population and shows promise as a means for predicting disease severity on liver biopsy.

Twelve-year survival after multiple recurrences and repeated metastasectomies for renal cell carcinoma

Background

Metastatic renal cell carcinoma (RCC) presents a therapeutic challenge for clinicians because of the unpredictable clinical course, resistance to chemotherapy or radiotherapy and the limited response to immunotherapy.

Patients and Methods

We report a case of a 62-year-old woman who underwent nephrectomy for T4N0 RCC, clear cell type, Fuhrman grade 3/4 in 1999. The patinet subsequently had multiple tumor recurrences.

Results

The patient underwent eight metastasectomies, including multiple partial left nephrectomies, right adrenalectomy, a complete left nephrectomy, and distal pancreatectomy. She remains well and tumor free 12 years after initial diagnosis.

Conclusion

Repeated resections after initial metastasectomy can be carried out safely and provide long-term survival in selected patients with recurrent metastasis from RCC. The findings from our case indicate that close follow-up for the early detection of recurrence and complete resection of metastases can improve the results after repeated resection.

Sarcomatoid Urothelial Carcinoma: A Single Cancer Center Experience

Background

Sarcomatoid bladder cancer is a rare and aggressive variant of urothelial carcinoma.

Methods

A retrospective review of our experience in managing patients with sarcomatoid bladder cancer (SRBC) between 1997 and 2011 was performed to better define the behavior and outcomes of this disease.

Results

The median age of the patients was 63 years. All patients presented with high grade histology. Eighty-five percent of the patients presented with muscle invasive disease and fifty percent presented with stage IV carcinoma. Ten of 14 (71%) of patients underwent a cystectomy. Patients with SRBC was younger (P < 0.01), more commonly presented with higher grade histology (P < 0.01) and advanced stage disease (P < 0.01), in comparison with patients with Urothelial carcinoma (UC). At a median follow-up of 7 months (range 1.3 - 112), five (35.7%) patients have died in last follow-up. Two-year survival was 53.5%. Three patients with long term survival were reported.

Conclusions

Sarcomatoid bladder cancer is associated with poor prognosis. Multimodality therapy may improve these patients outcome.

Anal-transitional and bronchial metaplasia within the ileostomy of a small bowel allograft: a case report

Epithelial metaplasia is a phenomenon where a native mucosal cell type is replaced by another due to altered stem cell differentiation, usually as the result of long-standing injury or inflammation. It is common in ileostomies performed with native small bowels for both neoplastic and inflammatory conditions. We present a case of anal-transitional and bronchial epithelial metaplasia that occurred near the ileostomy of a small bowel allograft in a seven-month-old male transplanted for short bowel syndrome related to gastroschisis. The anal-transitional metaplastic mucosa had an immunophenotype (CK7- and p63-positive) similar to that of normal mucosa at the anal transition zone and a DNA STR profile consistent with the donor. To our knowledge, this represents the first report of this type of metaplasia occurring in ileostomies in the English literature. It is important for clinicians and pathologists to recognize these benign mucosal alterations to avoid diagnostic confusion.

Characterization of Epithelial Apoptosis in Biopsies of Small-Bowel Allografts Using Cleaved Caspase 3 Immunostaining

Background. The diagnosis of acute cellular rejection (ACR) in small-bowel allograft biopsies depends in part on quantification of crypt apoptotic bodies (ABs). The definition of ABs varies between authors. Recently, immunoperoxidase stains specific for apoptotic material have been used in paraffin-embedded tissue. The aim was to characterize AB morphology and quantify ABs using immunoperoxidase and hematoxylin and eosin (H&E) staining. Methods. Allograft biopsies with diagnoses of negative for ACR, indeterminate for ACR, and mild ACR were selected. Sections were stained for cleaved caspase 3 (CC3). The number of ABs per 10 crypt epithelial cells was compared by H&E and CC3 staining. Results. A total of 39 cases (15 negative, 12 indeterminate, 12 mild ACR) were obtained. CC3 staining revealed that ABs varied from well-developed “classical” exploding crypt cells to intraepithelial clusters of basophilic material. In 61%, the number detected by CC3 was higher than on H&E stains (mean 4.30 and 3.56; P < .002), with good overall correlation. With the latter definition, AB numbers by H&E were significantly higher in most cases (72%), with the diagnosis of mild ACR being downgraded in 50% if only classical ABs were counted. Conclusions. ABs have a range of morphology in biopsies of intestinal allografts, and H&E identifies the majority. The results suggest that AB counts should include basophilic clusters.

A cribriform urothelial neoplasm of the renal pelvis: an adenoid cysticlike variant of inverted urothelial papilloma or florid ureteritis cystica?

