Original research in pathology: judgment, or evidence-based medicine?

Mapping the cited evidence of ductal carcinoma in situ from the 5th edition of the World Health Organisation classification of tumours of the breast

AIMS

Ductal carcinoma in situ (DCIS) is recognised by the World Health Organisation (WHO) Classification of Tumours (WCT) as a non-invasive neoplastic epithelial proliferation confined to the mammary ducts and lobules. This report categorises the references cited in the DCIS chapter of the 5th edition of the WCT (Breast Tumours) according to prevailing evidence levels for evidence-based medicine and the Hierarchy of Evidence for Tumour Pathology (HETP), identifying potential gaps that can inform subsequent editions of the WCT for this tumour.

METHODS AND RESULTS

We included all citations from the DCIS chapter of the WCT (Breast Tumours, 5th edition). Each citation was appraised according to its study design and evidence level. We developed our map of cited evidence, which is a graphical matrix of tumour type (column) and tumour descriptors (rows). Spheres were used to represent the evidence, with size and colour corresponding to their number and evidence level respectively. Thirty-six publications were retrieved. The cited literature in the DCIS chapter comprised mainly case series and were regarded as low-level. We found an unequal distribution of citations among tumour descriptors. 'Pathogenesis' and 'prognosis and prediction' contained the most references, while 'clinical features', 'aetiology' and 'diagnostic molecular pathology' had only a single citation each. 'Prognosis and prediction' had the greatest proportion of moderate- and high-levels of evidence.

CONCLUSION

Our findings align with the disposition for observational studies inherent in the field of pathology. Our map is a springboard for future efforts in mapping all available evidence on DCIS, potentially augmenting the editorial process and future editions of WCTs.

Pathological biopsy strategy by regulating intracellular ROS to precisely differentiate cancer cells from diseased tissues

We have developed an innovative pathological biopsy strategy by expanding the differences of ROS levels among cancer cells, inflammatory cells and normal cells using cross-linked lipoic acid vesicles loaded with vitamin C (VC@cLAVs), combined with chemiluminescence imaging technology. By analyzing the different trends of intracellular chemiluminescence intensity, the three types of cells were quickly and accurately differentiated from diseased tissues, thus holding clinical tumor diagnostic potential.

Phyllodes tumour evidence gaps mapped from the 5th edition of the WHO classification of tumours of the breast

AIMS

Breast phyllodes tumours (PTs) are a rare subset of fibroepithelial neoplasms categorised into benign, borderline, and malignant grades according to the World Health Organization (WHO) Classification of Tumours (WCTs). In this report, we developed an evidence gap map (EGM) based on the literature cited in the PT chapter of the 5th edition of the breast WCT in order to identify knowledge and research gaps in PT.

METHODS

A framework was first established where the dimensions of the EGM were defined as categories of tumour descriptors, tumour types, and evidence levels. Citations were collected into a Microsoft Excel form and imported into EPPI-reviewer to produce the EGM.

RESULTS

The EGM showed that the "Histopathology" and "Pathogenesis" sections contained the most citations, the majority being of low-level evidence. The highest number of citations considered of moderate-level evidence were found in the "Histopathology" section. There was no high-level evidence cited in this chapter. The "Localisation", "Aetiology", and "Staging" sections had the fewest citations.

CONCLUSION

This EGM provides a visual representation of the cited literature in the PT chapter of the breast WCT, revealing the lack of high-level evidence citations. There is an uneven distribution of references, probably due to citation practices. Pockets of low-level evidence are highlighted, possibly related to referencing habits, lack of relevant research, or the belief that the information presented is standard accepted fact, without the need for specific citations. Future work needs to bridge evidence gaps and broaden citations beyond those in the latest WCT.

Decline of case reports in pathology and their renewal in the digital age: an analysis of publication trends over four decades

AIMS

We investigated the trend in case reports (CRs) publication in a sample of pathology journals. Furthermore, we proposed an alternative publishing route through new digital communication platforms, represented by the 'social media case report'.

