Having weathered the gauntlet that is/was my inpatient pediatrics rotation, I have been kind of off the radar. But, lucky me, I just happened to land having family medicine during the one month that has a holiday that Americans have no justification for or idea about its origin: Labor Day!. The 1 extra day this weekend did leave me less sleep deprived to the point where I feel 'encouraged' to write for you, dear readers. So, I want to relate a story from the clinic.
While I was on the EHR software at my Family Medicine rotation site affiliated with not-to-be-named medical center recently, I came across... a somewhat awkwardly worded pathology report. The phrase found in the pap smear cytology report at the end of a reasonably long paragraph was simply: Trichomonas vaginalis. Not positive for Trichomonas vaginalis, not trichomonad organisms are visualized, just name dropped the bug and out.
At first I wasn't really sure what to make of this, whether it was positive/negative or just a transcription error. So, after looking up the appropriate treatment (metronidazole), I brought it up on presenting to the attending/preceptor with the 3rd year resident, sayin' "hey, this lady was [insert] positive for Trichomonas on the pathology report". Only to get a... "we only treat that if the patient is symptomatic." I mean, having T. vaginalis on the path report was simply pretty just served as a record that the pathologist saw it under the scope, it didn't add to a potential diagnosis. To the clinician, unless the patient is clinically symptomatic it's almost as if that line/information wasn't there. So it's really more of a record 'that we saw it', so to speak.
So this got me thinking about priorities, and layout of a pathology report. In terms of priorities, what is a clinician most likely going to want to know from the report? When it comes to gynecology specimens, clearly any tissue diagnosis be #1 priority. Then Cytology and HPV results. Additional comments or interesting facts can be saved for a comment at the end of the report. Maybe that the pathologist saw Trichomonas should have been reported in a 'not clinically useful/relevant' section (i.e. comment) instead of in the main report. This is why being a well-rounded doctor makes the best doctors (and pathologists), in being able to prioritize information in terms of clinical relevance.
I have to say, I kind of hate descriptive diagnoses and I'm sure clinicians do too. It feels like (and probably is) a cop out on the part of the pathologist. It is kind of a cover for, "hey I don't recognize how this fits into the bigger picture" or "I simply don't know what this entity is, so I'll just describe it for now". Which is probably not very satisfying from the standpoint of the clinician, or Ob/Gyn let's say, reading the report. From what I understand, pathologists and gynecologists had to sit down at a table and mutually agree upon terms understandable to both their specialties to agree on a shared language in order to communicate in said reports. Otherwise, I wonder if it would all be descriptive?
This brings me to my final point which I noticed with some regularity, and I'm only speaking to my personal experience right now is... Some gynecologists make themselves look pretty bad in the eyes of pathologists. I can't tell you how many times over the course of the year where I would be sitting at sign out with the pathologist and a slide with almost no tissue whatsoever graces our presence. Most of the time it would be signed out as an 'insufficient' or 'inadequate' specimen... Though it's really embarassing and really a waste of everyone's time when there is a fleck of tissue on the slide and the gynecologist still submits it like it's a bona-fide specimen. It makes me wonder, do they bill for more when they obtain/send a 'specimen' when there really isn't any? Because it doesn't fool me. Just because you put a piece of gauze in a formalin jar, doesn't mean there was anything on it... and I'm pretty sure they know this as well as we do. It's not hard to see that there's almost nothing with the naked eye. It's additionally extremely aggravating for the person grossing the specimen when it is a tiny... tiny... specimen, and it causes a whole lot of hulabuloo when there really isn't any specimen to be found or it gets "lost".
So, all I get from this is some gynecologists and pathologists make life harder for the other, though they have a very dependent working relationship. i.e. one cannot function without the other. Therefore, I think it is important to maintain good communication with all parties involved and make sure the working relationship is appropriate and congenial. That way one gives/receives feedback and collaboration happens to improve patient care. After all, we need each other.
Monday, September 3, 2018
Sunday, August 19, 2018
more transplant
Today I want to discuss another type of transplant.
The reason I became interested in this is due to having exposure to patients who have undergone combined liver/intestine transplants at not-to-be named children's hospital, where I am currently doing my inpatient pediatrics rotation on the gastroenterology service.
