Time Required for Gross Examination of Routine Second and Third Trimester Singleton Placentas by Pathologists' Assistants.

INTRODUCTION: In both Canada and the United States, workload measurement for anatomic pathology is mainly based on complexity and clinical significance of specimens, with gross examination being a considerable contributor. While Pathologists' Assistants (PAs) play an increasing role in gross examination, there is little known regarding the time required for PAs to complete grossing tasks. This information is essential for effective staffing and workload management in pathology laboratories. The objective of our study was to determine the time required for PAs to gross second and third trimester singleton placentas in a large tertiary hospital with a significant perinatal pathology service. MATERIALS AND METHODS: For our study, 7 certified PAs each grossed a minimum of 10 second and third trimester singleton placentas using a standard placental grossing protocol, an electronic laboratory information system, and voice recognition dictation software. Placental specimens requiring photography, sampling for ancillary studies, or immediate pathologist's consultation were excluded. We calculated average and standard deviation of grossing times for each PA, overall average grossing time, and 95% confidence interval using a mixed linear regression model. We analyzed the impact of PA job experience, degree obtained, and number of blocks prepared on overall average in a multivariate analysis. RESULTS: The mean grossing times for each PA ranged from 11.0 (standard deviation [sd] = 2.0) to 17.8 (sd = 4.5) minutes. The overall average grossing time was 14.5 minutes, with a 95% confidence interval of 11.7 to 17.3 minutes. In multivariate analysis, an increase in the number of blocks prepared was significantly associated with longer overall average grossing time. If 4 blocks were prepared consistently, the model predicted a slightly lower overall average of 13.3 minutes, with a 95% confidence interval of 10.9 to 15.7 minutes. DISCUSSION: To our knowledge, our study is the first to objectively report time required for PAs to perform gross examinations of routine second and third trimester singleton placentas. The methodology of our study is replicable and can be applied to other specimen types and laboratory settings. Previously, estimated grossing times for specimens were primarily based on retrospective surveys, which were susceptible to recall errors and subjectivity. However, our study demonstrates objective data collection is achievable. Furthermore, the data collected from this study offer valuable insights into the accuracy of previous and current pathology workload models for second and third trimester singleton placentas.

How I approach: The workup and management of patients with progressive transformation of the germinal center.

Progressive transformation of the germinal center (PTGC) is a common and underrecognized cause of pediatric lymphadenopathy. PTGC may be associated with numerous systemic medical conditions that require further workup and management, including malignancy, autoimmune conditions, lymphoproliferative conditions, immunodeficiency, and infection. Given the breadth and rarity of the associated conditions, workup should be tailored to the individual patient and occur in a tiered approach. Patients with PTGC require ongoing follow-up, given their long-term risk of malignancy and recurrent PTGC.

[Inflammatory diseases : anatomo-pathological features]. / Maladies inflammatoires : aspects anatomo-pathologiques.

The aim of this article is to describe the role of anatomic pathology in the management of acute and chronic inflammatory diseases. Granulomatous pathologies will be also addressed as well as some dysimmune pathologies and recent data on the prognostic role of the antitumoral inflammatory response.

: Le but de cet article est de décrire le rôle joué par l'anatomie pathologique dans la prise en charge de maladies inflammatoires aiguës et chroniques. Les pathologies granulomateuses seront également abordées de même que certaines pathologies dysimmunitaires et des données récentes sur le rôle pronostique de la réponse inflammatoire antitumorale.

Thermal Analysis of Paraffin-Embedded Tissue Blocks for Anatomic Pathology Processes.

We analyze temperature dynamics in anatomic pathology samples to identify the most efficient refrigeration method and to predict the time available for optimal sectioning before sample heating, thus getting appropriate information for a correct diagnosis by anatomopathologists. A thermal finite element (FE) analysis was carried out with comsolmultiphysics to evaluate temperature variations in paraffin-embedded tissues, i.e., muscle, bone and fat, and the corresponding thermal stresses. Experiments with different tissues and thermocouple-based measurements allowed validating the FE simulations. Simulations allowed to estimate the time needed to bring the sample at the optimal temperature for sectioning (-8 to -4 °C) in different conditions: refrigeration on a cold plate, refrigeration in a cooled environment, and refrigeration in an environment with forced convection. Among the three cooling methods tested, the forced convection at -20 °C and with an air-flow speed of 5 m/s resulted in the shortest cooling time. As compared to the other methods, thermal stresses can be modulated by varying the air-flow speed. For the different conditions, the time needed for the surface of the tissue block to exit from a temperature corresponding to an optimal cutting, when leaving the sample exposed to room temperature after refrigeration, ranged from 12 to 310 s. We quantify the time needed to adequately refrigerate paraffin-embedded tissue samples and the time available before they leave the optimal temperature window for sectioning. We also evaluate the maximum stress attained in the paraffin block during the cooling and the heating transients. This information will help optimize anatomic pathology processes.