METHODS

28 pathology journals were selected from SCImago database and searched in PubMed to identify the number of published CRs. Four reference decades (1981-2020) were selected. The 5-year impact factor (IF) was retrieved from the Academic Accelerator database.

RESULTS

CRs increased during the first three decades (6752, 8698 and 11148, respectively; mean values: 355, 27.3%; 334, 26.4%; 398, 28.8%) as the number of CR-publishing journals (19, 26 and 28, respectively). In the last decade, CRs significantly decreased (9341; mean 334, 23.6%) without variation in the number of CR-publishing journals (28). Half of the journals reduced CRs (from -1.1% to -37.9%; mean decreasing percentage -14.7%), especially if active since the first decade (11/14, 79%); the other half increased CRs (from +0.5% to +34.2%; mean increasing percentage +11.8%), with 8/14 (57%) starting publishing in the first decade. The 5-year IF ranged from 0.504 to 5.722. Most of the journals with IF ≥2 (10/14, 71%) reduced the CRs number, while 71% of journals with IF <2 increased CRs publication (especially journals with IF <1, +15.1%).

CONCLUSIONS

CRs publication decreased during the last decade, especially for journals which are older or have higher IF. Social media CRs may represent a valid alternative and by using standardised templates to enter all relevant data may be organised in digital databases and/or transformed in traditional CRs.

Relapsing Tubulointerstitial Nephritis with Antimitochondrial M2 Antibody Accompanied by Pulmonary Involvement

We herein report a 50-year-old woman who suffered from tubulointerstitial nephritis with antimitochondrial M2 antibody, distal renal tubular acidosis, and Fanconi syndrome. Our case also had interstitial pneumonia. After initially successful glucocorticoid therapy, tubulointerstitial nephritis and interstitial pneumonia relapsed. After the second successful round of glucocorticoid therapy, tubulointerstitial nephritis relapsed again and responded to glucocorticoid and azathioprine. This case might indicate (1) the association between pulmonary involvement and tubulointerstitial nephritis with antimitochondrial antibodies and (2) the need for a maintenance dose of glucocorticoid and immunosuppressants in tubulointerstitial nephritis with antimitochondrial antibodies.

False-positive pathology: improving reproducibility with the next generation of pathologists

The external validity of the scientific literature has recently come into question, popularly referred to as the "reproducibility crisis." It is now generally acknowledged that too many false positive or non-reproducible results are being published throughout the biomedical and social science literature due to misaligned incentives and poor methodology. Pathology is likely no exception to this problem, and may be especially prone to false positives due to common observational methodologies used in our research. Spurious findings in pathology contribute inefficiency to the scientific literature and detrimentally influence patient care. In particular, false positives in pathology affect patients through biomarker development, prognostic classification, and cancer overdiagnosis. We discuss possible sources of non-reproducible pathology studies and describe practical ways our field can improve research habits, especially among trainees.

Rethinking the doctor-patient relationship: toward a hermeneutically-informed epistemology of medical practice

Although typically implicit, clinicians face an inherent conflict between their roles as medical healers and as providers of technical biomedicine (Scott et al. in Philos Ethics Humanit Med 4:11, 2009). This conflict arises from the tension between the physicalist model which still predominates in medical training and practice and the extra-physicalist dimensions of medical practice as epitomised in the concept of patient-centred care. More specifically, the problem is that, as grounded in a "borrowed" physicalist philosophy, the dominant "applied scientist" model exhibits a number of limitations which severely restrict its ability to underwrite the effective practice of care. Moreover, being structural in character, these problems cannot be resolved by piecemeal modifications of the existing model, nor by an appeal to evidence-based medicine (Miles in J Eval Clin Pract 15(6):887-890, 2009; Miles in Folia Med 55(1):5-24, 2013; Miles et al. in J Eval Clin Pract 14(5):621-649, 2008). Hence, the need for medical theorists to "partner with experts in the humanities to build a sui generis philosophy of medicine" (Whatley in J Eval Clin Pract 20(6):961-964, 2014, p. 961). In response, the present paper seeks to vindicate the merits of hermeneutically-informed template in providing the requisite grounding. While capable of correcting for the limitations of the applied scientist model, a hermeneutically-informed template is a "both/and" approach, which seeks to complement rather than exclude the physicalist dimension, and thereby aspires to reconcile technical mastery with patient-centred care, rather than eschew one in favour of the other. As such, it can provide a cogent philosophical template for current best practice, which does justice to the art as well as the science of medical care.

