Educational Case: Nutrient Deprivation and Anemia

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹.

Educational Case: Burkitt Lymphoma

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Educational Case: Ductal Carcinoma In Situ (DCIS)

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

A Taxonomic Index for Retrieval of Digitized Whole Slide Images from an Electronic Database for Medical School and Pathology Residency Education

Since the advent of whole slide imaging, the utility of digitized slides for education in medical school and residency has been amply documented. Pathology departments at most major academic medical centers have made digitized slides available to pathology residents for study, even before the use of digitized slides for clinical purposes (i.e., primary diagnosis) has become commonplace. This article describes the experience of one academic medical center with the storage and indexing of large volumes of digitized slides. Our goal was to be able to retrieve scanned slides for a variety of educational applications and thereby maximize the heuristic value of the slides. This posed a formidable challenge in terms of development and deployment of an index system that would allow exemplary slides to be identified and retrieved irrespective of the purpose for which the slide was scanned. We used the structure inherent in Aperio's image management software (eSlide Manager) to build an educational database that allowed each image to be appended with a unique taxonomic identifier so that the individual files could be retrieved in a flexible and utilitarian manner.

Educational Case: The Bleeding Patient

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Educational Case: Human Papillomavirus-Positive Oropharyngeal Squamous Cell Carcinoma

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹.

How to Succeed in Fellowship Acquisition: A Survey of Pathology Residents

Medical school curricula limit students’ exposure to pathology practice while pathology subspecialty training programs require residents to apply for fellowships as early as the end of their first year of training. Thus, limited exposure to pathology practice creates significant confusion and anxiety, often making the fellowship application process premature. Additionally, early focus on subspecialty training in order to acquire a fellowship adds to the initial lack of emphasis on general pathology training. We prepared a voluntary online survey with questions developed through focus groups and advice from an expert in survey design to determine which fellowships are desired and how successful residents are in their pursuit of these fellowships. The survey was distributed through the Pathology Residency Program Directors' (PRODS) listserv. Answers were solicited from pathology trainees throughout the entire training cycle. There were 141 (4.6% response rate) total respondents with each postgraduate year represented. One hundred twenty-two (95%) of 129 residents plan on completing 1 or 2 fellowships after residency training. Encouragingly, 94 (75%) of 126 pathology residents attained their desired specialty fellowship. However, 32 (32%) of 99 residents who acquired at least one fellowship chose a general surgical pathology fellowship. Furthermore, 33 (24%) respondents had already decided to pursue a specific specialty while still in medical school. An additional 32 (23%) came to their decision during postgraduate year 1. Therefore, although most residents are successful in attaining their desired fellowship, further research is needed to understand the effect of early commitment to a subspecialty and its impact on pathology education.

Cancer biology as revealed by the research autopsy

A research autopsy is a post-mortem medical procedure performed on a deceased individual with the primary goal of collecting tissue to support basic and translational research. This approach has increasingly been used to investigate the pathophysiological mechanisms of cancer evolution, metastasis and treatment resistance. In this Review, we discuss the rationale for the use of research autopsies in cancer research and provide an evidence-based discussion of the quality of post-mortem tissues compared with other types of biospecimens. We also discuss the advantages of using post-mortem tissues over other types of biospecimens, including the large amounts of tissue that can be obtained and the extent of multiregion sampling that is achievable, which is not otherwise possible in living patients. We highlight how the research autopsy has supported the identification of the clonal origins and modes of spread among metastases, the extent that selective pressures imposed by treatments cause bottlenecks leading to parallel and convergent tumour evolution, and the creation of rare tissue banks and patient-derived model systems. Finally, we comment on the future of the research autopsy as an integral component of precision medicine strategies.

Practicing Histotechnologists Identify the Core Competencies Needed by Newly Graduated Biomedical Laboratory Scientists in Histotechnology and Histology

The universities of applied sciences in Finland offer 3.5-year courses for histotechnologists and they graduate as biomedical laboratory scientist with 12 credits in histology and histotechnology. The aim of this study was to survey practicing histotechnologists about the core competencies needed by newly graduated biomedical scientists in histology and histotechnology. The data were collected in Finland in 2015. We asked 43 participants to complete a questionnaire that comprised two background questions, five open-ended questions and 38 Likert scale questions, with the responses ranging from five (strongly agree) to one (strongly disagree), and 22 (51%) responded. They stated that the most important competencies were the principles of tissue processing (mean 4.77), embedding (4.64), laboratory safety (4.57), fixation methods (4.55), cutting by microtomy (4.55), quality control of sections (4.55), fixation methods (4.55), and principles of stains (4.36). The least important competencies were quality control of molecular pathology (2.56), interpretation of immunohistological stains (2.71), use of molecular pathology (2.89), and independent dissection (2.91). The respondents stated that there were 20 stains that newly graduated biomedical laboratory scientists needed to know. The practices involving staining emerged in the open responses and four were considered to be important: Hematoxylin-Eosin (n = 18), Periodic Acid Schiff (n = 11), Alcian Blue-Periodic Acid Schiff (n = 9), and Giemsa (n = 9). The most essential tissues to identify were the histology of the alimentary track (n = 9), skin (n = 6), and liver (n = 5). The core competencies that histotechnologists felt were important for newly graduated biomedical laboratory scientists seemed to be consistent with the current curriculum.

