Guidelines for resident training in veterinary clinical pathology. IV: Laboratory quality management-Teaching domains, competencies, and suggested learning outcomes

BACKGROUND

The 2019 ASVCP Education Committee Forum for Discussion, presented at the annual ASVCP/ACVP meeting, identified a need to develop recommendations for teaching laboratory quality management principles in veterinary clinical pathology residency training programs.

OBJECTIVES

To present a competency-based framework for teaching laboratory quality management principles in veterinary clinical pathology residency training programs, including entrustable professional activities (EPAs), domains of competence, individual competencies, and learning outcomes.

METHODS

A joint subcommittee of the ASVCP Quality Assurance and Laboratory Standards (QALS) and Education Committees executed this project. A draft guideline version was reviewed by the ASVCP membership and shared with selected ACVP committees in early 2022, and a final version was voted upon by the full QALS and Education Committees in late 2022.

RESULTS

Eleven domains of competence with relevant individual competencies were identified. In addition, suggested learning outcomes and resource lists were developed. Domains and individual competencies were mapped to six EPAs.

CONCLUSIONS

This guideline presents a framework for teaching principles of laboratory quality management in veterinary clinical pathology residency training programs and was designed to be comprehensive yet practical. Guidance on pedagogical terms and possible routes of implementation are included. Recommendations herein aim to improve and support resident training but may require gradual implementation, as programs phase in necessary expertise and resources. Future directions include the development of learning milestones and assessments and consideration of how recommendations intersect with the American College of Veterinary Pathologists training program accreditation and certifying examination.

353. Evaluation of the in vitro activity of amphotericin B used in the liposomal formulation AmBisome against contemporary human fungal pathogens

Background

Amphotericin B is an antifungal drug whose main limitation is toxicity. To reduce these side effects, liposomal formulations have been developed, being AmBisome (L-AmB, Gilead Science Inc) the most commonly used. We describe the in vitro antifungal activity of L-AmB component used in the AmBisome formulation

Methods

We performed a multicenter study to determine the susceptibility to L-AmB using CLSI and EUCAST reference methods. Contemporary human fungal pathogenic species (14 yeast spp and 23 mould spp from different geographical regions were included. Other antifungals (triazoles and echinocandins) were also evaluated.

Results

L-AmB showed activity against yeast species using both EUCAST and CLSI protocols. The strongest activity was shown against Candida albicans (GM-EUCAST 0.24 mg/L (n=85), CLSI 0.23 mg/L (n=111)), C. parapsilosis (GM-EUCAST 0.32 mg/L (n=82), CLSI 0.32 mg/L (n=124)), C. glabrata (GM-EUCAST 0.32 mg/L (n=84), CLSI 0.38 mg/L (n=145)), C. auris (GM-EUCAST 0.46 mg/L (n=20), CLSI 0.31 mg/L (n=22)). In filamentous fungi, lowest MICs were found for Aspergillus fumigatus (GM-EUCAST 0.62 mg/L (n=77), CLSI 0.65 mg/L (n=124)), and A. niger (GM-EUCAST 0.25 mg/L (n=72) , CLSI 0.32 mg/L (n=85)), while for other Aspergillus species, there was a higher variability in the MICs (A. flavus, GM-EUCAST 1.2 mg/L (n=71), CLSI 1.75 mg/L (n=76); A. terreus GM-EUCAST 1.7 mg/L (n=65), CLSI 1.04 mg/L (n=71); A. nidulans GM-EUCAST 1.38 mg/L (n=39), CLSI 0.73 mg/L (n=39)). For other genera from filamentous fungi, L-AmB had a strong activity (GM around 0.2-0.5 mg/L for both methods, including Talaromyces marneffei, Rhizopus arrhizus and R. microscoporus, Lichtheimia corymbifera, Mucor circinelloides). The less susceptible species corresponded to multi-resistant (MDR) species, such as Lomentospora prolificans and Cunninghamella bertholletiae.

Conclusion

The L-AmB component of AmBisome showed activity against most contemporary human fungal pathogens and only showed limited activity against some MDR mould species.