The Anatomic Pathology laboratory adjustments in the era of COVID-19 pandemic: The experience of a laboratory in a Portuguese central hospital.

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the world over the past weeks, with already 8,25 million infections and 445,000 deaths worldwide, leading to an unprecedented international global effort to contain the virus and prevent its spread. The emergence of novel respiratory viruses such as the SARS-CoV-2 creates dramatic challenges to the healthcare services, including surgical pathology laboratories, despite their extensive daily experience in dealing with biological and chemical hazards. Here, we cover important aspects on the knowledge on COVID-19 gathered during the first six months of the pandemic and address relevant issues on human biological sample handling in the Anatomic Pathology laboratory in the context of COVID-19 global threat. In addition, we detail our strategy to minimize the risk of contamination upon exposure to the different biological products received in the laboratory, which can be of general interest to other laboratories worldwide. Our approach has enabled a safe work environment for laboratory staff, while ensuring the maintenance of high quality standards of the work performed. In times of uncertainty and given the lack of specific guidelines directed at Anatomic Pathology services to better deal with the global COVID-19 public-health emergency, it is essential to share with the community rigorous methodologies that will enable us to better cope with probable novel waves of COVID-19 infection and other viruses that will possibly arise in the near future.

Pathologist Opinions about EPIC Beaker AP: a Multi-Institutional Survey of Early Adopters.

EPIC Systems Corporation provides a widely used electronic medical record. Beaker Anatomic Pathology is a newly developed laboratory information system (LIS) that has been implemented at a small number of academic pathology departments. Pathologist opinions of EPIC Beaker AP have not been well described in the literature. A 37-question survey was administered to pathologists and pathology trainees to assess overall satisfaction and efficiency of report generation using Beaker AP. Data about experience in pathology, signout responsibilities, Beaker AP usage, and the legacy LIS was also collected. Seventy-four pathologists (51 faculty, 23 residents) responded to the survey (overall response rate 29.7%). Overall pathologist satisfaction with Beaker AP showed high inter-institutional variability; institutions with legacy LISs with a graphical interface had a generally neutral to negative assessment of Beaker AP. The majority of respondents disagreed with the statement "Beaker AP is easy to use and designed for my needs". Pathologists felt that Beaker AP was useful for reviewing clinical information and billing; areas of weakness included searching for prior cases and grossing efficiency. Overall, pathologists had a neutral opinion of whether generating and signing out a complete report was faster in Beaker AP, with marked inter-institutional variation. This variability was likely due to a combination of the efficacy of the legacy LIS, familiarity with Beaker AP at the time of the survey, and institution-specific optimization efforts.

Impact of pre-analytical variables on deep learning accuracy in histopathology.

AIMS: Machine learning (ML) binary classification in diagnostic histopathology is an area of intense investigation. Several assumptions, including training image quality/format and the number of training images required, appear to be similar in many studies irrespective of the paucity of supporting evidence. We empirically compared training image file type, training set size, and two common convolutional neural networks (CNNs) using transfer learning (ResNet50 and SqueezeNet). METHODS AND RESULTS: Thirty haematoxylin and eosin (H&E)-stained slides with carcinoma or normal tissue from three tissue types (breast, colon, and prostate) were photographed, generating 3000 partially overlapping images (1000 per tissue type). These lossless Portable Networks Graphics (PNGs) images were converted to lossy Joint Photographic Experts Group (JPG) images. Tissue type-specific binary classification ML models were developed by the use of all PNG or JPG images, and repeated with a subset of 500, 200, 100, 50, 30 and 10 images. Eleven models were generated for each tissue type, at each quantity of training images, for each file type, and for each CNN, resulting in 924 models. Internal accuracies and generalisation accuracies were compared. There was no meaningful significant difference in accuracies between PNG and JPG models. Models trained with more images did not invariably perform better. ResNet50 typically outperformed SqueezeNet. Models were generalisable within a tissue type but not across tissue types. CONCLUSIONS: Lossy JPG images were not inferior to lossless PNG images in our models. Large numbers of unique H&E-stained slides were not required for training optimal ML models. This reinforces the need for an evidence-based approach to best practices for histopathological ML.

Infantile Hypertrophic Pyloric Stenosis: An Epidemiological Review.