Structured Annual Faculty Review Program Accelerates Professional Development and Promotion: Long-Term Experience of the Duke University Medical Center's Pathology Department

This retrospective observational study on faculty development analyzes the Duke University Pathology Department's 18-year experience with a structured mentoring program involving 51 junior faculty members. The majority had MD degrees only (55%). The percentage of young women faculty hires before 1998 was 25%, increasing to 72% after 2005. Diversity also broadened from 9% with varied heritages before 1998 to 37% since then. The mentoring process pivoted on an annual review process. The reviews generally helped candidates focus much earlier, identified impediments they individually felt, and provided new avenues to gain a national reputation for academic excellence. National committee membership effectively helped gain national exposure. Thirty-eight percent of the mentees served on College of American Pathologists (CAP) committees, exponential multiples of any other national society. Some used CAP resources to develop major programs, some becoming nationally and internationally recognized for their academic activities. Several faculty gained national recognition as thought leaders for publishing about work initiated to serve administrative needs in the Department. The review process identified the need for more protected time for research, issues with time constraints, and avoiding exploitation when collaborating with other departments. This review identified a rigorous faculty mentoring and review process that included annual career counseling, goal-oriented academic careers, monitored advancement to promotion, higher salaries, and national recognition. All contributed to high faculty satisfaction and low faculty turnover. We conclude that a rigorous annual faculty review program and its natural sequence, promotion, can greatly foster faculty satisfaction.

Underutilization of Meta-analysis in Diagnostic Pathology

CONTEXT

Underutilization of Meta-analysis No studies to our knowledge have investigated citations and utilization of meta-analysis in diagnostic pathology (DP).

OBJECTIVE

To characterize meta-analyses in DP compared with meta-analyses in medicine.

DESIGN

We searched PubMed for meta-analyses in 12 major DP journals without specifying years and in 4 major medicine journals in both 2006 and 2011. We compared articles' adjusted citation ratios (ACRs), defined as an article's citation count divided by the mean citations for the meta-analysis, review, and original research articles published in the same journal in the same year.

RESULTS

Forty-one of 76 DP articles, 74 of 125 medicine articles in 2011, and 52 of 83 medicine articles in 2006 were qualified meta-analyses as identified by PubMed. The ACRs of DP meta-analysis articles were higher than those of original research articles (2.62 ± 2.31 versus 0.92 ± 0.84, P < .001) and similar to those of review articles in 2006 (2.62 ± 2.31 versus 1.95 ± 1.59, P = .50), but they were similar to both in 2011 (1.85 ± 1.39 versus 0.99 ± 1.43, P = .11; 1.85 ± 1.39 versus 1.12 ± 1.43, P = .21, respectively). Diagnostic pathology and medicine meta-analyses had similar ACRs (1.85 ± 1.39 versus 1.57 ± 1.35 in 2011, P = .60; and 2.62 ± 2.31 versus 1.85 ± 1.90 in 2006, P = .50, respectively). However, although DP journals published fewer meta-analyses (0.97% versus 6.66% in 2011 and 0.67% versus 4.40% in 2006, P < .001 for both), they published more meta-analyses using both original and published data than medicine (21.95% versus 1.59%, P < .001). They also published more meta-analyses per year in 2011-2014 than in 2000-2010 (6.4 ± 1.29 versus 1.36 ± 1.03 articles per year, P < .001).