Educational Case: Mitochondrial Myopathy

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Education and Professional Development in Rheumatology: Translating Quality Improvement and Education to Clinical Practice

Academic institutions play an essential role in providing physicians with the necessary skills needed to improve the quality and value of care provided. The Accreditation Council for Graduate Medical Education has several milestones in the curriculum of fellowship programs that prioritize involvement in quality improvement (QI) and patient safety efforts. This article reviews the unique benefits and challenges of involving and teaching fellows to conduct QI initiatives. Strategies and resources available to overcome these challenges and develop a successful quality driven training environment are outlined in this article.

PREDICT: a checklist for preventing preanalytical diagnostic errors in clinical trials

Although the importance of guaranteeing a high level of preanalytical quality in routine diagnostic testing has already been largely acknowledged over the past decades, minor emphasis is currently being placed on the fact that accurate performance and standardization of many preanalytical activities are also necessary prerogatives of clinical trials. Reliable evidence exists that clear indications on how to manage the different preanalytical steps are currently lacking in many clinical trials protocols, nor have detailed authoritative documents been published or endorsed on this matter to the best of our knowledge. To fill this gap, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE) will provide here a specific checklist for preventing preanalytical diagnostic errors in clinical trials (PREDICT), especially focused on covering the most important preanalytical aspects of blood sample management in clinical studies, and thus encompassing test selection, patient preparation, sample collection, management and storage, sample transportation, as well as specimen retrieval before testing. The WG-PRE members sincerely hope that these recommendations will provide a useful contribution for increasing the success rate in clinical trials.

Educational Case: Hemolysis and Lipemia Interference With Laboratory Testing

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Educational Case: Developmental Neck Masses and Other Neck Tumors

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Educational Case: Ischemic Disorders of the Gut in Adult Patients

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040. ¹.

Pathology awareness in patients and patient's relatives applying to a pathology laboratory

Objectives:

To investigate pathology awareness in patients applying to a pathology laboratory.

Method:

This cross-sectional study included 150 patients and patients’ relatives. A questionnaire, prepared by the researchers according to the literature, was administered at the Pathology Laboratory, Necmettin Erbakan University, Konya, Turkey on May 2018.

Results:

Of the participants, 79 (52.7%) were female and 71 (47.3%) were male. The mean age was 39.56±14.16 years old. Ninety-eight (65.3%) of them thought that patients do not have right to choose their pathologist. Of the participants, 24 (16%) did not know that the medical school had to be completed in order to become a pathologist and 73 (48.7%) of them did not know that 4 years postgraduate training was required. Fifty-nine (39.3%) of the participants did not know the pathologists were a medical doctor. While 89 participants (59.4%) had no idea what “frozen section” means, 66 people (44%) did not know that the pathologist uses microscope and 64 (42.7%) of them thought that all diseases could be diagnosed 100% by pathological examination. Forty-six (30.7%) of the participants thought that all specimens are not needed to be examined.

Conclusion:

The knowledge and awareness of the participants about the pathology discipline came out to be inadequate.

Impact and Outcomes of the Oklahoma IDeA Network of Biomedical Research Excellence Summer Undergraduate Research Program

Participating in research under the guidance of faculty mentors can increase undergraduate students' skills, knowledge, and confidence in conducting scientific research and pursing a scientific career. The Oklahoma IDeA Network of Biomedical Research Excellence (OK-INBRE) in the US state of Oklahoma has established an infrastructure to develop future researchers and healthcare professionals by providing students with summer internships. However, long-term benefits have not typically been well quantified, and most prior investigations examining benefits and outcomes of undergraduate summer research experiences have been descriptive and/or observational in nature. To assess OK-INBRE summer program participants, educational and career outcomes were systematically tracked. Data for evaluation included 1) primary sources containing responses to learning surveys from OK-INBRE and national cohorts over a three-year period, and 2) secondary sources from the Oklahoma State Regents for Higher Education (OSRHE), that track educational outcomes of Oklahoma students over a 15-year period. Frequency statistics were compiled and bivariate analyses were conducted to examine participant academic and career outcomes. Survey responses reported higher satisfaction in various dimensions of learning among OK-INBRE students than among corresponding national cohorts, particularly on dimensions of knowledge, skills, and understanding of sciences. The OSRHE data showed that, compared with those in the control group, there was a 100% increase in OK-INBRE participants who enrolled in or had completed a professional degree (e.g., MD/DO) and a 175% increase in students attending a biomedical science graduate program. These findings demonstrate the contribution of the OK-INBRE program in promoting science education and professions.

Integrating Social Determinants of Health and Laboratory Data: A Pilot Study To Evaluate Co-Use of Opioids and Benzodiazepines

As the opioid crisis continues to have devastating consequences for our communities, families, and patients, innovative approaches are necessary to augment clinical care and the management of patients with opioid use disorders. As stewards of health analytic data, laboratories are uniquely poised to approach the opioid crisis differently. With this pilot study, we aimed to bridge laboratory data with social determinants of health data, which are known to influence morbidity and mortality of patients with substance use disorders. For the purpose of this pilot study, we focused on the co-use of opioids and benzodiazepines, which can lead to an increased risk of fatal opioid-related overdoses and increased utilization of acute care. Using the laboratory finding of the copresence of benzodiazepines and opioids as the primary outcome measure, we examined social determinants of health attributes that predict co-use. We found that the provider practice that ordered the laboratory result is the primary predictor of co-use. Increasing age was also predictive of co-use. Further, co-use is highly prevalent in specific geographic areas or “hotspots.” The prominent geographic distribution of co-use suggests that targeted educational initiatives may benefit the communities in which co-use is prevalent. This study exemplifies the Clinical Lab 2.0 approach by leveraging laboratory data to gain insights into the overall health of the patient.

Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: A cross-sectional study

INTRODUCTION

We describe the implementation of an Alberta-wide intervention aimed at educating clinicians about redundant vitamin B₁₂ testing. We hypothesized that the introduction of an educational comment outlining recommended vitamin B₁₂ test intervals would reduce the annual number of vitamin B₁₂ tests performed.

MATERIALS AND METHODS

We performed a cross-sectional observational study that included all vitamin B₁₂ tests ordered in Alberta between May 1, 2017 and April 30, 2018. An educational comment was appended to all vitamin B₁₂ test results in Alberta beginning May 2, 2017. Using a simple seasonal model, we compared predicted versus observed vitamin B₁₂ test volumes for the 12-month period following the introduction of the educational comment. The sole outcome measured was the monthly change in volume of vitamin B₁₂ testing. A cost-analysis of the effects of the intervention on test volumes was also performed.

RESULTS

Over the sum of the first 12 months of the intervention, 18,000 more vitamin B₁₂ tests were ordered compared to the predicted value in Alberta. With an estimated cost of $7 per test, this resulted in a $126,000 increase in costs for vitamin B₁₂ testing provincially.

CONCLUSIONS

An educational intervention aimed at limiting inappropriate vitamin B₁₂ testing in Alberta did not alter testing as desired. Multiple utilization management strategies and a longer observation period may be needed to reduce redundant vitamin B₁₂ testing.

Common Hormone Therapies Used to Care for Transgender Patients Influence Laboratory Results

Background

Many laboratory tests are reported and interpreted with sex-specific reference intervals. However, transgender individuals receiving masculinizing or feminizing hormone therapy experience physiological changes predisposing some laboratory tests to shift outside of existing reference intervals. In this study, we review laboratory testing of a large cohort of transgender individuals who were prescribed hormone therapy for at least 6 months at an academic medical center.

Methods

Transgender patients were identified using a search function within the electronic health record with gender identity status verified by chart review. Patients were grouped based on type of hormone therapy administered. All laboratory studies were ordered for medical purposes as part of clinical care; as a result, the exact laboratory tests differed among the patients. Some of the patients had sufficient data for both 6- and 12-month comparisons with baseline laboratory values.

Results

Statistically significant changes were observed at 6- and 12-month comparisons in basic chemistry, endocrine, and hematologic parameters for transgender individuals receiving masculinizing or feminizing hormones. Chart review demonstrated variation in route of administration of hormone therapy and frequency of gender-affirming surgery within the study population.

Conclusions

Transgender individuals receiving hormone therapy experienced significant changes in components of basic chemistry, endocrine, and hematologic parameters following administration of hormone therapy. Variability in hormone dosing and route of administration for gender-affirming treatment warrants further investigation.

Improving the Delivery of Healthcare through Clinical Diagnostic Insights: A Valuation of Laboratory Medicine through "Clinical Lab 2.0"

BACKGROUND

As healthcare payment and reimbursement begin to shift from a fee-for-service to a value-based model, ancillary providers including laboratories must incorporate this into their business strategy. Laboratory medicine, while continuing to support a transactional business model, should expand efforts to include translational data analytics, proving its clinical and economic valuation. Current literature in this area is limited.

CONTENT

This article is a summary of how laboratory medicine can support value-based healthcare. Population health management is emerging as a method to support value-based healthcare by aggregating patient information, providing data analysis, and contributing to clinical decision support. Key issues to consider with a laboratory-developed population health management model are discussed, including changing reimbursement models, the use of multidisciplinary committees, the role of specialists in data analytics and programming, and barriers to implementation. Examples of data considerations and value are given.

SUMMARY

Laboratory medicine is able to provide meaningful clinical diagnostic insights for population health initiatives that result in improved short- and long-term patient outcomes and drive cost-effective care. Opportunities include data analysis with longitudinal laboratory data, identification of patient-specific targeted interventions, and development of clinical decision support tools. Laboratories will need to leverage the skills and knowledge of their multidisciplinary staff, along with their extensive patient data sets, through innovative analytics to meet these objectives.

Society of Toxicologic Pathology Digital Pathology and Image Analysis Special Interest Group Article*: Opinion on the Application of Artificial Intelligence and Machine Learning to Digital Toxicologic Pathology

Toxicologic pathology is transitioning from analog to digital methods. This transition seems inevitable due to a host of ongoing social and medical technological forces. Of these, artificial intelligence (AI) and in particular machine learning (ML) are globally disruptive, rapidly growing sectors of technology whose impact on the long-established field of histopathology is quickly being realized. The development of increasing numbers of algorithms, peering ever deeper into the histopathological space, has demonstrated to the scientific community that AI pathology platforms are now poised to truly impact the future of precision and personalized medicine. However, as with all great technological advances, there are implementation and adoption challenges. This review aims to define common and relevant AI and ML terminology, describe data generation and interpretation, outline current and potential future business cases, discuss validation and regulatory hurdles, and most importantly, propose how overcoming the challenges of this burgeoning technology may shape toxicologic pathology for years to come, enabling pathologists to contribute even more effectively to answering scientific questions and solving global health issues. [Box: see text]