Before, I had really only ever thought about isolated liver transplants, most commonly seen in adult medicine due to liver failure or cancer. The need for a combined transplant is something that I did not really appreciate before seeing kids with short gut syndrome in the hospital. Liver transplant can occur by itself, with intestine, and also possibly other organs such as pancreas or stomach (when this happens it is called a 'multi-visceral' transplant).
The children who require a combined liver and intestine transplantation usually have a history of short gut syndrome. Short gut syndrome is essentially when the small intestine is not functioning well or is shorter due to surgical resection. There are many reasons a child might have short gut syndrome. It can be secondary to a variety of etiologies such as necrotizing enterocolitis associated with prematurity (premature infants are particularly vulnerable, because their lungs are not fully developed, and this can cause poor oxygenation of the bowel which allows existing gut bacteria to infiltrate and cause necrosis of the bowel), any sort of atresia (congenital blockage/obstruction of bowel) requiring surgical removal and anastomosis, or complicated gastroschisis (which is essentially when bowel herniates through a full thickness defect in the abdominal wall; in some cases, when the opening is small it can pinch the herniated bowel which loses blood supply and becomes necrotic, necessitating resection). Other reasons have to do with the functioning of the small intestine. There are some kids who have innervation issues (Hirshprung's disease), food allergies (i.e. milk protein), or recurrent infections that make their gut less functional.
Kids that are missing some or, in severe cases, most of their bowel or have less-functional bowel receive nutrition various ways either orally, intravenously (using total parenteral nutrition or TPN), or via tubes which deposit food directly into the digestive system (gastrostomy or G-tube, jejunostomy or J-tube, gastrostomy-jejunostomy or GJ-tube) which are placed surgically.
Some patients with short gut syndrome develop liver failure associated with receiving nutrition parenterally (a.k.a. via TPN). The reason for this is complex, however the current hypothesis has to do with bile stasis in the liver since the gut is not working to digest as much. For this reason, children with failure to thrive are slowly weaned off TPN and while their tube feeds are increased to avoid this issue. Additionally, the lipid component of the nutrition is carefully controlled as to not overwhelm the liver.
Recently, two of the patients on my service were children who had received combined intestine/liver transplants, and both had complications following transplantation. One of them was transplanted at an early age and subsequently developed hepatocellular carcinoma. He was terminally ill and died in the hospital. The other had acute-on-chronic rejection of the transplanted liver.
A phrase doctors like to say is "it's always about the patient". Although pathologists have minimal to no contact with patients on a day-to-day basis, the information pathologists supply to the clinical team is crucial. Another adage is that a physician who treats himself/herself has a fool for a patient.
Can you think of any other instances in which multiple transplants would be indicated? Share!
The reason I became interested in this is due to having exposure to patients who have undergone combined liver/intestine transplants at not-to-be named children's hospital, where I am currently doing my inpatient pediatrics rotation on the gastroenterology service.
Before, I had really only ever thought about isolated liver transplants, most commonly seen in adult medicine due to liver failure or cancer. The need for a combined transplant is something that I did not really appreciate before seeing kids with short gut syndrome in the hospital. Liver transplant can occur by itself, with intestine, and also possibly other organs such as pancreas or stomach (when this happens it is called a 'multi-visceral' transplant).
The children who require a combined liver and intestine transplantation usually have a history of short gut syndrome. Short gut syndrome is essentially when the small intestine is not functioning well or is shorter due to surgical resection. There are many reasons a child might have short gut syndrome. It can be secondary to a variety of etiologies such as necrotizing enterocolitis associated with prematurity (premature infants are particularly vulnerable, because their lungs are not fully developed, and this can cause poor oxygenation of the bowel which allows existing gut bacteria to infiltrate and cause necrosis of the bowel), any sort of atresia (congenital blockage/obstruction of bowel) requiring surgical removal and anastomosis, or complicated gastroschisis (which is essentially when bowel herniates through a full thickness defect in the abdominal wall; in some cases, when the opening is small it can pinch the herniated bowel which loses blood supply and becomes necrotic, necessitating resection). Other reasons have to do with the functioning of the small intestine. There are some kids who have innervation issues (Hirshprung's disease), food allergies (i.e. milk protein), or recurrent infections that make their gut less functional.
