Journal Article Maintenance of Certification for Pathologists: What We Know So Far Get access Robert W. McKenna, (chair), MD, Robert W. McKenna, (chair), MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar Diane D. Davey, MD, Diane D. Davey, MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar Rebecca L. Johnson, MD, Rebecca L. Johnson, MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar David Keren, MD, David Keren, MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar James L. Madara, MD, James L. Madara, MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar Sharon W. Weiss, MD, Sharon W. Weiss, MD *Maintenance of Certification Committee, American Board of Pathology Search for other works by this author on: Oxford Academic Google Scholar Betsy D. Bennett, (ex officio), MD, PhD Betsy D. Bennett, (ex officio), MD, PhD *Maintenance of Certification Committee, American Board of Pathology *Address reprint requests to Dr Bennett: American Board of Pathology, PO Box 2915, Tampa, FL 33622. Search for other works by this author on: Oxford Academic Google Scholar Pathology Patterns Reviews, Volume 124, Issue suppl_1, 1 December 2005, Pages S5–S7, https://doi.org/10.1309/UQJDWCJGK6032D2G Published: 01 December 2005
Inflammatory skin disease is a diagnostic challenge for both dermatologists and pathologists. Unlike the diagnosis of cutaneous neoplasms, biopsies of inflammatory disorders generally present a differential diagnosis for the pathologist. Similarly, the dermatologist is also presented with a clinical differential diagnosis prompting the biopsy. Assimilating all of the information is challenging yet rewarding when an accurate diagnosis is made. In this review we present several “newer” inflammatory diseases of the skin and discuss the differential diagnosis. Many of these entities are associated with underlying systemic disease, making early recognition and diagnosis critical. Pathologists should be familiar with these histopathologic findings to assist with the optimal clinical-pathological diagnosis.
The US Food and Drug Administration (FDA) has approved 4 rapid assays for detecting antibodies to HIV using whole blood, serum, plasma, or oral fluid specimens. The HIV antibodies are measured using lateral flow or flow-through immunoassay procedures. No special laboratory instrumentation is needed, and results are interpreted by visual observation in 20 minutes or less. The whole blood and oral fluid assays are waived tests and can be used in a point-of-care setting. The sensitivity and specificity of these HIV assays are similar to those of the standard HIV enzyme immunoassays. Rapid HIV results are required in the labor and delivery setting to help prevent mother-to-child transmission of HIV infection and in the occupational health setting to test the source patient after a needlestick injury. Rapid HIV testing also is used in emergency departments and outpatient clinics to help prevent the spread of HIV by identifying people with otherwise unrecognized HIV infection. If the FDA approves a rapid HIV test for home use, the public would be able to use it in the privacy of their homes, which would encourage more people to know their HIV status.
The debate about the existence of deleterious clinical effects of allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) continues and is now concentrated on differing interpretations of findings of randomized controlled trials (RCTs). This review focuses on the results of studies reported during the last 5 years, especially recent RCTs, studies of the association of ABT with all-cause mortality, studies of the hypothesis attributing TRIM effects to WBC-derived soluble mediators that accumulate during storage, and studies comparing the risk of adverse outcomes before and after the implementation of WBC reduction of cellular blood components. When this literature is considered along with that available before 2001, the results from studies of adverse clinical TRIM effects remain contradictory. Based on the totality of the evidence, there seems to be an association between WBC-containing ABT and short-term (≤3 months posttransfusion) mortality that becomes manifest in cardiac surgery and in comparison with administration of allogeneic blood components filtered before storage. However, with the possible exception of cardiac surgery, there is no area in the extensive TRIM literature in which there is agreement among the studies or in which the observed clinical effects follow consistently from a postulated biologic mechanism. Allogeneic blood transfusion (ABT) results in the infusion into the recipient of large amounts of foreign antigens in soluble and cell-associated forms. The persistence of these antigens in the circulation of the recipient may create conditions that allow for the development of immune down-regulation. Evidence from a variety of sources indicates that ABT enhances the survival of renal allografts 1 and may increase the recurrence rate of resected malignant neoplasms 2 and the incidence of postoperative bacterial infections, 3-8 as well as reduce the recurrence rate of Crohn disease 9 and/or activate infections with cytomegalovirus or HIV. 10 This syndrome, the mechanisms and clinical relevance of which remain to be defined, has been referred to in the transfusion medicine literature as ABT-related immunomodulation (TRIM). 11,12
In 2002, the Agency for Healthcare Research and Quality funded a consortium of hospital laboratories to study errors in the anatomic pathology diagnostic testing pathway. Currently, 9 laboratories are consortium members and share error data, perform root cause analysis, and design and implement error reduction initiatives. These laboratories have established baseline error frequencies and determined the causes of diagnostic, sampling, identification, and reporting errors. These laboratories have shown that interpretive variability is a major impediment to error reduction. During the last several years, error-reduction interventions have been attempted in many areas of anatomic pathology. Interventions such as double-slide viewing and process redesign have been shown to reduce significantly error proportions.