Disclosures

Oscar Zaragoza, Principal Investigator, Gilead: Grant/Research Support Teresa Merino-Amador, n/a, Gilead: Grant/Research Support Cristina de Armentia, n/a, Gilead: Grant/Research Support Cornelia Lass-Flörl, PhD, Gilead: Grant/Research Support Jochem B. Buil, PhD, Gilead: Grant/Research Support Paul E. Verweij, PhD, Gilead: Grant/Research Support Patrick C. Y. Woo, PhD, Gilead: Grant/Research Support Chi-Ching Tsang, PhD, Gilead: Grant/Research Support P. Lewis White, PhD, Associates of Cape Cod: Honoraria|F2G: Advisor/Consultant|Gilead: Grant/Research Support|IMMY: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria Jessica Price, PhD, Gilead: Grant/Research Support Carolyn Grimes, PhD, Gilead: Grant/Research Support Alessandro C. Pasqualotto, PhD, Gilead: Grant/Research Support Manuel Cuenca-Estrella, PhD, Gilead: Grant/Research Support.

Airway remodeling in horses with mild and moderate asthma

Background

There is a remodeling of the central airways in horses with severe asthma but whether a similar process occurs in horses with the mild or moderate asthma (MMA) is unknown.

Objectives

To evaluate lesions affecting the central airways of horses with MMA.

Animals

Twelve horses with MMA and 8 control horses.

Methods

Case‐control retrospective study of horses classified as MMA affected or controls based on history and bronchoalveolar lavage fluid cytology. Endobronchial biopsies were analyzed using histomorphometry and a semiquantitative histologic scoring system.

Results

Histomorphometry identified epithelial hyperplasia (47 μm²/μm [34‐57 μm²/μm]; P = .02), a thickened lamina propria (166 μm [73‐336 μm]; P = .04), and smooth muscle fibrosis (42% [33%‐78%]; P = .04) in horses with MMA when compared to controls horses (24 μm²/μm [21‐80 μm²/μm]; 76 μm [36‐176 μm]; and 33% [26%‐52%], respectively). The semiquantitative score results indicated, in horses with MMA, the presence of epithelial hyperplasia (7 of the 12 horses with MMA and only 1 of the 8 control horses had a score of 1/1), and submucosal inflammatory leucocytes in the central airway (11 of the 12 horses with MMA and only 4 of the 8 control horses had a score ≥ 1/2).

Conclusions and Clinical Relevance

Tissue remodeling of the bronchial lamina propria, epithelium, and smooth muscle was present in horses with MMA.

Retrospective investigation of automated hematology analyzer-determined indicators of neutrophil activation in blood samples from horses with asthma

OBJECTIVE

To investigate indicators of neutrophil activation in the blood of healthy and asthma-affected horses and assess associations between corticosteroid treatment and these variables.

ANIMALS

48 horses (14 with severe equine asthma [SEA], 21 with mild to moderate equine asthma [MEA], and 13 healthy controls).

PROCEDURES

In a 3-part retrospective study, hematology analyzer data for horses included in previous studies were reviewed. Neutrophil size, neutrophil light absorbance (NLA), and myeloperoxidase (MPO) index were recorded. Data for each variable were compared among groups for the entire study sample (part 1). Changes in each variable were assessed for one subset of horses (5 SEA-affected and 6 controls) after treatment for 2 weeks with dexamethasone (0.06 mg/kg, PO, q 24 h; part 2) and for another subset (8 SEA-affected horses) after the same treatment and after a 1-week posttreatment washout period (part 3).

RESULTS

All 3 variables were significantly greater for the SEA group, compared with the MEA and control groups in part 1. Following dexamethasone treatment, the control- and SEA-group NLA and MPO index significantly decreased and SEA-group neutrophil size significantly decreased in part 2; immediate posttreatment results for SEA-affected horses were similar in part 3, with significantly increased neutrophil size and nonsignificant increases in NLA and MPO index following washout.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested horses with exacerbated SEA have larger neutrophils that contain more MPO, compared with neutrophils of MEA-affected and healthy control horses. The clinical value of these variables for the diagnosis of equine asthma was deemed limited owing to data overlap among groups.