Some patients with short gut syndrome develop liver failure associated with receiving nutrition parenterally (a.k.a. via TPN). The reason for this is complex, however the current hypothesis has to do with bile stasis in the liver since the gut is not working to digest as much. For this reason, children with failure to thrive are slowly weaned off TPN and while their tube feeds are increased to avoid this issue. Additionally, the lipid component of the nutrition is carefully controlled as to not overwhelm the liver.
Recently, two of the patients on my service were children who had received combined intestine/liver transplants, and both had complications following transplantation. One of them was transplanted at an early age and subsequently developed hepatocellular carcinoma. He was terminally ill and died in the hospital. The other had acute-on-chronic rejection of the transplanted liver.
A phrase doctors like to say is "it's always about the patient". Although pathologists have minimal to no contact with patients on a day-to-day basis, the information pathologists supply to the clinical team is crucial. Another adage is that a physician who treats himself/herself has a fool for a patient.
Can you think of any other instances in which multiple transplants would be indicated? Share!
Saturday, July 7, 2018
transplants
Hi everyone, today I would like to discuss the role of pathology in the field of transplant medicine.
Specifically, I want to hone in on one of the most common solid organ transplant procedure performed - kidney, with possible simultaneous pancreas or pancreatic islet cell transplant. For anyone curious about this topic, I suggest Leiden University's Clinical Kidney, Pancreas and Islet Transplantation on Coursera. I've been slowly working my way through this course and can say that it has been extremely rewarding.
A major role of the clinical lab before such a transplant is to determine suitability of potential donor candidates to the recipient by finding out (1) the human leukocyte antigen subtypes and (2) antibodies. Here, clinical pathologists might serve in an advisory role.
During and after the operation, surgical pathologists may be involved in assessment of the viability of harvested tissue, gross examination of the explant, and determination of the type and severity of rejection if it occurs post-transplant. There are many histologic findings depending on the type of rejection, and in which organ. For example, here is a video on PathCast which shows histology of liver transplant. And here is a webisode from the Wustl series on renal transplant. These are good starting points for individual study.
This week, I watched Mixed Match, a hour-long documentary which delves into the complexities of finding HLA-compatible bone marrow transplant donor for people of mixed ethic heritage. It can be watched here, however you have to use a VPN to set your country's location to Canada. The bonus scenes (which can be accessed at the movie/production site) show the process of stem cell donation and cord blood banking from newborns.
Here is an open access article that discusses HLA in more detail.
Figure 6 talks about how HLA is genetically inherited.
Human Leucocyte Antigen (HLA) System in Solid Organ Transplantation and Few Novel Concepts on HLA Matching
These ideas are fascinating to me overall...
Please share your thoughts/comments below!
Specifically, I want to hone in on one of the most common solid organ transplant procedure performed - kidney, with possible simultaneous pancreas or pancreatic islet cell transplant. For anyone curious about this topic, I suggest Leiden University's Clinical Kidney, Pancreas and Islet Transplantation on Coursera. I've been slowly working my way through this course and can say that it has been extremely rewarding.
A major role of the clinical lab before such a transplant is to determine suitability of potential donor candidates to the recipient by finding out (1) the human leukocyte antigen subtypes and (2) antibodies. Here, clinical pathologists might serve in an advisory role.
During and after the operation, surgical pathologists may be involved in assessment of the viability of harvested tissue, gross examination of the explant, and determination of the type and severity of rejection if it occurs post-transplant. There are many histologic findings depending on the type of rejection, and in which organ. For example, here is a video on PathCast which shows histology of liver transplant. And here is a webisode from the Wustl series on renal transplant. These are good starting points for individual study.
This week, I watched Mixed Match, a hour-long documentary which delves into the complexities of finding HLA-compatible bone marrow transplant donor for people of mixed ethic heritage. It can be watched here, however you have to use a VPN to set your country's location to Canada. The bonus scenes (which can be accessed at the movie/production site) show the process of stem cell donation and cord blood banking from newborns.
Here is an open access article that discusses HLA in more detail.
Figure 6 talks about how HLA is genetically inherited.
Human Leucocyte Antigen (HLA) System in Solid Organ Transplantation and Few Novel Concepts on HLA Matching
These ideas are fascinating to me overall...
Please share your thoughts/comments below!