Should Margin Status of Biopsies Be Included in Dermatopathology Reports? Clinician Preferences and the Importance of Unambiguous Language

Significant communication occurs between pathologists and clinicians through the dermatopathology report. Our objective was to describe clinician preference about reporting of the margin status of skin biopsies of nonmelanoma skin cancers. An anonymous survey was sent to 243 medical providers who submitted specimens to a single institution university medical center; 50 complete responses from attending-level providers and advance practice providers were received. The majority (96%) of those surveyed indicated margins should be reported on skin biopsies of neoplasms, particularly nonmelanoma skin cancers (basal cell carcinoma 96% and squamous cell carcinoma 92%) and atypical nevi (96%). When asked about particular language used to describe the margin status, some phrasing led to more variance in respondents' clinical management decisions, with 96%-98% of respondents making the same decision when presented with "unambiguous" terms and 58%-84% of respondents making the same decision when presented with "ambiguous" language (P < 0.001). Respondents generally preferred "unambiguous" margin descriptions when shown an involved margin (70% vs. 30%, P < 0.001) but accepted "ambiguous" language when the margin was clearly uninvolved (68% vs. 32%, P = 0.015). Most respondents (88%) desire inclusion of treatment recommendations in dermatopathology reports. Microscopic descriptions were highly utilized, particularly by nondermatology trained clinicians (97% vs. 80%, P = 0.09). Clinicians desire inclusion of margins for skin biopsies in dermatopathology reports, at least in some circumstances. The choice of language used to describe the margin status in dermatopathology reports has important implications for patient care. Margin descriptors that are unclear or ambiguous may lead to more variance in clinical management.

Harmonization of Training, Training Requirements, Board Certification, and Practice of Hematopathology

OBJECTIVES

Hematopathology (HP) is a rapidly changing field with insufficient data to provide guidance to program directors (PDs), the Accreditation Council for Graduate Medical Education, or the American Board of Pathology.

METHODS

Two surveys were performed-one for HP PDs and one, given twice, for HP diplomates doing Maintenance of Certification/Continuing Certification reporting in 2017 to 2018.

RESULTS

Bone marrow (BM), lymph node (LN), and flow cytometry interpretations and peripheral blood/fluid reviews are performed by more than 80% of hematopathologists and are the areas with the greatest amount of training. A smaller proportion of hematopathologists is involved in other HP-related activities. Most PDs believed fellows should perform BM procedures. Interpretation of 400 or more LNs and 500 BMs was PDs' median expectations for fellows. PDs and HP diplomates considered coagulation and benign RBC disorders overemphasized on the certification examination.

CONCLUSIONS

These results highlight how varied the practice of HP is and can provide guidance to HP PDs, those responsible for assessing HP programs, and the American Board of Pathology.

Serving as a Temporary Pathology Chair: "Boon" or "Boondoggle"?

The 2019 Association of Pathology Chairs Annual Meeting included a discussion group sponsored by the Senior Fellows Group (former chairs of academic departments of pathology who have remained active in Association of Pathology Chairs) that was focused on serving as temporary pathology chair. Such positions include “acting chair” (service while the permanent chair is on leave or temporarily indisposed), “interim chair” (service after departure of the prior chair and before a new chair is appointed), “term-limited chair” (usually one nonrenewable term of less than 5 years), and “terminal chair” (permanent chair being asked to stay until a successor is appointed). Discussion group panelists represented each of these positions and included the perspective of 3 former deans about the rationale for making such appointments. The potential benefits and risks of serving in these roles were discussed. Issues addressed included acting as “caretaker manager” or “change-agent leader”; whether such service and experience would enhance or harm one’s chances to become a permanent chair of that or another department; the effect of such service on academic productivity; the influence of department and institutional factors on the position; the range of authority provided, particularly in addressing significant problems affecting the department’s future; and the impact of time served in these various positions. The “lame-duck” effect of prolonged service as “terminal chair” was also discussed. The observations and advice provided by the panelists and audience discussion are reported and may be useful for those considering service as temporary chair in pathology as well as other academic leadership positions.

Concerns about the pathology job market dominate a popular online pathology forum and likely deterred American medical students from pursuing pathology residency

From 2010 to 2019, 40.5% fewer senior students from United States (US) allopathic medical schools pursued pathology in the Main Residency Match. To possibly explain this trend, we sought to identify major concerns about pathology which were made during this time. Because the Student Doctor Network (SDN) website is widely used by students at American medical schools during the residency application process, SDN has been shown to influence career decisions. So, the 50 all-time most-viewed SDN pathology threads (as of February 2018) were analyzed. The words “job” and “jobs” were used in the title of 11 of the 50 (22%) threads, which altogether received more than 400,000 views. However, the term “job(s)” was rarely used by 14 other major medical specialties. Seven of the 11 (63.6%) job-related threads were created from 2009 to 2011, corresponding with the start of the decline in medical students pursuing pathology residency. It was reasoned that job-market concerns within SDN threads may have discouraged students from pursuing pathology. To test this hypothesis, 5 pathology residents were asked to read all 11 threads and then complete a survey. Most thread reviewers agreed that commenters, which included medical students, were concerned about the pathology job-market and that medical students who viewed the threads would be less likely to pursue pathology residency. Because more than 85% of SDN users are from the US, the threads likely had a greater impact on American medical students compared to foreign students. In conclusion, job-market concerns over the past decade are so prominent in the SDN pathology forum that they likely contributed to fewer seniors from US allopathic medical schools pursuing pathology residency. As of 2019, there are 12 job-related threads among the 50 all-time most-viewed, including threads created in 2016 and 2017. To improve recruitment, the pathology community should carefully review and address concerns about employment opportunities. Due to conflicting reports, additional studies are needed to determine if a mismatch in workforce supply and demand warrants prompt and thoughtful intervention.