Evaluation of 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester lipase concentrations in cats with kidney disease and with normal SNAP fPL

Measuring 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester (DGGR) lipase activity is a cost-effective test for diagnosing pancreatitis compared to the feline pancreas-specific lipase (Spec fPL) test. However, little is known about the influence of renal insufficiency on DGGR lipase in cats. This study evaluated the influence of renal function on serum DGGR lipase in the cat. Serum samples from 49 cats with normal pancreas-specific lipase immunoreactivity were analyzed for DGGR lipase activity and serum creatinine. Median serum DGGR lipase activity for cats with kidney disease (KD+) was 22 IU/L (range: 9 to 29 IU/L), whereas for cats without kidney disease (KD-) and healthy cats, the medians were 16 IU/L (range: 6 to 32 IUI/L), and 15 IU/L (range: 9 to 23 IU/L), respectively. The KD+ group had significantly higher DGGR lipase concentrations compared to the healthy group (P = 0.030), but most results were within the reference range. There was a weak positive correlation between creatinine and DGGR lipase values (R 2 = 19.6%; P = 0.0014) and no significant correlation between symmetric dimethylarginine (SDMA) and DGGR lipase. Key clinical message: Although cats with kidney disease had significantly higher serum DGGR lipase concentrations than the healthy controls, the difference was small and does not appear to be clinically relevant.

Cryptococcus gattii pneumonia in an adult horse which had travelled in an endemic area

A gelding from eastern Canada was presented for cough and exercise intolerance 14 months after it had travelled on Vancouver Island. Cryptococcus gattii pneumonia was diagnosed based on cytology, antigen titers, and polymerase chain reaction (PCR). The horse was treated with fluconazole for 10 months. Delayed C. gattii infection can occur after travel in an endemic area.

Investigation of blood biomarkers for the diagnosis of mild to moderate asthma in horses

Background

Asthma in horses is associated with nonspecific respiratory clinical signs and may be manifested only as exercise intolerance. Its diagnosis relies on bronchoalveolar lavage fluid (BALF) cytology in the presence of compatible clinical signs. The identification of blood biomarkers for this condition would facilitate diagnosis in the field, because there are regional areas where BAL is not routinely performed in clinical practice.

Objective

Identification of blood biomarkers for the diagnosis of asthma in horses.

Animals

Fourteen horses with asthma with increased neutrophil numbers in BALF (neutrophilic asthma), 9 healthy control horses, and 10 horses with other pathologic conditions (pathologic controls).

Methods

Physical examination, clinical score, hematology, and BALF cytology (in a subset of horses) were performed. Serum concentrations of surfactant protein D (SP‐D), haptoglobin, and secretoglobin (SCGB) were measured using commercial ELISA assays.

Results

Serum concentration of SP‐D > 43 ng/mL, serum concentration of haptoglobin >5730 ng/mL, and serum concentration of SCGB <19 ng/mL allowed differentiation of horses with neutrophilic asthma from horses of the control groups (healthy and pathologic) with sensitivity of 55, 95, and 75%, and specificity of 67, 28, and 60%, respectively. Specificity of 100% and sensitivity of 45% were obtained with the combination of SP‐D, haptoglobin, and SCGB at the serum concentrations indicated above. Specificity of 95% and sensitivity of 45% were obtained with the combination of SP‐D and SCGB serum concentrations.

Conclusions and Clinical Importance

Haptoglobin, SCGB, and SP‐D may be diagnostic aids in horses with clinical signs of lower airway disease and neutrophilic pulmonary inflammation.

Polymerase chain reaction for antigen receptor rearrangement: Benchmarking performance of a lymphoid clonality assay in diverse canine sample types

Background

Polymerase chain reaction for antigen receptor rearrangement (PARR) is a molecular diagnostic tool used for discrimination of lymphoid malignancies in dogs from benign processes. Assay variations have been described and are commercially available, but performance metrics are not uniformly reported.

Objectives

To describe performance (accuracy, sensitivity, specificity) and rigorous benchmarking of a PARR protocol (ePARR) in clinically relevant samples.

Animals

One hundred eighty‐one client‐owned dogs.

