Mechanical thrombectomy for pediatric stroke arising from an atrial myxoma: case report.

Children experiencing severe neurological deficit due to acute ischemic stroke may benefit from endovascular intervention. The authors describe the use of mechanical thrombectomy in the treatment of embolic occlusion secondary to an atrial myxoma in a pediatric patient. This case involved an 11-year-old boy with a history notable for Raynaud syndrome and a distal extremity rash who presented to the emergency department with dense hemiparesis secondary to thromboembolic occlusion of the M1 segment of the middle cerebral artery. Following mechanical thrombectomy, the patient's pediatric National Institutes of Health Stroke Scale score improved from a 16 to a 7. In the setting of acute pediatric stroke due to atrial myxoma emboli, mechanical thrombectomy may be a first-line therapy.

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.

Histopathologic characterization of chronic radiofrequency ablation lesions for pulmonary vein isolation.

OBJECTIVES: This study describes the histopathologic and electrophysiological findings in patients with recurrence of atrial fibrillation (AF) after pulmonary vein (PV) isolation who underwent a subsequent surgical maze procedure. BACKGROUND: The recovery of PV conduction is commonly responsible for recurrence of AF after catheter-based PV isolation. METHODS: Twelve patients with recurrent AF after acutely successful catheter-based antral PV isolation underwent a surgical maze procedure. Full-thickness surgical biopsy specimens were obtained from the PV antrum in areas of visible endocardial scar. Before biopsy, intraoperative epicardial electrophysiological recordings were taken from each PV using a circular mapping catheter. RESULTS: Twenty-two PVs were biopsied from the 12 patients 8 ± 11 months after ablation. Eleven of the 22 specimens (50%) revealed transmural scar, and 11 (50%) showed viable myocardium with or without scar. Each biopsy specimen demonstrated evidence of injury, most commonly endocardial thickening (n = 21 [95%]) and fibrous scar (n = 18 [82%]). Seven of the 22 specimens (32%) showed conduction block at surgery. Transmural scar was more likely to be seen in the biopsy specimens from the PVs with conduction block than in specimens from the PVs showing reconnection. However, viable myocardium alone or mixed with scar was seen in 2 specimens from PVs with conduction block. CONCLUSIONS: PVs showing electrical reconnection after catheter-based antral ablation frequently reveal anatomic gaps or nontransmural lesions at the sites of catheter ablation. Nontransmural lesions are noted in some PVs with persistent conduction block, suggesting that lesion geometry may influence PV conduction. The histological findings show that nontransmural ablation can produce a dynamic cellular substrate with features of reversible injury. Delayed recovery from injury may explain late recurrences of AF after PV isolation.

CD44(+)/CD24(-/low) cancer stem/progenitor cells are more abundant in triple-negative invasive breast carcinoma phenotype and are associated with poor outcome.

Women classified as having triple-negative tumors have a poor prognosis. The importance of CD44(+)/CD24(-/low) (stem/progenitor cell-phenotype) in breast cancer patients has also been appreciated. However, correlation between triple negativity and CD44(+)/CD24(-/low) with tumor recurrence remains elusive. In the present study, we evaluated tumor specimens of 50 breast cancer patients with known hormone receptor status for whom we had follow-up information and outcome data available, and performed immunohistochemistry analysis to determine CD44 and CD24 expression. Gene expression arrays were also independently performed on 52 breast cancer specimens with banked frozen tissue. Lastly, we used FVBN202 transgenic mouse model of breast carcinoma and determined the hormone receptor status, the proportion of CD44(+)/CD24(-/low) breast cancer stem-like cells, and the behavior of the tumor. We determined that patients with triple-negative tumors had significantly higher incidence of recurrence or distant metastasis associated with increased frequency of breast cancer stem cell phenotypes compared with those with non-triple-negative tumors. Preclinical studies in FVBN202 transgenic mice confirmed these findings by showing that relapsed tumors were triple negative and had significantly higher frequency of breast cancer stem cells compared with their related primary tumors. Unlike non-triple-negative primary tumors, relapsed triple-negative tumors were tumorigenic at low doses when inoculated into FVBN202 transgenic mice. These findings suggest that CD44(+)/CD24(-/low) breast cancer stem-like cells play an important role in the clinical behavior of triple-negative breast cancer and that development of therapeutic targets directed to breast cancer stem-like cells may lead to reduction in the aggressiveness of triple-negative breast cancers.