CONCLUSIONS

We found underutilization of meta-analyses in DP, despite their high ACRs and recently increased utilization. More DP meta-analyses are needed.

Underutilization of Meta-analysis in Diagnostic Pathology

Context

No studies to our knowledge have investigated citations and utilization of meta-analysis in diagnostic pathology (DP).

Objective

To characterize meta-analyses in DP compared with meta-analyses in medicine.

Design

We searched PubMed for meta-analyses in 12 major DP journals without specifying years and in 4 major medicine journals in both 2006 and 2011. We compared articles' adjusted citation ratios (ACRs), defined as an article's citation count divided by the mean citations for the meta-analysis, review, and original research articles published in the same journal in the same year.

Results

Forty-one of 76 DP articles, 74 of 125 medicine articles in 2011, and 52 of 83 medicine articles in 2006 were qualified meta-analyses as identified by PubMed. The ACRs of DP meta-analysis articles were higher than those of original research articles (2.62 ± 2.31 versus 0.92 ± 0.84, P &lt; .001) and similar to those of review articles in 2006 (2.62 ± 2.31 versus 1.95 ± 1.59, P = .50), but they were similar to both in 2011 (1.85 ± 1.39 versus 0.99 ± 1.43, P = .11; 1.85 ± 1.39 versus 1.12 ± 1.43, P = .21, respectively). Diagnostic pathology and medicine meta-analyses had similar ACRs (1.85 ± 1.39 versus 1.57 ± 1.35 in 2011, P = .60; and 2.62 ± 2.31 versus 1.85 ± 1.90 in 2006, P = .50, respectively). However, although DP journals published fewer meta-analyses (0.97% versus 6.66% in 2011 and 0.67% versus 4.40% in 2006, P &lt; .001 for both), they published more meta-analyses using both original and published data than medicine (21.95% versus 1.59%, P &lt; .001). They also published more meta-analyses per year in 2011–2014 than in 2000–2010 (6.4 ± 1.29 versus 1.36 ± 1.03 articles per year, P &lt; .001).

Conclusions

We found underutilization of meta-analyses in DP, despite their high ACRs and recently increased utilization. More DP meta-analyses are needed.

Evidence-based pathology: systematic literature reviews as the basis for guidelines and best practices

CONTEXT

Evidence-based medicine has been proposed as a new paradigm for the identification and evaluation of medical information. Best available evidence or data are identified and used as the basis for the diagnosis and treatment of individual patients. Evidence-based pathology has adapted basic evidence-based medicine concepts to the specific needs of pathology and laboratory medicine.

OBJECTIVES

To briefly review the history and basic concepts of evidence-based medicine and evidence-based pathology, describe how to perform and interpret systematic reviews, and discuss how to integrate best evidence into guidelines.

DATA SOURCES

PubMed (National Library of Medicine, Washington, DC) and Web of Science (Thompson Reuters, New York, New York) were used.

CONCLUSIONS

Evidence-based pathology provides methodology to evaluate the quality of information published in pathology journals and apply it to the diagnosis of tissue samples and other tests from individual patients. Information is gathered through the use of systematic reviews, using a method that is less biased and more comprehensive than ad hoc literature searches. Published data are classified into evidence levels to provide readers with a quick impression about the quality and probable clinical validity of available information. Best available evidence is combined with personal experience for the formulation of evidence-based, rather than opinion-based, guidelines that address specific practice needs.