Methods

Lymphoma and benign tissues representative of the clinical spectrum with gold standard histopathologic and immunohistochemical diagnoses were collected. Assay development and benchmarking were performed on fresh frozen (FF) tissue, formalin‐fixed paraffin‐embedded (FFPE) tissue, flow cytometry pellets, and air‐dried fine‐needle aspirates (FNA). Assay performance was determined for FFPE from 56 dogs (18 B‐cell lymphoma, 24 T‐cell lymphoma, and 14 non‐lymphoma), 80 frozen flow cytometry pellets (66 B‐cell lymphoma, 14 T‐cell lymphoma, 0 non‐lymphoma), and 41 air‐dried FNA slides (23 lymphoma, 18 non‐lymphoma).

Results

For discrimination of lymphoma versus non‐lymphoma, ePARR had 92% and 92% sensitivity and specificity on FFPE with 92% accuracy, 85% sensitivity from flow cytometry pellets (non‐lymphoma was not evaluated to calculate specificity) with 85% accuracy, and 100% and 100% sensitivity and specificity for FNA with 100% accuracy. Stringent quality control criteria decreased assay success rate without significant performance improvement. Performance metrics were lower in most cases for discrimination of B‐ or T‐cell versus non‐B‐ or non‐T‐cell samples than for lymphoma versus non‐lymphoma.

Conclusions and Clinical Importance

These benchmarking data facilitate effective interpretation and application of PARR assays in multiple sample types.

Survival associated with cerebrospinal fluid analysis in downer adult dairy cows: A retrospective study (2006-2014)

Background

Threshold values for total nucleated cell count (TNCC) and protein concentration in cerebrospinal fluid (CSF) of downer dairy cows suggestive of a spinal cord lesion were recently published.

Objectives

Determine short‐ and long‐term survival of downer cows that underwent CSF analysis using the reported threshold values. Evaluate the prognostic value of these threshold values to predict short‐ and long‐term survival.

Animals

Two hundred and fourteen downer adult dairy cows that underwent CSF analysis during hospitalization at the Centre Hospitalier Universitaire Vétérinaire (CHUV) of the Université de Montréal.

Methods

Retrospective study. Medical records of downer adult dairy cows presented to the hospital between January 2006 and October 2014 for which CSF analysis results were available were studied. Short‐term (discharge from hospital) and long‐term (completion of lactation) survival were determined and compared in accordance with CSF TNCC and protein concentration, using a Chi‐square test.

Results

Cows with CSF TNCC and/or protein concentration above the threshold values had a significantly lower short‐term survival rate (P = .02). The odds of nonsurvival of cows with one or both CSF values above the threshold values was 2.16 times higher than the odds for cows with values under the threshold values. CSF TNCC >4.5 cells/μL had sensitivity and specificity of 17.3% (95% CI: 10.7%‐25.7%) and 92.3% (95% CI: 85.4%‐96.6%), respectively, for predicting short‐term nonsurvival. CSF protein concentration >0.39 g/L had sensitivity and specificity of 20.9% (95% CI: 13.7%‐29.7%) and 91.4% (95% CI: 84.2%‐96.0%), respectively.

Conclusions

CSF analysis above threshold values used in this study is associated with increased odds of short‐term nonsurvival.

Cerebrospinal Fluid Analysis in Recumbent Adult Dairy Cows With or Without Spinal Cord Lesions

Background

Diagnosis of central nervous system (CNS) lesions in recumbent dairy cattle (RDC) is challenging because neurologic examination is limited and medical imaging often is challenging or unrewarding. Cerebrospinal fluid (CSF) analysis is useful in the diagnosis of CNS disorders in cattle. However, its utility in identifying spinal cord lesions in RDC remains to be evaluated.

Hypothesis/Objectives

We hypothesized that CSF analysis would discriminate between RDC with and without spinal cord lesions.

Animals

Twenty‐one RDC with spinal cord lesions (RDC+) and 19 without (RDC−) were evaluated.

Methods

Spinal cord lesions were confirmed at necropsy. Signalment, clinical findings, and CSF results were compared retrospectively. Total nucleated cell count and differential, protein concentration, and red blood cell count in RDC+ and RDC− were compared.

Results

Neoplasia, trauma, and infectious processes were the most frequent spinal cord lesions identified. Cerebrospinal fluid protein concentrations and TNCC were significantly higher in RDC+ compared to RDC− (P = .0092 and P = .0103, respectively). Additionally, CSF protein concentrations and TNCC in RDC− were lower than previously published reference ranges. Using an interpretation rule based on CSF protein concentration and TNCC, it was possible to accurately identify 13 RDC with spinal cord lesions and 6 RDC without lesions. It was not possible to determine spinal cord status in the remaining 18 RDC.