Ten years have passed since the Graylyn Conference Report on Laboratory Medicine Clinical Pathology training was issued. Over that period, the Accreditation Council for Graduate Medical Education substantially revised the requirements for training programs; the American Board of Pathology amended both the requirements and the periods needed for certification; and the discipline itself, along with the broader discipline of pathology, evolved significantly. Recently, a curriculum proposal in anatomical pathology was published as a potential template to be used by training programs to help meet these new and evolving needs. Toward the same end, the Academy of Clinical Laboratory Physicians and Scientists has now developed a template for a curriculum in clinical pathology (laboratory medicine), taking into account newly designated and revised areas of residency core competency, the alterations in training requirements promulgated by the Accreditation Council for Graduate Medical Education and American Board of Pathology, and the rapidly developing nature of the discipline itself. The proposed clinical pathology curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by pathology residency training programs.
This study was designed to identify high-risk process steps for phlebotomy at the Westwood UCLA Medical Center, Los Angeles, CA, using failure mode and effects analysis (FMEA). A Six Sigma design phase and SIPOC (suppliers, input, process, output, and customers) analysis were also completed. Laboratory phlebotomists had 4 high-risk process steps, and the highest risk for error occurred during patient wristband identification (risk priority number [RPN] score, 140). Nursing phlebotomy had 7 high-risk FMEA steps. The 2 highest RPN scores were associated with comparing preprinted, nonbarcoded admission labels with patient wristbands and comparing hospital information order sheets with patient wristbands. FMEA analysis and Six Sigma projects require a strong partnership with other health care professionals for successful completion and review.
We describe the cultural transformation of the surgical pathology laboratory at Henry Ford Hospital, Detroit, MI, to one that has adopted an expectation for empowered workers to see their daily work in the context of continually learning and making effective process improvements that are designed and tested by the scientific method. This transformation has been achieved by creating an organizational and educational framework for implementing guiding principles originally systematized as the basis of lean manufacturing by our founder, Henry Ford, at the turn of the century, and incorporating the innovations of the Toyota Production System. We present novel data collection techniques to establish baseline states by which to gauge the success of changes and lessons from rapid process improvement studies. Herein, we share our experiences, lessons learned, and successes to date in the pathology-based Henry Ford Production System. We do not make changes for the sake of making them, but we never fail to make a change once it is demonstrated that the new way is better than the old way. We hold it our duty to permit nothing to stand in the way of progress. —Henry Ford 1
The use offine-needle aspiration biopsy or percutaneous core needle biopsy to diagnose breast lesions has increased during the past few decades. Although the benefits of these procedures are well known, controversies remain about the management of certain categories of breast lesions detected by these methods. This article discusses the management issues in categories of breast lesions, including papillary lesions, atypical lobular hyperplasia and lobular carcinoma in situ, and mucinous lesions diagnosed by the preoperative techniques of aspiration or core biopsy.
This article discusses the fundamentals for measuring the viscosity of whole blood, serum, and plasma and its application to the diagnosis of hyperviscosity syndrome. We describe some of the terminology in the field, including relevant definitions, the different units of measure, and general principles of clinical laboratory viscosity measurement. The 3 main categories of instrumentation for viscosity measurement--capillary, falling-sphere, and rotational viscometers--are discussed. We compare the various types of instrumentation for their usefulness with various types of clinical specimens. Relevant features that may be important in selecting a viscometer are described. We describe our 1.5-year experience with the viscometer that we chose. We hope the information in this review will be useful to pathologists and clinical laboratory staff in explaining the available choices for measuring serum, plasma, and whole blood viscosity.
