Role of Shellfish Aquaculture in the Reduction of Eutrophication in an Urban Estuary.

Land-based management has reduced nutrient discharges; however, many coastal waterbodies remain impaired. Oyster "bioextraction" of nutrients and how oyster aquaculture might complement existing management measures in urban estuaries was examined in Long Island Sound, Connecticut. Eutrophication status, nutrient removal, and ecosystem service values were estimated using eutrophication, circulation, local- and ecosystem-scale models, and an avoided-costs valuation. System-scale modeling estimated that 1.31% and 2.68% of incoming nutrients could be removed by current and expanded production, respectively. Up-scaled local-scale results were similar to system-scale results, suggesting that this up-scaling method could be useful in bodies of water without circulation models. The value of removed nitrogen was estimated using alternative management costs (e.g., wastewater treatment) as representative, showing ecosystem service values of $8.5 and $470 million per year for current and maximum expanded production, respectively. These estimates are conservative; removal by clams in Connecticut, oysters and clams in New York, and denitrification are not included. Optimistically, the calculation of oyster-associated removal from all leases in both states (5% of bottom area) plus denitrification losses showed increases to 10%-30% of annual inputs, which would be higher if clams were included. Results are specific to Long Island Sound, but the approach is transferable to other urban estuaries.

Prioritizing the Interview in Selecting Resident Applicants: Behavioral Interviews to Determine Goodness of Fit.

From our initial screening of applications, we assess that the 10% to 15% of applicants whom we will interview are all academically qualified to complete our residency training program. This initial screening to select applicants to interview includes a personality assessment provided by the personal statement, Dean's letter, and letters of recommendation that, taken together, begin our evaluation of the applicant's cultural fit for our program. While the numerical scoring ranks applicants preinterview, the final ranking into best fit categories is determined solely on the interview day at a consensus conference by faculty and residents. We analyzed data of 819 applicants from 2005 to 2017. Most candidates were US medical graduates (62.5%) with 23.7% international medical graduates, 11.7% Doctors of Osteopathic Medicine (DO), and 2.1% Caribbean medical graduates. Given that personality assessment began with application review, there was excellent correlation between the preinterview composite score and the final categorical ranking in all 4 categories. For most comparisons, higher scores and categorical rankings were associated with applicants subsequently working in academia versus private practice. We found no problem in using our 3-step process employing virtual interviews during the COVID pandemic.

Bioextractive Removal of Nitrogen by Oysters in Great Bay Piscataqua River Estuary, New Hampshire, USA.

Eutrophication is a challenge to coastal waters around the globe. In many places, nutrient reductions from land-based sources have not been sufficient to achieve desired water quality improvements. Bivalve shellfish have shown promise as an in-water strategy to complement land-based nutrient management. A local-scale production model was used to estimate oyster (Crassostrea virginica) harvest and bioextraction of nitrogen (N) in Great Bay Piscataqua River Estuary (GBP), New Hampshire, USA, because a system-scale ecological model was not available. Farm-scale N removal results (0.072 metric tons acre-1 year-1) were up-scaled to provide a system-wide removal estimate for current (0.61 metric tons year-1), and potential removal (2.35 metric tons year-1) at maximum possible expansion of licensed aquaculture areas. Restored reef N removal was included to provide a more complete picture. Nitrogen removal through reef sequestration was ~ 3 times that of aquaculture. Estimated reef-associated denitrification, based on previously reported rates, removed 0.19 metric tons N year-1. When all oyster processes (aquaculture and reefs) were included, N removal was 0.33% and 0.54% of incoming N for current and expanded acres, respectively. An avoided cost approach, with wastewater treatment as the alternative management measure, was used to estimate the value of the N removed. The maximum economic value for aquaculture-based removal was $105,000 and $405,000 for current and expanded oyster areas, respectively. Combined aquaculture and reef restoration is suggested to maximize N reduction capacity while limiting use conflicts. Comparison of removal based on per oyster N content suggests much lower removal rates than model results, but model harvest estimates are similar to reported harvest. Though results are specific to GBP, the approach is transferable to estuaries that support bivalve aquaculture but do not have complex system-scale hydrodynamic or ecological models.

Training the Next Generation of Pathologists: A Novel Residency Program Curriculum at Montefiore Medical Center/Albert Einstein College of Medicine.