Terahertz pulsed spectroscopy of paraffin-embedded brain glioma

The refractive indices, absorption coefficients, and complex dielectric constants of paraffin-embedded brain glioma and normal brain tissues have been measured by a terahertz time-domain spectroscopy (THz-TDS) system in the 0.2- to 2.0-THz range. The spectral differences between gliomas and normal brain tissues were obtained. Compared with normal brain tissue, our results indicate that paraffin-embedded brain gliomas have a higher refractive index, absorption coefficient, and dielectric constant. Based on these results, the best THz frequencies for different methods of paraffin-embedded brain glioma imaging, such as intensity imaging, coherent imaging with continuum THz sources, and THz pulsed imaging with short-pulsed THz sources, are analyzed.

The business value and cost–effectiveness of genomic medicine

Genomic medicine offers the promise of more effective diagnosis and treatment of human diseases. Genome sequencing early in the course of disease may enable more timely and informed intervention, with reduced healthcare costs and improved long-term outcomes. However, genomic medicine strains current models for demonstrating value, challenging efforts to achieve fair payment for services delivered, both for laboratory diagnostics and for use of molecular information in clinical management. Current models of healthcare reform stipulate that care must be delivered at equal or lower cost, with better patient and population outcomes. To achieve demonstrated value, genomic medicine must overcome many uncertainties: the clinical relevance of genomic variation; potential variation in technical performance and/or computational analysis; management of massive information sets; and must have available clinical interventions that can be informed by genomic analysis, so as to attain more favorable cost management of healthcare delivery and demonstrate improvements in cost–effectiveness.

Histology of adipose tissue inflammation in Dercum's disease, obesity and normal weight controls: a case control study

Background

Dercum's disease (DD) is characterised by obesity and chronic pain (> 3 months) in the adipose tissue. The pathogenesis of DD is unknown, but inflammatory components have been proposed. In previous reports and studies, an inconsistent picture of the histological appearance of the adipose tissue in DD has been described. The aim of this investigation was to examine the histological appearance of adipose tissue in patients with DD, with particular focus on inflammatory signs.

Methods

Fat biopsies were sampled from painful regions from 53 patients with DD. In 28 of the patients, a control adipose tissue biopsy was taken from a location where the patient did not experience any pain. In addition, fat biopsies were sampled from 41 healthy pain-free obese control patients and 11 healthy pain-free normal weight control patients. The extent of inflammation was evaluated on histological sections stained with haematoxylin-eosin.

Results

There was no statistically significant difference in the extent of inflammation between the biopsies from the painful knee and the biopsies from the non-painful area (p = 0.5), nor between the biopsies from the abdomen, and the biopsies from the non-painful area (p = 0.4), in patients with DD. A statistically significant difference in extent of inflammation was observed between DD and obese control patients regarding the abdomen (p = 0.022), but not the knee (p = 0.33). There were no differences in extent of inflammation between DD patients and normal weight controls (p = 0.81).

Conclusion

The findings suggest that there is an inflammatory response in the adipose tissue in DD. However, this response is not more pronounced than that in healthy obese controls. This contradicts inflammation as the aetiology of DD.

How does a pathologist make a diagnosis?

A pathologic diagnosis is the result of a complex series of activities, mastered by the pathologist. The nature of these activities is, however, rarely talked about in depth. The medical literature occasionally discusses aspects of the pathologic diagnosis processes, generally departing from the pathologic practice. The lack of a model makes discussions about the subject a matter of preference or personal style. Educational programs are largely based on the apprenticeship model, and the development of specific abilities rests on the personal aspects of both apprentice and mentor. A model for the pathologic diagnostic process is proposed. The process of diagnosis can be viewed as an action plan, encompassing 4 domains: (1) cognitive, (2) communicative, (3) normative, and (4) medical conduct. The cognitive domain involves processes of perception, attention, memory, search, hypothesis creation, and verification, among others. Communicative skills consist of providing arguments in support of a diagnostic conclusion, with adequate clinical and relevant pathologic information. Pathologic diagnosis is also subject to technical rules (based on empirical experiences), rules of rational choice (strategies aiming at definite goals), and consensual rules among peers. Finally, the pathologic diagnosis has to be evaluated in the sphere of medical conduct, from the perspectives of both the pathologist and the referring clinician. An understanding of the diagnostic process from a theoretic perspective will benefit pathology as a science and a medical specialty because it provides the basis for understanding diagnostic variations and discrepancies. Pathologic difficulties or errors can be mapped, allowing the institution of specific remedies. This model may also enhance training and educational strategies because specific emphasis can be directed toward a particular difficulty.

