Medical Histopathology Laboratories: Remote Teaching in Response to COVID-19 Pandemic.

The COVID-19 pandemic required the rapid conversion of medical school curricula to virtual instruction. Prior to the crisis, histopathology teaching laboratories at UT Health San Antonio included completion of an Individual Laboratory Quiz before the laboratory session, a Team Application Exercise released and completed during the laboratory session with guidance from faculty, and a graded Team Laboratory Quiz at the end of the laboratory session. Adaptation of this interactive, in-person activity to a fully online platform included releasing the Team Application Exercise earlier to provide ample time for students to work virtually with their teams, conducting laboratory sessions using Microsoft Teams, with 5 to 6 teams led by a single instructor, and requiring the Team Laboratory Quiz to be taken individually for ensuring quiz security and test integrity. For incentivizing collaboration while completing the Team Application Exercise, the final score was either the student's individual score on the Team Laboratory Quiz or their team's average, whichever was higher. Comparison of student scores on the modified Team Laboratory Quiz to Team Laboratory Quiz scores using the earlier laboratory format prior to COVID-19 showed a significant decline; however, scores on other weekly quizzes or examinations were unaffected. Students welcomed the early release of Team Application Exercise and easier access to faculty but indicated that the modified Team Laboratory Quiz decreased peer-teaching and learning experience and increased anxiety. Faculty indicated the loss of personal interaction with students as a major theme. These data suggest that novel pedagogical approaches are required for online histopathology instruction to accommodate differences in learning styles while maintaining the benefits of team collaboration.

Clinical Case-Based Image Portfolios in Medical Histopathology.

This descriptive article describes the use of clinical case-based portfolios in histopathology teaching laboratories in conjunction with virtual microscopy not only to integrate histology and pathology disciplines for first and second year medical students but also to stimulate student engagement, promote self-directed and group-based learning and enhance student-to-student interaction in a structured manner. Portfolios consisted of PowerPoint files encompassing four to five clinical case studies relevant to the topics covered that week. Portfolios integrated study materials provided in the module-specific lectures, clinical skill lectures, and online interactive content. Two sets of portfolios, Individual and Group, were used. Individual Portfolios were completed by each student and uploaded prior to the laboratory session. Group Portfolios were completed by students working together in small groups during the laboratory session with minimal faculty assistance. The functional utility and acceptance of Individual and Group Portfolios among first- and second-year medical students was evaluated using electronic surveys and examination performances. Both first- and second-year students agreed that the use of portfolios in conjunction with virtual microscopy promoted understanding and encouraged discussion of the topics covered during the week and that group members worked well together and contributed to the completion of the portfolios. Performances on the Histology and Cell Biology and Pathology sections on the United States Medical Licensing Examination® (USMLE® ) remained consistent and in line with national averages. Overall, use of portfolios promoted peer teaching and contributed towards successful transition to the new system-based integrated curriculum with continued strong performance on the USMLE.

Hospital-Based Hepatitis C Screening of Baby Boomers in a Majority Hispanic South Texas Cohort: Successes and Barriers to Implementation.

OBJECTIVE: To comply with the 2012 CDC recommendations for hepatitis C virus (HCV) screening, we implemented a new HCV screening program for patients born between 1945 and 1965 at a South Texas safety-net hospital. METHODS: Patients with no HCV diagnosis or prior HCV test received an automated order for HCV antibody (anti-HCV) tests combined with reflex HCV ribonucleic acid (RNA) polymerase chain reaction. An inpatient counselor educated anti-HCV-positive patients. A bilingual patient navigator assisted newly diagnosed chronic HCV patients with linkage to primary and specialty care. We examined results for Hispanic vs. non-Hispanic patients in the first 10 months of project implementation in 2013-2014. RESULTS: Of 2,327 patients screened for HCV, the 192 (8%) patients who tested anti-HCV positive were younger than those who tested negative (56 vs. 58 years, respectively, p<0.001) and more likely to be male (p<0.001). Of the 167 anti-HCV-positive patients tested for HCV RNA, 108 (65%) were HCV RNA positive (5% of cohort). Barriers to care for HCV RNA-positive patients included a lack of health insurance, current substance abuse, incarceration, and homelessness. Hispanic HCV RNA-positive patients were more likely than non-Hispanic HCV RNA-positive patients to be substance abusers or incarcerated. Of all HCV RNA-positive patients, 103 patients (95%) received counseling, 94 patients (87%) were linked to primary care, 47 patients (44%) were linked to specialty care, and eight patients (7%) started treatment. CONCLUSION: The prevalence of anti-HCV-positive and chronically HCV-infected patients was higher than many Hispanic or non-Hispanic white cohorts. Most Hispanic patients newly diagnosed with chronic HCV had barriers to care for HCV infection that must be overcome if HCV screening is to reduce morbidity and mortality in this population.