Pathology residency training is currently a time-intensive process, frequently extending up to 6 years in duration as residents complete 1 or 2 fellowships following graduation. Innovative training curricula may help address the impending changes in the health-care landscape, particularly future shortfalls in pathology staffing and changing health-care models that incorporate more work within interdisciplinary teams. Montefiore has created a novel residency training program aimed at accelerating the acquisition of competency in pathology, preparing residents for independent practice at the completion of residency training, and providing residents with the requisite adaptability and consultative skills to excel wherever they choose to practice. We describe the implementation of this novel pathology residency training curriculum at Montefiore Medical Center/Albert Einstein College of Medicine and the perception of residents in both the old curriculum and the new curriculum.

Report and Recommendations of the Association of Pathology Chairs' Autopsy Working Group.

Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training.A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident.Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision.Technical standardization of autopsy performance and reporting must be improved.The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.

Professionalism in Pathology: A Case-Based Approach as a Potential Educational Tool.

CONTEXT: -Professionalism issues in residency training can be difficult to assess and manage. Generational or role-based differences may also exist between faculty and residents as to what constitutes unprofessional behavior and how to manage it. OBJECTIVE: -To examine and compare how faculty and residents would approach the same 5 case scenarios detailing various aspects of unprofessional behavior. DESIGN: -Five case scenarios highlighting various unprofessional behaviors were presented in a workshop at an annual meeting of pathology department chairs, residency program directors, and undergraduate pathology medical educators (ie, pathologists involved in medical student pathology education). The same cases were presented to a cohort of pathology residents currently in training. A standard set of responses were offered to the participants, polling results were collected electronically, and results were compared. RESULTS: -Faculty and residents were fairly consistent within their respective groups. In a subset of cases, faculty were more likely to favor working with the individual in the scenario, whereas resident respondents were more likely to favor either no response or a severe response. Generational or role-based differences were also potentially evident. CONCLUSIONS: -Assessing expectations and differences around professionalism for both faculty and residents should be considered as part of any educational and management approach for professionalism. Although a level of generational differences appears to be evident in this study regarding the recognition and management of unprofessional behavior, there was also agreement in some cases. Further exploration into the discrepant responses between faculty and residents may prove useful in developing educational, assessment, and remediation resources.

Effects of desialylation of ovine submaxillary gland mucin (OSM) on humoral and cellular immune responses to Tn and sialylated Tn.

Resected carcinoma patients were immunized 3-5 times with ovine submaxillary gland mucin (OSM) containing predominantly sialylated Tn (sTn), completely desialylated ovine submaxillary gland mucin (dOSM) containing predominantly Tn, or 50% desialylated OSM containing Tn and sTn plus bacillus Calmette-Guerin (BCG) as an immunologic adjuvant. Pre- and postimmunization sera were quantified by ELISA, whole-cell ELISA, and immune stain dot blots. Fifteen of 17 patients produced IgG antibody titers from 40 to 5120 times more reactive with OSM and dOSM postimmunization. More importantly, these IgG antibodies reacted with LS-174T, a human colon carcinoma cell line. Significant DTH-like responses (1-17 cm) were observed in 15 of 17 patients; the strength of these responses was dependent on the presence or absence of sialic acid. Biopsies of these DTH-like reactions revealed infiltration with some CD8+ lymphocytes and mast cells. These results suggest that a single 9-carbon sugar can affect cellular immune responses to mucin antigens. It is thought that these large erythematous, nonindurated cellular reactions are antibody-mediated Arthus-like reactions. OSM, and especially dOSM, were also found to inhibit lymphocyte proliferation.

Training Pathology Residents to Practice 21st Century Medicine: A Proposal.