Infantile hypertrophic pyloric stenosis (IHPS) is the most common gastrointestinal disease among infants. IHPS occurs as an isolated condition or together with other congenital anomalies. Association with genetic and environmental factors, bottle feeding, younger maternal age, maternal smoking, and erythromycin administration in the first two weeks of life has been shown. Familial aggregation has been described and a family history is seen in 47.9 percent of siblings. Infants typically present with projectile vomiting associated with symptoms of failure to thrive. An olive-like mass palpable in the right upper abdominal quadrant is being reported less frequently because of earlier diagnosis by ultrasound. IHPS is generally corrected through laparoscopic pyloromyotomy. Endoscopic pyloric balloon dilation is a novel alternative. Further studies on different populations, the general population, and familial segregation to determine the prevalence, influence, and mode of familial aggregation and correlation with environmental factors are needed to determine the etiology of IHPS.

Diagnostic electron microscopy and the influence of Dr. Juan Rosai.

Transmission electron microscopy (TEM) was introduced by Ruska and Knoll as a laboratory technique in 1933. Thereafter, several decades passed before the methods required for its optimal implementation were fully developed. Early uses of TEM were in Botany, rather than in Medicine; however, isolated publications did catalog the ultrastructural characteristics of several individual human tumor types. Finally, in 1968, Rosai and Rodriguez authored an important article, introducing the concept that TEM could be used for the differential diagnosis of histologically similar neoplasms. This publication heralded the steadily increasing application of TEM in anatomic pathology over the following decade, including continuing contributions by Dr. Juan Rosai. This brief review summarizes his influence on clinical electron microscopy, and lists some of the lesions for which that procedure is still a useful means of analysis.

Technical Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper.

This white paper explores the technical challenges and solutions for acquiring (capturing) and managing enterprise images, particularly those involving visible light applications. The types of acquisition devices used for various general-purpose photography and specialized applications including dermatology, endoscopy, and anatomic pathology are reviewed. The formats and standards used, and the associated metadata requirements and communication protocols for transfer and workflow are considered. Particular emphasis is placed on the importance of metadata capture in both order- and encounter-based workflow. The benefits of using DICOM to provide a standard means of recording and accessing both metadata and image and video data are considered, as is the role of IHE and FHIR.

Clinical and anatomic pathology effects of serial blood sampling in rat toxicology studies, using conventional or microsampling methods.

UNLABELLED: As a general practice in rodent toxicology studies, satellite animals are used for toxicokinetic determinations, because of the potential impact of serial blood sampling on toxicological endpoints. Besides toxicological and toxicokinetic determinations, blood samples obtained longitudinally from a same animal may be used for the assessment of additional parameters (e.g., metabolism, pharmacodynamics, safety biomarkers) to maximize information that can be deduced from rodents. We investigated whether removal of up to 6 × 200 µL of blood over 24h can be applied in GLP rat toxicology studies without affecting the scientific outcome. METHODS: 8 week-old female rats (200-300 g) were dosed for up to 1 month with a standard vehicle and subjected or not (controls) to serial blood sampling for sham toxicokinetic/ancillary determinations, using miniaturized methods allowing collection of 6 × 50, 100 or 200 µL over 24h. In-life endpoints, clinical pathology parameters and histopathology of organs sensitive to blood volume reduction were evaluated at several time points after completion of sampling. RESULTS: In sampled rats, minimal and reversible changes in red blood cell mass (maximally 15%) and subtle variations in liver enzymes, fibrinogen and neutrophils were not associated with any organ/tissue macroscopic or microscopic correlate. CONCLUSION: Serial blood sampling (up to 6 × 200 µL over 24h) is compatible with the assessment of standard toxicity endpoints in adult rats.

Histologic study of the effects of chemoembolization with preloaded doxorubicin beads in patients with hepatocellular carcinoma.

OBJECTIVE: To determine the degree of tumor necrosis in surgical specimens of hepatocellular carcinomas treated with microspheres preloaded with doxorubicin and to analyze the relationship between the degree of necrosis and a) morphologic factors and b) imaging biomarkers. MATERIAL AND METHODS: We studied the livers of 21 patients who had undergone selective arterial chemoembolization with DC beads (Biocompatibles, UK) before receiving liver transplants. RESULTS: Imaging techniques detected 43 nodules (mean size, 25 mm). Angiography showed 25 hypervascularized nodules, 12 slightly vascularized nodules, and 6 avascular nodules. A total of 81 hepatocellular carcinomas (mean size, 15 mm) were detected in the specimens: two were capsular and two had vascular infiltration. The mean degree of necrosis after chemoembolization was 39%; necrosis was greater than 60% in 28 hepatocellular carcinomas and less than 60% in 52. The degree of necrosis correlated significantly with the time elapsed between the last chemoembolization treatment and liver transplantation (the degree of necrosis decreased as time increased), with the number of nodules in the specimen, and with capsular infiltration. When imaging techniques detected 1 or 2 nodules, there was a greater probability of achieving greater than 90% necrosis. No relation with the degree of necrosis achieved was found for the size of the nodules detected at imaging, the enhancement pattern, or the number of chemoembolization treatments. CONCLUSION: The degree of necrosis achieved depends on the time spent on the waiting list, on the number of nodules in the specimen, and on whether capsular infiltration is present.