The "Race" Toward Diversity, Inclusion, and Equity in Pathology: The Johns Hopkins Experience

With 3.8% black trainees in 2012, pathology had significantly fewer trainees from groups underrepresented in medicine compared to other specialties. To address this, faculty in the Johns Hopkins Department of Pathology established an outreach program and funded rotation for students underrepresented in medicine and from disadvantaged groups. The aims were to increase exposure to the field and improve diversity, inclusion, and equity in pathology. A 1-month rotation for students underrepresented in medicine was established in 2013. Rotation schedules tailored to each rotator's interests included resident conferences and individual faculty meetings. In 2016, a proactive outreach program was established. Faculty visited historically black medical schools and underrepresented in medicine student groups at other institutions, where they gave a "Careers in Pathology" presentation targeted to second- and third-year medical students. Faculty also attended underrepresented in medicine student conferences and participated in high school student programs to further expand the underrepresented in medicine pipeline into medicine and pathology. Since 2016, fourteen outreach presentations have been delivered. The number of rotators increased from 1 in 2013 to 18 in July 2019. Rotators self-identified as African, African American, Hispanic, and Native American. Most were second- to fourth-year medical students, and 1 was a pathology resident. Six rotators are currently pathology residents, and others are strongly considering applying to pathology. The outreach efforts account for the success of our rotation, which, in turn, has had a positive impact on interest in pathology. However, we recognize barriers to retention and intend to incorporate additional professional development activities to further address equity.

Pathology of liver disease: advances in the last 50 years

Liver disease has been recognized in various forms for centuries. Incredible advances, however, have been made especially in the last 50 years, driven by improvements in histology, the development of immunostains, the development of high resolution imaging methods, improved biopsy and resection methods, and the emergence of the molecular era. With these tools, pathologists and their clinical and basic science colleagues moved from classifying liver disease using an observational, pattern-based approach to a refined classification of disease, one based on etiology for medical disease and tumor classification for neoplastic disease. Examples of liver specific diseases are used to illustrate these exciting advances. These impressive advances of the past provide the foundation for hope in the future, as liver pathology continues to play an important role in improving patient care through disease identification and classification and emerging roles in guiding therapy for cures.

A Historical Review of Key Events and Components of Faculty and Professional Development in Psychiatry

Psychiatry's evolution has entailed clinical, educational, research, and administrative missions. Faculty development efforts concern ways in which professional identity, attitudes and skills are transmitted and enhanced from generation to generation. Top-down efforts by national and international organizations and bottom-up movements by individuals in numerous local settings have helped faculty and guided the profession forward. Organizations have provided new faculty with access to mentors and peers across the country, training opportunities, and up-to-date information on emerging scientific, pedagogical, and regulatory trends. Additional innovations and evaluation regarding best practices for faculty development initiatives in psychiatry are needed.

Defining Professional Development in Medicine, Psychiatry, and Allied Fields

Professional development refers to training, formal education, and/or advanced professional learning intended to help clinicians, teachers, researchers, and administrators improve their professional knowledge and effectiveness. Institutions have been trying to adapt to a rapidly changing internal and external environment, with resource constraints and competitive health care. Professional development may be contextualized using adult development, educational, and organizational perspectives, and most best practices overlap. Key partners are faculty, departments, institutions, and national organizations. Interprofessional, team-based and project-based longitudinal initiatives may ignite educational innovations, and serve as a method to learn authentically in the workplace, promote socialization, and change attitudes.

Clinical utility and economic burden of routine serum lipase determination in the Emergency Department

BACKGROUND

Serum lipase is a rapid and reliable laboratory test central to diagnosing acute pancreatitis (AP). Routine use in the emergency department (ED) setting for all cases of abdominal pain or as part of a standard laboratory biochemical profile may lead to unnecessary expenses.

AIM

To examine the utility of serum lipase determination at a tertiary care centre ED.

METHODS

Retrospective cross-sectional study of ED patients having serum lipase determination over a 12-month period. Electronic medical records were reviewed for indication and interpretation leading to additional diagnostic imaging, specialist consultation, interventions or hospital admission.

RESULTS

A total of 24 133 adult patients visited the ED during the study period: 4976 (20.6%) had serum lipase determination, 614 (12.4%) had abnormal lipase, 130 of which (21.1%) were above the diagnostic threshold for acutre pancreatitis (AP) (>3× ULN). A total of 75 patients had confirmed AP (0.3% of all adult ED visits). The positive and negative predictive values of serum lipase (>3× ULN) for AP were 43.6% and 99.6%, respectively. One thousand eight hundred and ninety patients (38.0%) had no abdominal pain on history or physical examination. In this group, the total charge associated with lipase determination was $51 030 with 251 (13.3%) elevated lipase values triggering cross-sectional abdominal imaging in 61 (24.3%) patients and unwarranted gastroenterology consultation in three (1.2%) for an additional charge of $28 975.