Senior pathology resident in-service examination scores correlate with outcomes of the American Board of Pathology certifying examinations.

The Resident In-Service Examination (RISE) addresses 1 area of the Accreditation Council for Graduate Medical Education Outcome Project; RISE results demonstrate progressive attainment of pathology knowledge during training. We compared RISE scores with primary pathology board certification success for residents graduating in 2008 and 2009. Overall RISE and nearly all sectional scores in anatomic and clinical pathology were significantly higher for residents passing all certifying examinations at the first attempt vs residents who failed any examination. The risk of failing increased with each lower quartile of overall RISE score, such that 34% (2009) and 54% (2008) of residents in the lowest quartile failed at least 1 certifying examination. Two thirds of graduating residents with lowest quartile scores had a similar quartile ranking in the previous RISE, identifying them as at risk. Residents passing the American Board of Pathology certifying examinations have a higher level of medical knowledge in general and specific pathology disciplines as assessed by senior RISE scores.

Tumor escape and progression of HER-2/neu negative breast cancer under immune pressure.

BACKGROUND: Emerging data from pre-clinical and clinical studies suggest that HER-2/neu-specific T cell responses could induce HER-2/neu antigen loss in the tumor cells. These data suggest that patients with HER-2/neu negative breast cancer might have had HER-2/neu positive premalignant lesions in the past that progressed to HER-2/neu negative breast cancer under HER-2/neu-specific immune pressure. METHODS: We conducted a pilot study in patients with HER-2/neu positive and HER-2/neu negative breast cancers as well as a patient with ductal carcinoma in situ (DCIS). HER-2/neu expression was determined by FISH. HER-2/neu-specific T cell responses were determined by using IFN-γ ELISA. Expression of IFN-γ Rα in the tumors was determined by immunohistochemistry analysis of paraffin-embedded tissues. RESULTS: We determined that majority of (10 of 12) patients with HER-2/neu negative breast cancer had HER-2/neu-specific IFN-γ producing T cell responses which was stronger than those in patients with HER-2/neu positive tumors. Such immune responses were associated with nuclear translocation of IFN-γ Rα in their tumor cells. Patient with DCIS also showed HER-2/neu-specific T cell responses. CONCLUSION: These data suggest that conducting retrospective studies in patients with HER-2/neu negative breast cancers and prospective studies in patients with HER-2/neu positive DCIS can determine whether HER-2/neu negative invasive carcinomas arise from HER-2/neu positive DCIS under the immune pressure.

Certification and maintenance of certification: updates from the American Board of Pathology.

The American Board of Pathology continues to update the certification process to ensure that all candidates have appropriate training and credentials and meet the competency requirements of the Accreditation Council for Graduate Medical Education. The maintenance of certification process, instituted in 2006, has gone through 2 reporting cycles; and the American Board of Pathology is preparing for administration of the first maintenance of certification examination in 2014. This article updates the pathology community on these changes.

Adequacy of pathology resident training for employment: a survey report from the Future of Pathology Task Group.