Veterinary and human biobanking practices: enhancing molecular sample integrity.

Animal models have historically informed veterinary and human pathophysiology. Next-generation genomic sequencing and molecular analyses using analytes derived from tissue require integrative approaches to determine macroanalyte integrity as well as morphology for imaging algorithms that can extend translational applications. The field of biospecimen science and biobanking will play critical roles in tissue sample collection and processing to ensure the integrity of macromolecules, aid experimental design, and provide more accurate and reproducible downstream genomic data. Herein, we employ animal experiments to combine protein expression analysis by microscopy with RNA integrity number and quantitative measures of morphologic changes of autolysis. These analyses can be used to predict the effect of preanalytic variables and provide the basis for standardized methods in tissue sample collection and processing. We also discuss the application of digital imaging with quantitative RNA and tissue-based protein measurements to show that genomic methods augment traditional in vivo imaging to support biospecimen science. To make these observations, we have established a time course experiment of murine kidney tissues that predicts conventional measures of RNA integrity by RIN analysis and provides reliable and accurate measures of biospecimen integrity and fitness, in particular for time points less than 3 hours post-tissue resection.

Survey of NAACLS accredited histotechnology programs in the United States.

Histotechnology educational programs are accredited by the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) and currently number fewer than 50 in the United States which contributes to the shortages of laboratory personnel. A survey tool designed with REDCap software was distributed to all programs identified on the NAACLS website and consisted of three parts: a) program information, b) facility information, and c) challenges. Programs are located primarily in large urban centers where populations are most concentrated. The median class size was 6 which may explain the excellent student outcomes to include 96% graduation rates and 90.7% board of registry examination pass rates. Overall, programs had ample equipment, funding, and administrative support. Costs to attend the programs were relatively low (<$3,000 per semester) for over half of the programs. However, due to the small number of accredited education programs across the US, potential students do not often have access to an institution in their area. The programs indicated that the most common challenge was recruitment of adequate high-quality candidates which may explain, in part, the persistent shortage of personnel in the histology laboratory.

Virtual biopsies: Proof of concept for a novel quantitative approach to liver biopsy adequacy and pathology education.

OBJECTIVES: To quantitatively measure liver biopsy adequacy requirements and the effect of a teaching intervention that uses a virtual biopsy platform. METHODS: A library of virtual liver biopsies was created using digital whole-slide, trichrome-stained tissue sections from liver resection material and QuPath image analysis software. Blinded participants staged fibrosis on the virtual biopsies before and after a teaching intervention. RESULTS: This platform both modeled adequacy requirements for cirrhosis diagnosis on biopsy material and measured the effect of a teaching intervention on participant performance. Using this platform, diagnostic accuracy for cirrhosis could be modeled according to the function y = λ(1 ‒ e‒x/γ). The platform demonstrated that the relationship between biopsy size and diagnostic accuracy was statistically significant and that biopsies smaller than 6 mm long and 0.8 mm wide were insufficient to diagnosis cirrhosis. The platform also measured improvement in fibrosis staging accuracy among participants following a teaching intervention. CONCLUSIONS: These results provide proof of concept for a virtual biopsy method by which outstanding questions in anatomic pathology can be addressed quantitatively using open source software. Future work is needed to validate these findings in clinical practice.

Intra- and post-pandemic impact of the COVID-19 outbreak on Stanford Health Care.

Stanford Health Care, which provides about 7% of overall healthcare to approximately 9 million people in the San Francisco Bay Area, has undergone significant changes due to the opening of a second hospital in late 2019 and, more importantly, the COVID-19 pandemic. We examine the impact of these events on anatomic pathology (AP) cases, aiming to enhance operational efficiency in response to evolving healthcare demands. We extracted historical census, admission, lab tests, operation, and AP data since 2015. An approximately 45% increase in the volume of laboratory tests (P < 0.0001) and a 17% increase in AP cases (P < 0.0001) occurred post-pandemic. These increases were associated with progressively increasing (P < 0.0001) hospital census. Census increase stemmed from higher admission through the emergency department (ED), and longer lengths of stay mostly for transfer patients, likely due to the greater capability of the new ED and changes in regional and local practice patterns post-pandemic. Higher census led to overcapacity, which has an inverted U relationship that peaked at 103% capacity for AP cases and 114% capacity for laboratory tests. Overcapacity led to a lower capability to perform clinical activities, particularly those related to surgical procedures. We conclude by suggesting parameters for optimal operations in the post-pandemic era.