High priority for hepatitis C screening in safety net hospitals: Results from a prospective cohort of 4582 hospitalized baby boomers.

UNLABELLED: Low-income populations are disproportionately affected by hepatitis C virus (HCV) infection. Thus, implementing baby boomer screening (born 1945-1965) for HCV may be a high priority for safety net hospitals. We report the prevalence and predictors of HCV infection and advanced fibrosis or cirrhosis based on the Fibrosis-4 score plus imaging for a baby boomer cohort admitted to a safety net hospital over a 21-month interval with >9 months of follow-up. Anti-HCV antibody testing was performed for 4582, or 90%, of all never-screened patients, of whom 312 (6.7%) tested positive. Adjusted odds ratios of testing anti-HCV-positive were 2.66 for men versus women (P<0.001), 1.25 for uninsured versus insured (P=0.06), 0.70 for Hispanics versus non-Hispanic whites (P=0.005), and 0.93 per year of age (P<0.001). Among 287 patients tested for HCV RNA (91% of all anti-HCV-positive cases), 175 (61%) were viremic (3.8% overall prevalence in cohort), which was 5% less likely per year of age (P<0.03). Noninvasive staging of 148 (84.6%) chronic HCV patients identified advanced fibrosis or cirrhosis in 50 (33.8%), with higher adjusted odds ratios of 3.21 for Hispanics versus non-Hispanic whites/Asians (P=0.02) and 1.18 per year of age (P=0.001). Other factors associated with significantly higher adjusted odds ratios of advanced fibrosis or cirrhosis were alcohol abuse/dependence, obesity, and being uninsured. CONCLUSION: In this low-income, hospitalized cohort, 4% of 4582 screened baby boomers were diagnosed with chronic HCV, nearly twice the rate in the community; one-third had noninvasive testing that indicated advanced fibrosis or cirrhosis, which was significantly more likely for Hispanics, those of older age, those with obesity, those with alcohol abuse/dependence, and those who lacked insurance.

Implementing hospital-based baby boomer hepatitis C virus screening and linkage to care: Strategies, results, and costs.

BACKGROUND/OBJECTIVE: The US Preventive Services Task Force recommends 1-time hepatitis C virus (HCV) screening of all baby boomers (born 1945-1965). However, little is known about optimal ways to implement HCV screening, counseling, and linkage to care. We developed strategies following approaches used for HIV to implement baby boomer HCV screening in a hospital setting and report results as well as costs. DESIGN/PATIENTS: Prospective cohort of 6140 baby boomers admitted to a safety-net hospital in South Texas from December 1, 2012 to January 31, 2014 and followed to December 10, 2014. PROCEDURES/MEASUREMENTS: The HCV screening program included clinician/staff education, electronic medical record algorithm for eligibility and order entry, opt-out consent, anti-HCV antibody test with reflex HCV RNA, personalized inpatient counseling, and outpatient case management. Outcomes were anti-HCV antibody-positive and HCV RNA-positive results. RESULTS: Of 3168 eligible patients, 240 (7.6%) were anti-HCV positive, which was more likely (P < 0.05) for younger age, men, and uninsured. Of 214 (89.2%) patients tested for HCV RNA, 134 (4.2% of all screened) were positive (chronic HCV). Among patients with chronic HCV, 129 (96.3%) were counseled, 108 (80.6%) received follow-up primary care, and 52 (38.8%) received hepatology care. Five patients initiated anti-HCV therapy. Total costs for start-up and implementation for 14 months were $286,482. CONCLUSIONS: This inpatient HCV screening program diagnosed chronic HCV infection in 4.2% of tested patients and linked >80% to follow-up care. Yet access to therapy is challenging for largely uninsured populations, and most programmatic costs of the program are not currently covered.