Conclusions and Clinical Importance

Cerebrospinal fluid analysis is valuable in the evaluation of spinal cord status in RDC. The prognosis associated with these findings remains to be determined.

Acute-Phase Proteins and Iron Status in Cats with Chronic Kidney Disease

Background

The role of inflammation in the development and progression of chronic kidney disease (CKD) in cats is not well characterized. Hepcidin is a recently discovered acute‐phase protein (APP) that plays an important role in iron metabolism and contributes to the development of anemia in humans with CKD.

Objectives

To compare serum APP concentrations, iron status, and erythropoietin (EPO) concentrations in healthy cats and cats with naturally occurring CKD.

Animals

A total of 18 healthy control cats and 38 cats with CKD.

Methods

Prospective study. After complete physical examination and routine blood analysis, the following tests were performed: serum amyloid A (SAA), haptoglobin (HAP), EPO, serum iron and ferritin concentration as well as total iron‐binding capacity (TIBC). Serum hepcidin‐25 concentration was measured by ELISA kit designed for use in humans.

Results

Mean SAA and hepcidin concentrations were significantly higher and mean total iron and TIBC were significantly lower in the CKD group (P < .05). There was a significant positive correlation between serum creatinine concentration (CRT) and 2 of the APPs (SAA and hepcidin; P < .05). Increases in SAA and hepcidin were associated with decreases in TIBC and hematocrit in the CKD group. Fourteen (37%) of the cats with CKD were anemic, and these cats had significantly lower TIBC (P < .05), suggesting a functional iron deficiency. There was no association between survival time and APP, iron status, or EPO concentrations.

Conclusions

Our data suggest that CKD in cats is associated with systemic inflammation and altered iron metabolism. With further validation in cats, hepcidin assays may help better characterize these relationships.

The relationship in neonates between clinically measured head circumference and brain volume estimated from head CT-scans

OBJECTIVE

To determine if the frontal-occipital head circumference correlates with brain volume on CT and to investigate correlations between the volumes of different brain subdivisions in live neonates.

METHODS

Records were studied from 27 neonates with anatomically normal head CT-scans which were ordered for clinical reasons, and which were performed at Johns Hopkins Hospital. Clinical data were abstracted from medical records. Brain volumes were estimated by digitizing the structures of interest on each slice of head CT-scans.

RESULTS

In this sample of 27 infants with a mean birth weight of 3000.4 +/- 668 g, mean head circumference of 33.5 +/- 1.8 cm, and mean gestational age of 37 weeks and 4 days +/- 24 days, the mean of total brain volume was 333.0 +/- 78.3 ml. The correlation between clinically measured head circumference and total brain volume was 0.55 (P < 0.003). Regression of total brain volume on head circumference and its second and third powers accounted for 43% of the variation in total brain volume. Other predictor variables, namely infant race, sex, gestational age, and maternal age, were not significant in this regression once head circumference was included. The slope of the cubic function of head circumference as a predictor of brain volume was greatest below the mean head circumference of 33.5 cm. Brain volume leveled off at head circumferences greater than the mean.

CONCLUSION

Head circumference is a powerful predictor of total brain volume in the neonate: below the approximate head-circumference mean of 33.5 cm, smaller head circumference indicates smaller total brain volume.

Specific membrane receptor gene expression targeted with radiolabeled peptide employing the erbB-2 and DF3 promoter elements in adenoviral vectors