Journal Article Foreword to Proceedings from the May 18-19, 2006, Conference on Improving Hospital and Lab Safety Get access Karen Wolk Feinstein, PhD Karen Wolk Feinstein, PhD 1Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, Pittsburgh, PA Search for other works by this author on: Oxford Academic Google Scholar Pathology Patterns Reviews, Volume 126, Issue suppl_1, 1 December 2006, Pages S5–S6, https://doi.org/10.1309/J7FYA20Y2W3C36E2 Published: 01 December 2006
Spindle cell lesions of the thyroid gland (T-SCL) are not encountered routinely in clinical practice or in the context of thyroid pathology. They commonly are classified as primary or secondary to metastatic disease. Primary T-SCL can be derivedfromfollicular, C-cell (parafollicular), or mesenchymal components and may be the result of reactive or neoplastic processes, including post-fine-needle aspiration spindle cell nodules, Riedel thyroiditis, solitary fibrous tumor, leiomyoma, peripheral nerve sheath tumor, hyalinizing trabecular tumor, spindle epithelial tumor with thymus-like differentiation, follicular dendritic cell tumor, medullary carcinoma, papillary carcinoma, anaplastic carcinoma, sarcoma, squamous cell carcinoma, and carcinoma showing thymus-like differentiation. Because T-SCL may represent the expression of benign and highly malignant neoplasms, distinction among these processes is crucial because it dictates therapy and defines prognosis. The present article reviews the clinical, imaging, pathologic, and immunohistochemical characteristics of primary T-SCL.
The use of quality benchmarking and performance tracking techniques has been successful in reducing errors in the practices of pathology and laboratory medicine. However, techniques developed in the manufacturing industry, specifically those pioneered by Toyota Motor have been more efficient and effective in reducing errors than those developed in the health care industry. We discuss some of those techniques and draw analogies as to how they might be applied in the laboratory.
Although some autoantibodies do not cause hemolysis and their workup is performed routinely, others might lead to life-threatening hemolysis. In the latter situation, the pathologist often is involved in the urgent decision to transfuse before completion of the evaluation. However, every effort must be made to exclude the presence of concurrent alloantibodies. This identification of RBC autoantibodies is less common than alloantibody identification, and the evaluation often requires techniques and expertise available only in specialized laboratories. Unlike emergency release of units for trauma victims, an autoantibody by definition will react with all units in the inventory; thus, all crossmatches are expected to be incompatible. To avoid additional untoward consequences of transfusion, there has to be close communication between the consulting pathologist and the clinician, including close monitoring of the patient during and after transfusion. This review is intended to serve as a guide to general pathologists in the appropriate evaluation and interpretation of laboratory tests in the diagnosis and management of autoimmune hemolytic anemia.
Multiple federal and private organizations are closely monitoring health care system performance improvement, based on the availability of a plethora of evidence that has been generated regarding best practices in the last 5 to 6 years. Unfortunately, the ability to transform research into practice has been difficult, and increasing consideration is being given to some form of pay-for-performance (P4P) incentive program by federal and private payers. The biggest limitation to the implementation of P4P for laboratory services includes the lack of a group of nationally standardized quality performance metrics to validly use for performance comparisons between laboratories and for benchmarking. Lack of standardized quality metrics also prevents longitudinal tracking as part of a national systematic and standardized quality management program. Resistance among pathologists and other laboratory professionals to promote and undertake this collaborative task undoubtedly will hurt pathology practice in the long run, as nonlaboratorians promote and mandate laboratory processes related to improving quality and increasing patient safety without a firsthand, working knowledge of pathology practice.
In this paper, we review those pathologic entities that may mimic papillary thyroid carcinoma. These include specimen preparation and handling issues such as decalcification, frozen section, and artifacts occurring following fine-needle aspiration (FNA). Also discussed are true disease entities, including chronic lymphocytic thyroidits, benign papillary hyperplastic lesions, hyalinizing trabecular neoplasm, and post-FNA changes. Both the cytologic and histopathologic preparations containing these changes are reviewed and illustrated; guidelines for distinctions among these entities are provided.
In May 2006, the Second Annual Improving Hospital and Laboratory Safety Meeting was held at the University of Pittsburgh, Pittsburgh, PA. This meeting was designed to bring pathology laboratory professionals and nonlaboratory health care professionals who use laboratory diagnostic testing services together with patient safety experts to discuss current evidence regarding errors and error-reduction methods associated with all phases of laboratory diagnostic testing, identify priority areas in pathology laboratory diagnostic testing services to target for quality improvement (QI) initiatives, and present specific QI changes that attendees could consider implementing in their laboratories. The majority of meeting activities were formal presentations given by local and nonlocal patient safety investigators and experts; however, 4 hours of the meeting were devoted to open and informal discussions focused on significant questions and issues related to laboratory diagnostic testing QI. We summarize the major thoughts and suggestions expressed during these discussions.