CONCLUSIONS

Serum lipase is widely overutilised in the emergency setting resulting in unnecessary expenses and investigations. Evidence-based review of clinical guidelines and more restrictive testing can result in substantial cost savings and improved patient care.

[Pathology training in Spain: What is the status quo and how should we improve?]

The unpopularity of Pathology among medical students is of concern worldwide, as is the high drop-out rate during the speciality training programme. Spain is no exception, with an estimated annual drop-out rate greater than 20%. In the present study, we aimed to analyse factors related to motivation, teaching and satisfaction with post-graduate training. Postgraduates in their 3^rd and 4^th year of speciality training programmes and pathologists during their first three years as specialists were asked to fill in a questionnaire; 155 participants from different parts of Spain took part in the study. Our results revealed a high level of satisfaction among those who had chosen pathology as their specialty and that their satisfaction correlated significantly with two factors: a previous knowledge of the speciality when choosing it and the quality of the training received. We detected certain differences amongst different training centres. The weakest points and thus those that need to be improved were training in molecular techniques, research methods and fine needle aspiration. Improving speciality training is certainly possible and should be the concern of all those who are responsible for postgraduate education in teaching hospitals.

The Patient-Pathologist Consultation Program: A Mixed-Methods Study of Interest and Motivations in Cancer Patients

Context.—

There is a wide disconnect between patients and the pathologists who make their diagnoses. Recent literature highlights successful programs in which patients meet with pathologists to review their pathology reports and see their tissue under a microscope. We do not know how many patients are interested in such a service, nor do we understand what drives interested patients to want to meet with their pathologist and what specific value it may provide.

Objective.—

To quantify patient interest in a patient-pathologist consultation program and qualitatively assess motivations for patient interest or disinterest.

Design.—

Subjects were recruited from an academic cancer center and a local community cancer support group to respond to a survey about their interest in a patient-pathologist consultation program. Both online forms and paper surveys were available. The online survey was promoted via social media.

Results.—

There was a high level of patient interest, with 75% of respondents indicating they were definitely interested in a patient-pathologist consultation program. Key themes of interest were enhanced understanding of the diagnosis and disease, an opportunity to demystify the diagnostic process, and the perception that additional knowledge would empower the patient.

Conclusions.—

In a select group of cancer patients, there is a very high level of interest in a patient-pathologist consultation program. Pathologists, clinicians, and hospital leadership should work together to pilot these programs in diverse settings. Additional quantitative work to scale interventions for the interested population and qualitative work to design effective, patient-centered consultation programs and to assess value are needed.

Intraoral appliances for in situ oral biofilm growth: a systematic review

Background: Oral biofilms are the root cause of major oral diseases. As in vitro biofilms are not representative of the intraoral milieu, various devices have been manufactured over the years to develop Appliance Grown Oral Biofilm (AGOB). Objective: To review various intraoral appliances used to develop AGOB for microbiological analysis, and to judge the optimal means for such analyses. Design: Four databases (PubMed, Science Direct, Scopus and Medline) were searched by two independent reviewers, and articles featuring the key words 'device' OR 'splint' OR 'appliance'; 'Oral biofilm' OR 'dental plaque'; 'in vivo' OR 'in situ'; 'Microbiology' OR 'Bacteria' OR 'microbiome'; were included. The standard Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were adopted for data gathering. Results: Of the 517 articles which met the initial inclusion criteria, 24 were deemed eligible for review. The age of the AGOB, sampled at various intervals, ranged from 30 min to 28 days. The most commonly used microbiome analytical methods were fluorescence microscopy, total cell count using conventional, and molecular tools including Next Generation Sequencing (NGS) platforms. Conclusions: No uniformly superior method for collecting AGOB could be discerned. NGS platforms are preferable for AGOB analyses.

Entrustable professional activities in health care education: a scoping review

CONTEXT

The shift in medical education from time-based learning to outcome-based learning has drawn much attention to entrustable professional activities (EPAs) as an ideal assessment framework to translate competencies into clinical practice. Given the relative novelty of EPAs, this review aims to highlight research gaps and explore and consolidate available evidence pertaining to the development and implementation of EPAs in health care.

METHOD

Arksey and O'Malley's scoping review framework was used to present the findings. The authors performed a systematic search of PubMed, Embase, CINAHL, Scopus, MedNar, OpenGrey and ProQuest Dissertation and Theses for English articles published from the inception of each database to May 2018. A manual search of the reference lists of the included studies was conducted and an expert panel was consulted. Two reviewers screened the articles for eligibility using the inclusion criteria. All authors extracted key data and analysed the data descriptively. Thematic analysis was used to categorise the results into themes.

RESULTS

Eighty articles were included in the review. All articles were published between 2010 and 2018. Three major themes and eight sub-themes were generated: (i) development of EPAs (frameworks for EPA development and implementation, identifying core or specialty-specific EPAs, and EPAs for faculty development), (ii) evaluation of EPAs and EPA entrustment factors (revised curriculum, entrustment decisions for professional activities, and feedback on implemented EPAs and the development process), and (iii) future directions and recommendations for EPAs (implementation of EPAs in undergraduate medical education and specific disciplines, and other criticisms and recommendations for EPAs).