Scientific advances, open information access, and evolving health-care economics are disrupting extant models of health-care delivery. Physicians increasingly practice as team members, accountable to payers and patients, with improved efficiency, value, and quality. This change along with a greater focus on population health affects how systems of care are structured and delivered. Pathologists are not immune to these disruptors and, in fact, may be one of the most affected medical specialties. In the coming decades, it is likely that the number of practicing pathologists will decline, requiring each pathologist to serve more and often sicker patients. The demand for increasingly sophisticated yet broader diagnostic skills will continue to grow. This will require pathologists to acquire appropriate professional training and interpersonal skills. Today's pathology training programs are ill designed to prepare such practitioners. The time to practice for most pathology trainees is typically 5 to 6 years. Yet, trainees often lack sufficient experience to practice independently and effectively. Many studies have recognized these challenges suggesting that more effective training for this new century can be implemented. Building on the strengths of existing programs, we propose a redesign of pathology residency training that will meet (and encourage) a continuing evolution of American Board of Pathology and Accreditation Council for Graduate Medical Education requirements, reduce the time to readiness for practice, and produce more effective, interactive, and adaptable pathologists. The essence of this new model is clear definition and acquisition of core knowledge and practice skills that span the anatomic and clinical pathology continuum during the first 2 years, assessed by competency-based metrics with emphasis on critical thinking and skill acquisition, followed by individualized modular training with intensively progressive responsibility during the final years of training. We anticipate that implementing some or all aspects of this model will enable residents to attain a higher level of competency within the current time-based constraints of residency training.

Onboarding for Pathology Residency Programs-The Montefiore Experience.

Onboarding is a system frequently used in the corporate world as a means of orienting incoming employees to their duties and inculcating the workplace values. The program aims to facilitate transition into new work roles and improve employee retention rates. At Montefiore, we have instituted an onboarding curriculum that is given to new anatomic and clinical pathology residents about a month prior to the start of residency. The program includes an introductory video series of basic histology and a series of anatomic and clinical case studies illustrating basic laboratory principles. This didactic content is tagged to learning objectives and short self-assessment modules. In addition, content related to the work ethos at Montefiore and the role of the core competencies and milestones in residency education are included. Finally, a broader component of the onboarding gives the incoming residents a social welcome to our area, including key information about living in the area surrounding Montefiore. The program has been well received by our residents for whom the content has helped to boost confidence when starting. We feel that the program is helpful in ensuring that all incoming residents start having received the same baseline didactic content. Transmitting this didactic content via onboarding allows our residents to begin the work of learning pathology immediately, rather than spending the first weeks of residency covering remedial content such as basic histology. Such a program may be useful to other pathology residencies, most of whom have residents from a range of backgrounds and whose prior exposure to pathology may be limited.

Anatomic and clinical pathology boot camps: filling pathology-specific gaps in undergraduate medical education.

CONTEXT: The Liaison Committee on Medical Education began an initiative to change medical education across the United States in the early 2000s. With the explosion in medical science knowledge, the need arose to teach selected fundamental information both in a contextual and in an active learning manner. OBJECTIVE: To identify ways to address gaps in training and knowledge that became apparent following implementation of learner-centered teaching methods, with devotion of more time to Internet-based learning and less emphasis on face-to-face lecture time. There was a dramatic departure from or de-emphasis of many traditional courses, such as embryology, gross anatomy, microscopic anatomy, and pathology, to the integration of these sciences into system-based active learning courses. This change in medical school curricula produces a medical graduate who hopefully thinks differently but certainly lacks subject-specific knowledge for a variety of medical specialties. DATA SOURCES: Pathology residency programs have developed "boot camps" for the initial months of residency training both to provide the necessary foundation of pathology-specific medical science and to introduce basic skills and processes required for practice of anatomic pathology and laboratory medicine. The College of American Pathologists Graduate Medical Education Committee sent a questionnaire out on the Program Directors Section Listserv; the results are discussed and 3 boot camp programs are described. CONCLUSIONS: Boot camps have 2 purposes: (1) to teach or strengthen knowledge required to practice pathology and (2) to introduce basic skills and processes that will be used during the practitioner's career.

A team-based approach to autopsy education: integrating anatomic and clinical pathology at the rotation level.