CONTEXT: The recent change in accreditation requirements for anatomic pathology and clinical pathology residency training from 5 to 4 years and the rapid advances in technologies for pathology services have sparked a renewed debate over the adequacy of pathology residency training. In particular, perceived deficiencies in training have been declared from a variety of sources, both in the form of recent editorial opinions and from surveys of community hospital pathologist employers in 1998, 2003, and 2005 by Dr Richard Horowitz. OBJECTIVE: To obtain more comprehensive data on the perceptions of strengths and weaknesses in pathology residency training. DESIGN: The College of American Pathologists conducted a survey of potential pathology employers (senior College of American Pathologists members, members designated as head of group, and members of the Association of Directors of Anatomic and Surgical Pathology). Also surveyed were recent graduates of pathology residency programs, who were identified as being junior members of the College of American Pathologists, were recent recipients of certification from the American Board of Pathology, or were contacted through their directors of pathology residency programs. RESULTS: There were 559 employer respondents, of whom 384 were responsible for hiring and/or supervising new pathologists. There were 247 recent graduates of pathology residency training programs who responded. From the employers' standpoint, the majority expressed overall satisfaction with recent graduates, but almost one third of employers indicated that new hires had a major deficiency in a critical area. Specific areas of deficiency were clinical laboratory management and judgment in ordering special stains and studies. In addition, one half of employers agreed that more guidance and support for newly trained pathologists is needed now than was required 10 years ago. Academic employers generally were more satisfied than private sector employers. Newly trained pathologists did not appear to be inappropriately overconfident in their abilities. In addition, their perceptions of those specific areas in which they are most and least prepared are very similar to the ratings provided by employers. On average, newly trained pathologists' ratings of their own preparedness are highest for specific aspects of general pathology and anatomic pathology, and lowest for specific aspects of clinical pathology and administration. In selecting new pathologists, employers perceived medical knowledge and interpersonal skills as the most important discriminating applicant characteristics. When new employees were asked why they thought they were offered their position, the discriminating qualifications cited most often were academic background and training, as well as completion of a fellowship and subspecialty training. CONCLUSIONS: It is our hope that the results of this survey can be used as input for further discussions and recommendations for training of pathology residents so as to further advance the ability of pathologists to provide quality patient care upon their graduation from training.

Localized malignant mesothelioma.

Localized malignant mesotheliomas are uncommon sharply circumscribed tumors of the serosal membranes with the microscopic appearance of diffuse malignant mesothelioma but without any evidence of diffuse spread. Little is known about their behavior. We report 23 new cases. The mean age at presentation was 63 years, and the sex ratio was approximately 2:1 (male/female). Twenty-one tumors were pleural and 2 were peritoneal. Sixteen tumors reproduced microscopic patterns of diffuse epithelial mesotheliomas, 6 had mixed epithelial and sarcomatous patterns, and 1 was purely sarcomatous. After surgical excision of the tumor, 10 of 21 patients with follow-up data were alive without evidence of disease from 18 months to 11 years after diagnosis. Patients who died had developed local recurrences and metastases, but none had diffuse pleural spread. Localized malignant mesotheliomas should be separated from diffuse malignant mesotheliomas because of their localized presentation, quite different biologic behavior, and far better prognosis.

Electrifying a medical school course: a case study.

BACKGROUND: At Virginia Commonwealth University School of Medicine, the Dean charged the curriculum office to "electrify the curriculum." An instructional development team chose a 2nd-year course to serve as a model e-course and to provide evaluation data for a 2-year study. DESCRIPTION: The instructional development process used instructional and Web design principles. An evaluation plan included a number of data collection methods: e-mail surveys, a focus group, student diaries, and comprehensive end-of-course student assessments. The e-course allowed students to take advantage of learning opportunities that traditional face-to-face instruction normally does not. EVALUATION: Students found access to multiple images; interactivity; and meaningful, efficient navigation within the site to be useful. Web-based instruction shows promise to aid students in the transition from concept acquisition to complex "doctor thinking." It does not replace the need for human teachers. CONCLUSION: The authors conclude with instructional design suggestions to exploit the power of Web-based teaching for the enhancement of complex learning.

Focal asymmetric densities seen at mammography: US and pathologic correlation.

The American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) defines four different types of asymmetric breast findings: asymmetric breast tissue, densities seen in one projection, architectural distortion, and focal asymmetric densities. These lesions are frequently encountered at screening and diagnostic mammography and are significant because they may indicate a neoplasm, especially if an associated palpable mass is present. Once these lesions are detected at standard mammography, supplementary breast imaging with additional mammographic views and ultrasonography (US) can be a key aspect of work-up. The role of US in this setting has not been clearly defined. However, a positive US finding such as a solid mass or an area of focal shadowing increases the level of suspicion for malignancy. A thorough knowledge of the patient's clinical history, along with a fundamental understanding of the ACR BI-RADS lexicon and the role and limitations of supplementary breast imaging, will allow more accurate interpretation of these potentially perplexing soft-tissue findings.