CONCLUSIONS

Entrustable professional activities are an essential means to translate competencies into observable and measurable clinical practice. However, high-level evidence-based research on the efficacy, development and implementation of EPAs for specific target groups (i.e. undergraduates and staff) and geographical regions (i.e. Asia and Africa) is still lacking, which suggests a direction for future research.

Improving Cancer Diagnosis and Care: Patient Access to High-Quality Oncologic Pathology

Drawing on discussions at a workshop hosted by the National Cancer Policy Forum, current challenges in pathology are reviewed and practical steps to facilitate high‐quality cancer diagnosis and care through improved patient access to expertise in oncologic pathology are highlighted

Pathology perspective on gynaecologic malignancy screening questions in electronic consultation

INTRODUCTION

The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries.

METHODS

This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value.

RESULTS

In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings.

CONCLUSION

This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice.

Broadening Our Scope: A Pilot Curriculum in Bioethics for Pathology Graduate Medical Trainees, the Emory University Experience

Despite mandates from the Accreditation Council for Graduate Medical Education and American Board of Pathology, little guidance is available for educating pathology trainees on bioethics. We endeavored to describe the development and implementation of a pathology-specific pilot curriculum in bioethics for pathology trainees at Emory University. After institutional review board review and exemption, we performed a literature search on pathology and ethics, conducted an intradepartmental survey for ethics topics relevant to our trainees and faculty, and referenced the Pathology Milestones related to ethics to develop the framework and materials for the pilot curriculum. The curriculum consisted of 2 introductory and 3 topic-focused sessions over 14 months moderated by pathology faculty with interest and expertise in ethics. Sessions included a short didactic component followed by small group discussions of cases created by the investigators. Surveys were administered to participants before and 16 months after completion of the curriculum. Twenty-nine pathology trainees participated in the curriculum. In baseline surveys, 93% (27/29) of participants believed that ethical dilemmas occur in pathology practice; 62% (18/29) reported having either experienced one or more ethical dilemmas themselves or knowing a pathologist or pathology trainee who had experienced one. In postcurriculum surveys, 87% (13/15) of respondents reported having learned something new, 92% (12/13) anticipated applying this knowledge to pathology practice, and 81% (13/16) would recommend it to a pathology trainee colleague. Limitations include single institution, small sample size, and limited outcome measures for ethics education. Our curriculum may serve as a model for other pathology training programs.

An Examination of Advocacy Education in Residency Training

CONTEXT.—

Pathology-related advocacy is best when performed directly by pathologists. Practicing advocacy is included in the Milestones 2.0 and should be introduced during residency training.

OBJECTIVE.—

To understand advocacy education in residency training we surveyed pathologists to ask what training they had in residency, what resources were available, and what experiences were most impressionable.

DESIGN.—

Two types of inquiry were performed. First, a survey to program graduates asking about leadership and advocacy activities during training and about leadership and advocacy activities since graduation. Secondly, focused email and telephone inquiries were made to 12 pathologists-4 in practice for more than 20 years, 4 within the first 10 years of practice, and to 4 PGY4 (postgraduate year 4) residents-asking what training and experiences were available to them, and how they became motivated to become active in practice.

RESULTS.—

Our results showed that resources available outside of the home program have changed through the years and more national resident groups are available that were not available in the past. These groups may educate trainees in leadership and advocacy. Internally, opportunities to shadow faculty at interdepartmental leadership meetings, as well as selection of the chief resident, are enduring tools for honing these skills.

CONCLUSIONS.—

Teaching advocacy in training is important and part of the Accreditation Council for Graduate Medical Education core requirements as well as a level 5 Milestone. Education may require a balance of internal and external resources since different programs may offer different opportunities. Shadowing during real advocacy events was the most impressionable experience.

Interpretation and Utility of Drug of Abuse Screening Immunoassays: Insights From Laboratory Drug Testing Proficiency Surveys

Context.—

Urine drug testing is frequently ordered by health care providers. Immunoassays are widely used for drug testing, yet have potential limitations, including variable cross-reactivity. The last decade has seen worsening of a prescription drug abuse epidemic.

Objective.—

To use data from a College of American Pathologists proficiency testing survey, Urine Drug Testing, Screening, to determine and summarize the characteristics, performance, and limitations of immunoassays.

Design.—

Seven years of proficiency surveys were reviewed (2011–2017).

Results.—

Rapid growth was seen in participant volumes for specific immunoassays for synthetic opioids (eg, buprenorphine, fentanyl, oxycodone) and 3,4-methylenedioxymethamphetamine (“ecstasy”). Participant volumes remained high for immunoassays targeting less commonly abused drugs such as barbiturates and phencyclidine. For opiate immunoassays, the number of laboratories using a 2000 ng/mL positive cutoff remained stable, and an increasing number adopted a 100 ng/mL cutoff. Opiate and amphetamine immunoassays showed high variability in cross-reactivity for drugs other than the assay calibrator. Assays targeting a single drug or metabolite generally performed well on drug challenges.

Conclusions.—

Survey results indicate strong clinical interest in urine drug testing and some adoption of new assays. However, urine drug testing availability does not parallel prevailing patterns of drug prescribing and abuse patterns. In particular, specific immunoassays for synthetic opioids and a lower positive cutoff for opiate immunoassays may be underused, whereas immunoassays for barbiturates, methadone, propoxyphene, and phencyclidine may be overused. Laboratories are encouraged to review their test menu, cutoffs, and assay performance and adjust their test offerings based on clinical needs and technical capabilities.