Tumors with cribriform appearance, similar to that of salivary gland adenoid cystic carcinoma, have been described at various anatomic sites. We present an unusual polypoid tumor, discovered incidentally, in the renal pelvis of an elderly man. The mass displayed a prominent cribriform architecture, akin to adenoid cystic carcinoma with an immunophenotype that supported a urothelial origin. Because of its lack of significant invasive growth and other adverse morphologic features, this lesion will likely behave in a banal fashion. This cribriform urothelial neoplasm of the renal pelvis may, in fact, represent a variant of an inverted urothelial neoplasm with a prominent cystic component or florid ureteritis cystica. It is important for pathologists to recognize this growth pattern as a possible variant of urothelial tumors.

Pure erythropoiesis in clear cell renal cell carcinoma

Extramedullary hematopoiesis (EMH) is a phenomenon in which benign immature hematopoietic cells are found in sites other than the bone marrow. Although usually associated with an underlying hematologic abnormality such as myelofibrosis, it can be found in some physiologic states or occasionally within solid tumors. In most instances, foci of EMH contain elements of all cell lineages. Presented here is the second reported case of EMH occurring in a low-grade clear cell renal cell carcinoma in a patient without evidence of hematologic disease. As previously, it manifested as pure erythropoiesis as confirmed by morphology and immunohistochemistry. It is possible that this finding is related to erythropoietin secretion by the tumor and not hematologic malignancy.

Simple melanosis of the bladder: a rare entity

Simple melanosis of the bladder is an uncommon condition with fewer than 15 reported cases characterized by multifocal, diffuse melanin pigmentation of the urothelial mucosa. It is frequently associated with urinary incontinence or urgency. Histologically, melanin granules are present within urothelial cells or lamina propria macrophages with or without bland-appearing mucosal melanocytes. Although considered a benign entity, the rarity of the lesion warrants regular follow-up cystoscopic evaluation with biopsies to screen for the development of malignancy, especially malignant melanoma. This study presents a "typical" case with light, cytochemical, immunohistochemical, and ultrastructural characterization.

Lymphocyte-depleted thymic remnants: a potential diagnostic pitfall in the evaluation of central neck dissections

The head and neck region is a frequent site for potentially confusing incidental benign findings not related to the primary pathologic process and having no impact on patient prognosis. Several lesions are thymic in origin. We report 3 cases of lymphocyte-poor thymic remnants identified in central cervical (level VI) lymph node dissections for unrelated benign and malignant pathology. In each, the rests were nearly completely composed of bland epithelial cells with rare admixed lymphocytes. These cells were immunophenotypically similar to thymic epithelial cells, although they differed in the paucity of associated thymic lymphocytes and lack of Hassall corpuscles. Lymphocyte-depleted thymic remnants in the central cervical compartment are not well described in the literature. It is important to be aware of these and other benign inclusions to avoid making incorrect diagnoses of malignancy.

Capillary Hemangioma of the Testis

Testicular hemangiomas are benign vascular neoplasms usually occurring in children. Pathologists must be aware of this entity when performing intraoperative frozen sections as, after diagnosis, testicle-sparing surgery is adequate. The authors present a typical case with immunohistochemical studies and a review of the literature.

Serous Cystadenoma of the Epididymis

Tumors reminiscent of müllerian epithelial tumors of the ovary have been reported outside of the ovary, including in the pancreas and paratesticular region. The latter are most commonly serous tumors of borderline malignant potential and involve the tunicae. We present the first case of a serous cystadenoma of the epididymis in English reports with a brief literature review.

Mesenchymal Hamartoma of the Liver With an Interstitial Deletion Involving Chromosome Band 19q13.4: A Theory as to Pathogenesis?

Mesenchymal hamartoma of the liver is the third most common liver tumor of infancy. The lesion is primarily mesenchymal in origin, believed to arise from a developmental abnormality in the formation of ductal plates during late embryogenesis. Several studies have revealed a recurrent translocation in mesenchymal hamartomas, all involving a breakpoint at chromosome band 19q13.4. We present a case with a deletion involving this locus. A 10-month-old girl presented with an asymptomatic abdominal mass. The 21.0-cm tumor arose from the surface of the liver. The cut surfaces displayed multiple cysts with intervening loose fibrous tissue. Microscopically, the tumor was mostly composed of edematous connective tissue with intervening cysts, islands of hepatocytes, and haphazard branching bile ducts. Cytogenetic analysis revealed an interstitial deletion on the long arm of chromosome 19(q13.1q13.4). The patient was discharged on postoperative day 4 without complications. The cytogenetic findings support the involvement of an alteration of a gene at chromosome band 19q13.4 in the pathogenesis of mesenchymal hamartoma of the liver.