Wednesday, July 4, 2018
Online Resources
For the past few weeks, I have been spending my Wednesday mornings in nephrology outpatient clinic at unnamed academic medical center, in order to fulfill the 'longitudinal clinical experience' requirement of getting through medical school. Because of this exposure, I find myself more interested in renal pathology.
I stumbled upon a wonderful resource, the Washington University in St. Louis Nephrology Web Series, created by Timothy Yau, M.D. which is a YouTube series of webisodes that discuss aspects of physiology, history, and pathology related to the kidney. Many of them involve a renal pathologist and nephrology fellow collaboratively interpreting kidney biopsy images. While watching his videos, I came across an online textbook which helped me understand some of the finer points of renal physiology. Another for those interested in nephropathology is Arkana lab's Blog. Another site is NephSim, a website which is also mobile phone compatible. Also AJKD's cases.
Now that I am on the topic of youtube and pathology, I would like to list channels and videos that I personally have found helpful/entertaining.
pathCast - pathology experts from a variety of institutions
Cleveland Clinic Laboratories - Pathology Insights series
Jerad Gardner - dermato- and soft tissue pathologist involved in social media
Mount Sinai Department of Pathology - didactics that are streamed
Websites:
PathologyOutlines - outlines in bullet point form
Board Review Pathology - navigate by changing the last number (1 to 2648)
International Society of Urological Pathologists - access imagebase/cases with an account
Bethesda System for Cervical Cytopathology - helpful for cervical cytology
Honorable mention:
Video
DermPro DermPath - compilation of derm spotters
UAMS Pathophysiology - from the very basic to beyond
Web Pathology - pictures with detailed explanations
Libre Pathology - aims to be Wikipedia for pathology (some pages not filled in)
Clinical Key - if your institution has a subscription, you can read pathology books for free!
ImmunoQuery - helps you rule in / out diagnoses based on IHC (my home institution does not have a subscription).
Share your resources in the comments below!
I stumbled upon a wonderful resource, the Washington University in St. Louis Nephrology Web Series, created by Timothy Yau, M.D. which is a YouTube series of webisodes that discuss aspects of physiology, history, and pathology related to the kidney. Many of them involve a renal pathologist and nephrology fellow collaboratively interpreting kidney biopsy images. While watching his videos, I came across an online textbook which helped me understand some of the finer points of renal physiology. Another for those interested in nephropathology is Arkana lab's Blog. Another site is NephSim, a website which is also mobile phone compatible. Also AJKD's cases.
Now that I am on the topic of youtube and pathology, I would like to list channels and videos that I personally have found helpful/entertaining.
pathCast - pathology experts from a variety of institutions
Cleveland Clinic Laboratories - Pathology Insights series
Jerad Gardner - dermato- and soft tissue pathologist involved in social media
Mount Sinai Department of Pathology - didactics that are streamed
Websites:
PathologyOutlines - outlines in bullet point form
Board Review Pathology - navigate by changing the last number (1 to 2648)
International Society of Urological Pathologists - access imagebase/cases with an account
Bethesda System for Cervical Cytopathology - helpful for cervical cytology
Honorable mention:
Video
DermPro DermPath - compilation of derm spotters
UAMS Pathophysiology - from the very basic to beyond
Web Pathology - pictures with detailed explanations
Libre Pathology - aims to be Wikipedia for pathology (some pages not filled in)
Clinical Key - if your institution has a subscription, you can read pathology books for free!
ImmunoQuery - helps you rule in / out diagnoses based on IHC (my home institution does not have a subscription).
Share your resources in the comments below!
First Post
Hi readers! This is my first blog post.
What I hope to accomplish:
- review topics that interest me
- share resources (online, print)
- discuss guidelines
My ultimate goal for this blog is to generate curiosity about pathology as a medical specialty. My personal goal is to continue to stay motivated towards my goal of becoming a pathologist while in medical school. I hope reading this blog will be entertaining and helpful no matter where you are in your education/training.
What I hope to accomplish:
- review topics that interest me
- share resources (online, print)
- discuss guidelines
My ultimate goal for this blog is to generate curiosity about pathology as a medical specialty. My personal goal is to continue to stay motivated towards my goal of becoming a pathologist while in medical school. I hope reading this blog will be entertaining and helpful no matter where you are in your education/training.
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