Reconceptualizing the Electronic Health Record for a New Decade: A Caring Technology?

Since the 2009 publication by Petrovskaya et al on, "Dilemmas, Tetralemmas, Reimagining the Electronic Health Record," and passage of the Health Information Technology for Economic Clinical Health (HITECH) Act, 96% of hospitals and 78% of providers have implemented the electronic health record. While many positive outcomes such as guidelines-based clinical decision support and patient portals have been realized, we explore recent issues in addition to those continuing problems identified by Petrovskaya et al that threaten patient safety and integrity of the profession. To address these challenges, we integrate polarity thinking with the tetralemma model discussed by Petrovskaya et al and propose application of a virtue ethics framework focused on cultivation of technomoral wisdom.

YAP/TAZ: a promising target for squamous cell carcinoma treatment

Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ) are two homologous transcriptional coactivators and the final effectors of the Hippo signaling transduction pathway. The transcriptional activity of YAP/TAZ is dependent on their recruitment to the nucleus, which promotes binding to the transcription factor of TEA domain family members 1–4 (TEAD1-4). In Hippo-signaling pathway, YAP/TAZ is inactivated and its translocation to the nucleus is blocked via a core kinase cascade stimulated by a variety of upstream signals, such as G-protein-coupled receptor signaling, mechanical pressure, and adherens junction signaling. This pathway plays a very important role in regulating organ size, tissue homeostasis, and tumor development. In recent years, many studies have reported upregulation or nuclear localization of YAP/TAZ in a number of human malignancies, such as breast cancer, melanoma, lung cancer, especially squamous cell carcinoma in different organs. A large number of experiments demonstrate that YAP/TAZ activation promotes cancer formation, progression, and metastasis. Therefore, in this review, we summarize the evidence of regulation and function of YAP/TAZ and discuss its role in squamous cell carcinoma. Collectively, this summary strongly suggests that targeting aberrant YAP/TAZ activation is a promising strategy for the suppression of squamous cell carcinoma.

Induction of labour indications and timing: A systematic analysis of clinical guidelines

BACKGROUND

There is widespread and some unexplained variation in induction of labour rates between hospitals. Some practice variation may stem from variability in clinical guidelines. This review aimed to identify to what extent induction of labour guidelines provide consistent recommendations in relation to reasons for, and timing of, induction of labour and ascertain whether inconsistencies can be explained by variability guideline quality.

METHOD

We conducted a systematic search of national and international English-language guidelines published between 2008 and 2018. General induction of labour guidelines and condition-specific guidelines containing induction of labour recommendations were searched. Guidelines were reviewed and extracted independently by two reviewers. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II Instrument.

FINDINGS

Forty nine guidelines of varying quality were included. Indications where guidelines had mostly consistent advice included prolonged pregnancy (induction between 41 and 42 weeks), preterm premature rupture of membranes, and term preeclampsia (induction when preeclampsia diagnosed ≥37 weeks). Guidelines were also consistent in agreeing on decreased fetal movements and oligohydramnios as valid indications for induction, although timing recommendations were absent or inconsistent. Common indications where there was little consensus on validity and/or timing of induction included gestational diabetes, fetal macrosomia, elevated maternal body mass index, and twin pregnancy.

CONCLUSION

Substantial variation in clinical practice guidelines for indications for induction exists. As guidelines rated of similar quality presented conflicting recommendations, guideline variability was not explained by guideline quality. Guideline variability may partly account for unexplained variation in induction of labour rates.

Regulation of Laboratory-Developed Tests

OBJECTIVES

To provide a clinical laboratory perspective on the Verifying Accurate Leading-edge IVCT Development Act (VALID) discussion draft. This potential legislative effort, if enacted, would overhaul the regulatory oversight of in vitro diagnostics (IVDs) in the United States and create a single system for regulation of conventional IVDs and laboratory-developed tests (LDTs).

METHODS

A concise literature-based review of LDT regulation is presented followed by a discussion of key concerns pertinent to clinical laboratories that should be considered in future IVD regulatory reform efforts.

RESULTS

Key issues identified include the importance of fostering innovation, preserving patient safety, protecting the practice of laboratory medicine, and minimizing undue regulatory burden. Clinical laboratories are not equivalent to manufacturing facilities and would therefore encounter challenges in implementing device-centric regulatory oversight models.

CONCLUSIONS

It is imperative that a clinical laboratory perspective on LDTs is understood and incorporated prior to advancement of future legislative proposals.

Emerging Role of Genomics and Cell-Free DNA in Breast Cancer

OPINION STATEMENT

Precision Medicine is gaining momentum as the future gold standard healthcare strategy as it enables treatment optimization and consequently a potential improvement for quality of life and survival. This paradigm shift was possible thanks to new high-throughput genomics technologies, which provide prognostic and predictive information on tumor biology and potential treatment options, as standard pathological procedures are unable to capture both spatial and temporal tumor heterogeneity. As a result of decreasing costs, both solid and liquid-based genomics have an increasingly important role in clinical trials' screening procedures and are gradually being incorporated into clinical practice. Notwithstanding the great potential, its clinical utility is still a matter of debate and clinicians need to be aware of caveats in interpreting resulting data.