Patient safety: a macrosystems perspective

Coupling anatomic pathology work cells with a macrosystem construct creates a decision-making perspective that can improve service quality, reduce risk, and enhance patient safety. The authors examine recent changes that have had an impact on anatomic pathology macrosystems, the evolving macrosystem tactics to ensure maintenance of patient safety, and macrosystem change theory. They explore the usefulness of high reliability organization theory and normal accident theory. They conclude with an analysis of the potential for enhanced patient safety through macrosystem consolidation, standardization, and communication in a best care algorithm based on outcome analysis.

Validation of novel optical imaging technologies: the pathologists' view

Noninvasive optical imaging technology has the potential to improve the accuracy of disease detection and predict treatment response. Pathology provides the critical link between the biological basis of an image or spectral signature and clinical outcomes obtained through optical imaging. The validation of optical images and spectra requires both morphologic diagnosis from histopathology and parametric analysis of tissue features above and beyond the declared pathologic "diagnosis." Enhancement of optical imaging modalities with exogenously applied biomarkers also requires validation of the biological basis for molecular contrast. For an optical diagnostic or prognostic technology to be useful, it must be clinically important, independently informative, and of demonstrated beneficial value to patient care. Its usage must be standardized with regard to methods, interpretation, reproducibility, and reporting, in which the pathologist plays a key role. By providing insight into disease pathobiology, interpretive or quantitative analysis of tissue material, and expertise in molecular diagnosis, the pathologist should be an integral part of any team that is validating novel optical imaging modalities. This review will consider (1) the selection of validation biomarkers; (2) standardization in tissue processing, diagnosis, reporting, and quantitative analysis; (3) the role of the pathologist in study design; and (4) reference standards, controls, and interobserver variability.

Predicting impact factor one year in advance

The first impact factor (IF) to reflect the sole efforts of a new editorial team occurs 4 years into what is usually a 5-year editorship, owing to the lag times of: paper accrual and publication, accumulation of citations in derivative literature, and compiling of such citations by the Thomson ISI Web of Knowledge service. Through weekly collection of citation data from the Web of Science over the past 2 years, we now demonstrate that the evolution of IF can be tracked weekly over the course of a calendar year, enabling prediction of the next year's IF beginning at the middle of the previous year. The methodology used to track the developing IF for Lab Invest is presented in this study and a prediction made for the 2006 IF, along with IF predictions for other general pathology journals (American Journal of Pathology, Journal of Pathology, Modern Pathology, American Journal of Surgical Pathology, and Human Pathology). Despite the fact that the 2006 IF for Lab Invest will not be issued until June 2007, it became apparent as early as July 2006 that the Lab Invest IF would be greatly improved over 2004 and 2005 by a predicted 0.5 units. However, as important as IF can be to a journal, it is vital not to let IF considerations influence every aspect of the editors' decisions. Rather, the significance of early prediction lies in earlier validation of editorial policies for journal management as a whole, and reassurance that the philosophy for journal operations is on track.

Why microscopy will remain a cornerstone of surgical pathology

Recent years have seen increasing predictions of the demise of conventional microscopy in patient care and investigative medicine. However, these predictions fail to recognize the power of morphologic analysis by a skilled observer. The amount of information that can be obtained from a simple H&E slide represents a windfall in terms of data quality, quantity and cost when compared to any other available technique. Moreover, the value of such interpretation is irreplaceable as we develop newer and more sophisticated technologies. Overall, it appears that reports of the death of microscopy have been greatly exaggerated.