Fibrin ring granulomas in Rickettsia typhi infection.

We describe a 71-year-old man hospitalized for fever and productive cough. Laboratory investigation showed anemia, thrombocytopenia, elevated transaminases, hyponatremia, and hypoalbuminemia. Computerized tomography of the abdomen, thorax, and sinuses, echocardiography, and a gallium scan did not reveal the source of the fever. The patient remained febrile despite courses of piperacillin-tazobactam/azithromycin and ceftriaxone/vancomycin. A bone marrow biopsy showed fibrin ring granulomas, and 2 rickettsial serologic panels were positive for Rickettsia typhi infection and negative for Q fever. The patient was given doxycycline, and the fever resolved within 48 h. We propose that fibrin ring granulomas also occur in murine typhus.

Timing of specimen collection for blood cultures from febrile patients with bacteremia.

Bloodstream infections are an important cause of morbidity and mortality. Physician orders for blood cultures often specify that blood specimens be collected at or around the time of a temperature elevation, presumably as a means of enhancing the likelihood of detecting significant bacteremia. In a multicenter study, which utilized retrospective patient chart reviews as a means of collecting data, we evaluated the timing of blood culture collection in relation to temperature elevations in 1,436 patients with bacteremia and fungemia. The likelihood of documenting bloodstream infections was not significantly enhanced by collecting blood specimens for culture at the time that patients experienced temperature spikes. A subset analysis based on patient age, gender, white blood cell count and specific cause of bacteremia generally also failed to reveal any associations.

Susceptibility of Neisseria meningitidis to 16 antimicrobial agents and characterization of resistance mechanisms affecting some agents.

Neisseria meningitidis represents a pathogen of great public health importance in both developed and developing countries. Resistance to some antimicrobial agents used either for therapy of invasive infections or for prophylaxis of case contacts has long been recognized, although specific guidelines for susceptibility testing have not been fully developed. We have examined the susceptibilities of a collection of 442 meningococcal clinical isolates from 15 countries to 16 antimicrobial agents. These included isolates recovered between 1917 and 2004, with representatives of all major serogroups. All isolates were tested by the Clinical and Laboratory Standards Institute (formerly NCCLS) broth microdilution method using Mueller-Hinton lysed horse blood broth, while a subset of 102 isolates was tested by agar dilution using Mueller-Hinton sheep blood agar. Most isolates provided adequate growth for MIC determinations by both broth and agar methods. Growth in broth was enhanced by CO(2) incubation and was required for two strains (1.7%). MICs of the study drugs compared favorably between the broth and agar methods (79 to 100% essential agreement), and MICs also generally agreed closely (92 to 100% essential agreement, excluding azithromycin) between broth tests incubated in the two different atmospheres. Elevated penicillin and ampicillin MICs (> or =0.12 microg/ml and > or =0.25 microg/ml, respectively) occurred in 14.3% and 8.6% of strains and were associated with polymorphisms of the penA gene encoding a modified penicillin-binding protein 2. None of the 442 isolates produced beta-lactamase. Elevated tetracycline and doxycycline (but not minocycline) MICs were associated with efflux-mediated resistance encoded by tet(B) in 13 strains. Resistance to sulfisoxazole in 21.7% of strains and to trimethoprim-sulfamethoxazole in 21.0% resulted from polymorphisms of folP encoding a modified dihydropteroate synthetase. Seven strains were resistant to rifampin due to mutations in the rpoB gene, and two strains were resistant to chloramphenicol due to production of chloramphenicol acetyltransferase mediated by catP. Two strains had reduced quinolone susceptibility due to mutations of gyrA. The determination of the susceptibilities of a large group of meningococcal strains (including strains with characterized resistance mechanisms) to 16 antimicrobial agents has served as the essential first step in defining susceptibility testing breakpoints specific for this organism.

Induction of telithromycin resistance by erythromycin in isolates of macrolide-resistant Staphylococcus spp.

Staphylococcal isolates were examined for possible macrolide-inducible resistance to telithromycin. All macrolide-resistant isolates demonstrated telithromycin D-shaped zones. This result did not discriminate between resistance due to an efflux mechanism (msrA) or a ribosomal target modification (ermA or ermC). Inducible telithromycin resistance in staphylococci does not appear to be analogous to inducible clindamycin resistance.