CONTEXT: Pathology residency training programs should aim to teach residents to think beyond the compartmentalized data of specific rotations and synthesize data in order to understand the whole clinical picture when interacting with clinicians. OBJECTIVE: To test a collaborative autopsy procedure at Montefiore Medical Center (Bronx, New York), linking residents and attending physicians from anatomic and clinical pathology in the autopsy process from the initial chart review to the final report. Residents consult with clinical pathology colleagues regarding key clinical laboratory findings during the autopsy. This new procedure serves multiple functions: creating a team-based, mutually beneficial educational experience; actively teaching consultative skills; and facilitating more in-depth analysis of the clinical laboratory findings in autopsies. DESIGN: An initial trial of the team-based autopsy system was done from November 2010 to December 2012. Residents were then surveyed via questionnaire to evaluate the frequency and perceived usefulness of clinical pathology autopsy consultations. RESULTS: Senior residents were the most frequent users of clinical pathology autopsy consultation. The most frequently consulted services were microbiology and chemistry. Eighty-nine percent of the residents found the clinical pathology consultation to be useful in arriving at a final diagnosis and clinicopathologic correlation. CONCLUSION: The team-based autopsy is a novel approach to integration of anatomic and clinical pathology curricula at the rotation level. Residents using this approach develop a more holistic approach to pathology, better preparing them for meaningful consultative interaction with clinicians. This paradigm shift in training positions us to better serve in our increasing role as arbiters of outcomes measures in accountable care organizations.

The pathology milestones and the next accreditation system.

CONTEXT: In the late 1990s, the Accreditation Council for Graduate Medical Education developed the Outcomes Project and the 6 general competencies with the intent to improve the outcome of graduate medical education in the United States. The competencies were used as the basis for developing learning goals and objectives and tools to evaluate residents' performance. By the mid-2000s the stakeholders in resident education and the general public felt that the Outcomes Project had fallen short of expectations. OBJECTIVE: To develop a new evaluation method to track trainee progress throughout residency using benchmarks called milestones. A change in leadership at the Accreditation Council for Graduate Medical Education brought a new vision for the accreditation of training programs and a radically different approach to the evaluation of residents. DATA SOURCES: The Pathology Milestones Working Group reviewed examples of developing milestones in other specialties, the literature, and the Accreditation Council for Graduate Medical Education program requirements for pathology to develop pathology milestones. The pathology milestones are a set of objective descriptors for measuring progress in the development of competency in patient care, procedural skill sets, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. CONCLUSIONS: The milestones provide a national standard for evaluation that will be used for the assessment of all residents in Accreditation Council for Graduate Medical Education-accredited pathology training programs.

Superficial siderosis of the central nervous system due to chronic hemorrhage from a giant invasive prolactinoma.

Superficial siderosis of the central nervous system (CNS) is a rare disorder caused by deposition of hemosiderin in neuronal tissue in the subpial layer of the CNS due to slow subarachnoid or intraventricular hemorrhage. The most common neurologic manifestations include progressive gait ataxia, sensorineural hearing loss, and corticospinal tract signs. We present a case of superficial siderosis in a 43-year-old man who presented to the Emergency Department with sudden onset bilateral visual deterioration and a loss of consciousness. A hemorrhagic giant prolactinoma was diagnosed based on brain CT scan, T1-weighted MRI, and an endocrine blood examination. Susceptibility-weighted non-contrast MRI showed pathognomonic signs of superficial siderosis in the form of a hypointensity rim surrounding the brainstem, cerebellar fissures, and cranial nerves VII and VIII. This report demonstrates that superficial siderosis can be caused by pituitary apoplexy.

DNA biomarkers antecede semiquantitative anthracycline cardiomyopathy.

Adriamycin (ADM, or doxorubicin hydrochloride) is an effective antineoplastic agent whose use is restricted by its well-described, dose-dependent cardiotoxicity. This study measures ADM DNA adduct formation by 32P-radiolabeling DNA, enzymatically digesting radiolabeled DNA, separating the formed adducts on two-dimensional thinlayer chromatography (2D-TLC), and quantitating the adducts with autoradiography and densitometry. Thirty-six male Sprague-Dawley rats are randomized to receive ADM at varying intraperitoneal (i.p.) injection concentrations: 0.9% saline i.p. controls, 4 mg/kg ADM i.p., and 6 mg/kg ADM i.p. Myocardial and pulmonary tissues are harvested 48 hours after i.p. injection for autoradiographic and histopathologic analyses. The results indicate differences in the amount and type of adduct formation as a function of ADM concentration. Increased partial depurination of dGMP and dAMP occurs with increasing ADM concentration at equal incubation times. This depurination correlates with the emergence of new adducts HM-dUMP, 8-OH-dGMP, HM-dCMP, and Me-dCMP. The quantification of these adducts can potentially represent an early marker of ADM cardiotoxicity and thereby optimize the efficacy of individual chemotherapy regimens while minimizing adverse effects.