Anatomic and clinical pathology services and infrastructure in Zambia.

OBJECTIVES: Pathology services are limited across most of sub-Saharan Africa. We sought to ascertain the availability of anatomic and clinical pathology services and diagnostic resources in Zambia. METHODS: Two individual surveys-one for anatomic pathology and one for clinical pathology/laboratory medicine-were developed by subject matter experts. These surveys were administered to individuals involved in pathology and laboratory medicine diagnostic services at hospitals and laboratories across Zambia from May to October 2022 using the American Society for Clinical Pathology email listserv. RESULTS: A total of 20 responses were received from 17 unique laboratories-8 sites provide anatomic pathology (AP) services, 12 provide clinical pathology (CP) services, and 3 perform both AP and CP services. Anatomic pathology services are variable and generally limited to a few of the responding laboratories, as only 1 laboratory performs immunohistochemical staining on surgical pathology specimens, and only 2 perform general histochemical stains. Conversely, certain microbiology testing (eg, for HIV) is more widely available. CONCLUSIONS: This study of 17 unique laboratories represents the most complete analysis of pathology capabilities in Zambia. Despite initiatives to improve pathology services, both personnel and infrastructure challenges remain. Given a population of approximately 20 million, expansion of anatomic pathology in Zambia must be prioritized.

Jonas Friedenwald, Eugene Wolff, and the Two Books That Helped Bridge the Specialty Gap.

Background: Eugene Wolff (1896-1954) and Jonas S. Friedenwald (1897-1955) were life-long students and educators of anatomic pathology and ophthalmology. Both contributed toward narrowing the gap between the two rapidly diverging specialties of pathology and ophthalmology. Friedenwald in 1929 and Wolff in 1934 each published textbooks of ophthalmic pathology that influenced medical education for decades to come. Summary: Friedenwald's The Pathology of the Eye and Wolff's A Pathology of the Eye introduced ophthalmologists in training and practice to anatomic pathology, while familiarizing pathologists with the nature of ocular disease. Both books appeared at the time when anatomic pathology was departing from its mostly academic roles in education and research to assume more active participation in clinical care by establishing diagnoses through biopsy. Key Messages: Wolff and Friedenwald dedicated their careers to teaching the art and science of anatomic pathology to clinical ophthalmologists. Their efforts helped anchor ophthalmology to the traditions of mainstream medicine.

A longitudinal mixed-methods study of pathology explanation clinics in patients with newly diagnosed localized prostate cancer.

OBJECTIVES: To characterize the role of pathology explanation clinics (PECs) in prostate cancer care and determine their impact on patients, urologic oncologists, and quality of care. METHODS: Semistructured interviews with 10 patients with newly diagnosed prostate cancer were conducted before and after a PEC pilot and at the 1- and 6-month follow-up visits. Information about participants' cancer knowledge and anxiety were collected quantitatively. Documented pathologist communications and proper review of outside biopsy slides were collected. Semistructured interviews were also completed with participating urologic oncologists following the pilot. RESULTS: Pathology explanation clinics improved participants' understanding of their diagnosis, cognitively and emotionally supporting them first in their urologic oncology visit and later in making an informed treatment decision. Mean knowledge scores were high, and a minority of participants had prostate cancer anxiety. Urologic oncologists noted improved understanding and reduced anxiety among participants, enabling nuanced conversations about prognosis and management during the visit. By ensuring review of outside biopsy slides and communication of clinically significant or unexpected diagnoses, PECs supported high-quality care and patient safety. CONCLUSIONS: In this small pilot, PECs positively affected patients with prostate cancer, their clinicians, and the overall care system. Additional studies in larger populations and diverse settings will be useful.

What's in a Name? Replacing Pejorative Terminology in Anatomic Pathology.

Recent changes to medical terminology and nomenclature have made strides to improve ethical integrity in healthcare. Removing tarnished eponymous namesakes and depreciative descriptions from the medical lexicon is a challenging, but righteous undertaking. In this article, the authors propose replacing the pejorative histologic description of "Indian file" with "Tusken Raider file."