Radioimmunotherapy is limited by a variety of factors, including poor tumor penetration of monoclonal antibodies and low levels of intratumoral antigen expression. To address these limitations, a gene therapy strategy was devised to genetically induce tumor cells to express enhanced levels of membrane receptors with high affinity for a radiolabeled peptide. We designated this approach as genetic radioisotope targeting strategy. To this end, an adenoviral vector (AdCMVGRPr) encoding the murine gastrin-releasing peptide receptor (GRPr) was used to achieve a high level of binding of radiolabeled bombesin (BBN). To achieve genetic induction of membrane GRPr specifically to tumor cells, we constructed two adenoviral vectors encoding the GRPr gene under the control of the tumor-specific regulatory elements, DF3 (AdDF3GRPr) or erbB-2 (AderbGRPr). We investigated the binding of [125I]BBN to the GRPr following infection with AdDF3GRPr and AderbGRPr in a panel of human breast, pancreatic, and cholangiocarcinoma tumor cell lines. [125I]BBN binding and GRPr expression increased with increasing multiplicities of infection of AdCMVGRPr in all of the cell lines tested. Breast cancer cell lines expressing erbB-2 showed significant GRPr expression using AderbGRPr. A similar result was observed in breast and cholangiocarcinoma cells infected with AdDF3GRPr expressing MUC1 as detected by immunohistochemistry but was not seen in the pancreatic cell lines tested. Thus, adenoviral vectors with tissue-specific promoter elements can be used to achieve a selective expression of membrane receptors that can be targeted with a radiolabeled peptide. The use of such a transcriptional targeting approach may restrict gene expression to tumors and limit the radiation dose deposited in normal tissues in vivo.

Cervicovaginal cytology in an indigent population. Comparison of results for 1964, 1981 and 1989

To evaluate the usefulness of cervicovaginal cytology in decreasing the incidence of cervical carcinoma in an indigent population, the cytologic findings from 10,000 consecutive smears in 1964 (when cytology screening started) were compared to the results of 10,000 consecutive smears in 1981 and 1989. There was a marked (statistically significant) decrease in invasive cervical squamous carcinoma at all ages between the first and later periods. Squamous carcinoma in situ showed a significant decrease beginning in patients under 40 in 1981. The number of atypias and mild dysplasias showed a proportional increase, from 2% in 1964 to 13.4% in 1981 to 21.8% in 1989, predominantly in young patients. These results reaffirm that cervicovaginal cytology remains the most inexpensive and effective diagnostic tool for the elimination of cervical cancer.

CT of an actively-hemorrhaging liver laceration in a 9-year-old child

A 9-year-old female with blunt abdominal trauma following a motor vehicle accident was referred from the Emergency Room for abdominal CT imaging. CT demonstrated the unusual and heretofore unreported finding of an actively hemorrhaging liver laceration.

Otosclerosis surgery in a resident training program

Controversy exists regarding the appropriateness of offering all residents training in stapes surgery due to dwindling case loads in residency programs nationally. A recent study indicated poorer results for stapes surgery performed by residents than results obtained by practicing otologists. One hundred consecutive stapedectomies performed by residents over a three-year period at our institution were reviewed retrospectively, with the objective of determining whether these results should be generalized.

Orbital abscess

Although orbital or subperiosteal abscess may originate from a number of sources, paranasal ethmoidal sinus disease is the most common source of infection, particularly in children. Prompt diagnosis and treatment are necessary to prevent severe visual loss and even death. The authors review the five-group classification of orbital abscess and summarize data regarding source, bacteriology, treatment and visual results from 13 series reporting 148 patients. Four new cases are presented in detail. Diagnostic procedures, including laboratory testing, sinus radiography, ultrasound and CT scanning, are discussed and recommendations are given for medical and surgical management.

Laryngeal tuberculosis: review of twenty cases

Despite a dramatic reduction in incidence of laryngeal tuberculosis over the last three decades, tuberculous involvement still has to be considered in the differential diagnosis of laryngeal lesions. The majority of the 20 cases in our series consists of patients in whom the working diagnosis of carcinoma of the larynx was initially made. These patients presented with the chief complaint of hoarseness of several months duration, frequently associated with dysphagia, but in most cases with chest symptoms that were not prominent despite the fact that most of these patients had far advanced pulmonary tuberculosis. This presentation consists of a detailed analysis of 20 cases, and a discussion of the incidence, pathogenesis, clinical presentation and management of laryngeal tuberculosis.

Melkersson-Rosenthal syndrome

The Melkersson-Rosenthal syndrome (MRS) is a rare condition characterized by the triad of familial relapsing peripheral facial palsy, facial edema, and lingua plicata. Within a well-documented family aggregate of MRS, an index case simultaneously demonstrated all the elements of the triad, as well as gingival changes similar to those of cheilitis granulomatosa. When the incomplete or oligosymptomatic forms are considered, the MRS may be more common than previously thought.