International clone of Neisseria meningitidis serogroup A with tetracycline resistance due to tet(B).

Thirteen Neisseria meningitidis clinical isolates from Africa, Asia, and the United States for which the tetracycline MICs were elevated (> or =8 microg/ml) were examined for 14 recognized resistance genes. Only the drug efflux mechanism encoded by tet(B) was detected. All isolates were in serogroup A, belonged to complex ST-5, and were closely related by pulsed-field gel electrophoresis analysis.

Development and verification of an automated sample processing protocol for quantitation of human immunodeficiency virus type 1 RNA in plasma.

We developed and verified an automated sample processing protocol for use with the AMPLICOR HIV-1 MONITOR test, version 1.5 (Roche Diagnostics, Indianapolis, Ind.). The automated method uses the MagNA Pure LC instrument and total nucleic acid reagents (Roche Applied Science, Indianapolis, Ind.) to extract human immunodeficiency virus type 1 (HIV-1) RNA from plasma specimens. We compared the HIV-1 load results for a dilution series (1 to 5 nominal log(10) copies/ml) and 175 clinical specimens processed by the automated method to those for the same samples processed by the manual methods specified by the manufacturer. The sensitivity, dynamic range, and precision of the viral load assay obtained by automated processing of specimens were similar to those obtained by an ultrasensitive manual processing method. The results were highly correlated (R(2), 0.95), and were in close agreement, with a mean difference of 0.09 log(10) (standard deviation, 0.292). The limits of agreement were +/-0.58 log(10) for results for samples processed by both the manual and the automated methods. These performance characteristics were achieved with a smaller sample volume (200 versus 500 microl) and without a high-speed centrifugation step and required only 15 min of labor for a batch of 32 samples. In conclusion, the automated sample preparation protocol can replace both the standard and the ultrasensitive manual methods used with the AMPLICOR HIV-1 MONITOR test and can substantially reduce the labor associated with this test.

Clinical evaluation of two methods for genotyping hepatitis C virus based on analysis of the 5' noncoding region.

We compared the performance characteristics of a standardized direct sequencing method (TRUGENE HCV 5'NC; Visible Genetics Inc., Toronto, Ontario, Canada) and a reverse hybridization line probe assay (INNO-LiPA HCV II; Bayer Corp., Tarrytown, N.Y.) for genotyping of hepatitis C virus (HCV). Both methods are based on detection of sequence heterogeneity in the 5' noncoding (5'NC) region. Concordance between the genotyping methods was assessed by testing 172 samples representing the six major genotypes. Sequence analysis of the more phylogenetically informative nonstructural 5B (NS5B) region was also done with 148 (86%) samples to confirm the accuracy of and resolve discrepancies between the 5'NC genotyping results. The sensitivities of the methods were assessed by using the 5'NC amplicon from both the qualitative and quantitative AMPLICOR HCV tests (Roche Diagnostics Corp., Indianapolis, Ind.). The ability of the methods to detect mixed-genotype infections was determined with mixtures of two different genotypes at relative concentrations ranging from 1 to 50%. Both 5'NC methods were able to genotype 99.4% of the samples with type agreement for 99.5% and subtype agreement for 68.2% of the samples. No or ambiguous subtype results were found by the line probe assay for 16.5% and by the TRUGENE 5'NC test for 17.1% of the samples. Discrepancies occurred between the line probe assay and NS5B results at the type level for 1.4% of the samples and at the subtype level for 14.2% of the samples. Discrepancies also occurred between the TRUGENE 5'NC and NS5B results at the type level for 2% of the samples and at the subtype level for 8.1% of the samples. We also found two distinct strains of HCV classified as type 2 by analysis of the 5'NC region that were type 1 by analysis of the NS5B region. The sensitivities of the two 5'NC genotyping methods were comparable and dependent on the amplification test used ( approximately 10(3) IU/ml with the qualitative HCV RNA tests and approximately 10(5) IU/ml with the quantitative HCV RNA tests). Genotype mixtures were successfully identified at a relative concentration of 5% by the line probe assay and 10% by the TRUGENE 5'NC test. In conclusion, the performance characteristics of the 5'NC methods were similar and both methods produced accurate results at the genotype level but neither method should be used for subtyping.