Ruyong formula improves thymus function of CUMS-stimulated breast cancer mice

ETHNOPHARMACOLOGICAL RELEVANCE

Ruyong Formula (RYF) is a famous Chinese herbal formula composed of 10 traditional Chinese herbs. It has been used as a therapeutic agent for breast cancer patients with depressive symptoms in China. However, its underlying pharmacological mechanism remains unclear.

AIM OF THE STUDY

This study aimed to explore the mechanism of RYF on the changes of thymus immune function in breast cancer body under mood disorders such as depression/anxiety.

MATERIALS AND METHODS

The chronic unpredictable mild stress (CUMS) was used to stimulate 4T1 breast cancer mice. The behavioral changes, 5-hydroxytryptamine (5-HT) level in brain, cytokeratin 5 (CK5) and 8 (CK8) expression in thymus, the proportion of T cell subsets, the thymic output, phenotypic changes of thymus epithelial cells (TECs), the expression levels of immune-related factors and downstream proteins of TSLP were analyzed after RYF treatment.

RESULTS

In CUMS stimulated group, the level of 5-HT in brain was significantly increased after RYF treatment. The output function of the thymus was improved, and the number of TECs in the medulla (CK5+), the proportion of CD3+CD4-CD8- (Double negative) and CD3+CD4+CD8+ (Double positive) T cells were all increased. The mRNA level of TSLP in mouse thymus was significantly decreased, but increased for IL-7. The protein levels of TSLP and Vimentin were decreased, but increased for p-STAT3, p-JAK2, E-cadherin, and p-PI3K p55 in vivo. In vitro study was showed the levels of Snail 1, Zeb 1 and Smad increased significantly in TGF-β1 group, and RYF could reverse their expression.

CONCLUSIONS

RYF could restore the structure and function of the thymus in depressed breast cancer mice by reversing the phenotypic changes of TECs and activating the JAK2/STAT3/PI3K pathway.

Ligustilide prevents thymic immune senescence by regulating Thymosin β15-dependent spatial distribution of thymic epithelial cells

BACKGROUND

Thymus is the most crucial organ connecting immunity and aging. The progressive senescence of thymic epithelial cells (TECs) leads to the involution of thymus under aging, chronic stress and other factors. Ligustilide (LIG) is a major active component of the anti-aging Chinese herbal medicine Angelica sinensis (Oliv.) Diels, but its role in preventing TEC-based thymic aging remains elusive.

PURPOSE

This study explored the protective role of Ligustilide in alleviating ADM (adriamycin) -induced thymic immune senescence and its underlying molecular mechanisms.

METHOD

The protective effect of Ligustilide on ADM-induced thymic atrophy was examined by mouse and organotypic models, and conformed by SA-β-gal staining in TECs. The abnormal spatial distribution of TECs in the senescent thymus was analyzed using H&E, immunofluorescence and flow cytometry. The possible mechanisms of Ligustilide in ADM-induced thymic aging were elucidated by qPCR, fluorescence labeling and Western blot. The mechanism of Ligustilide was subsequently validated through actin polymerization inhibitor, genetic engineering to regulate Thymosin β15 (Tβ15) and Tβ4 expression, molecular docking and β Thymosin-G-actin cross-linking assay.

RESULTS

At a 5 mg/kg dose, Ligustilide markedly ameliorated ADM-induced weight loss and limb grip weakness in mice. It also reversed thymic damage and restored positive selection impaired by ADM. In vitro, ADM disrupted thymic structure, reduced TECs number and hindered double negative (DN) T cell differentiation. Ligustilide counteracted these effects, promoted TEC proliferation and reticular differentiation, leading to an increase in CD4+ single positive (CD4SP) T cell proportion. Mechanistically, ADM diminished the microfilament quantity in immortalized TECs (iTECs), and lowered the expression of cytoskeletal marker proteins. Molecular docking and cross-linking assay revealed that Ligustilide inhibited the protein binding between G-actin and Tβ15 by inhibiting the formation of the Tβ15-G-actin complex, thus enhancing the microfilament assembly capacity in TECs.

CONCLUSION

This study, for the first time, reveals that Ligustilide can attenuate actin depolymerization, protects TECs from ADM-induced acute aging by inhibiting the binding of Tβ15 to G-actin, thereby improving thymic immune function. Moreover, it underscores the interesting role of Ligustilide in maintaining cytoskeletal assembly and network structure of TECs, offering a novel perspective for deeper understanding of anti thymic aging.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BACKGROUND

While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

AIM

To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

DESIGN & SETTING

A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

METHOD

Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

RESULTS

A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

CONCLUSION

The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Intramyocardial Hematoma During Catheter Ablation for Scar-Related Ventricular Tachycardia

BACKGROUND

Intramural hematoma during ablation for scar-related ventricular tachycardia (VT) is a rare but life-threatening complication.

OBJECTIVES

The goal of this study was to describe the features and outcomes of intramural hematoma during ablation for scar-related VT.

METHODS

From 2010 to 2022, >3,514 ablations for ventricular arrhythmias were performed at 2 institutions. Four cases of intramural hematoma complicating VT ablation for scar-related VT were identified. Intraprocedural details, imaging data, and surgical notes were reviewed to create a recognizable pattern of events highlighting this complication.

RESULTS

In 3 of 4 cases, intramural hematoma occurred during catheter ablation with an open irrigated 3.5 mm tipped catheter using normal saline for irrigation. In one case, hematoma was noted after ablation using an investigational needle electrode catheter. The occurrence of a steam pop preceded detection of an expanding intramural hematoma in 3 cases. ST-segment elevation on electrocardiography was evident in 3 cases; intracardiac echocardiographic imaging detected the hematoma in all cases. Epicardial rupture and pericardial effusion requiring drainage occurred in 3 cases, whereas 1 hematoma was self-contained and did not require intervention. Surgical intervention was performed in 2 cases, with successful outcomes. One patient who was deemed not a surgical candidate died of progressive cardiogenic shock.

CONCLUSIONS

Intramural hematoma during ablation for scar-related VT is a rare but potentially catastrophic complication that requires prompt recognition. Steam pops during ablation frequently precede the hematoma formation. Surgical intervention may be life-saving, although contained hematomas can occasionally be managed conservatively.

How influential are medical school curriculum and other medical school characteristics in students' selecting pathology as a specialty?

There has been a significant decline in the number of United States allopathic medical students matching to pathology residency programs. Data acquired from the American Association of Medical Colleges (AAMC) show sustained variation in the medical school production of students who go on to pathology residency. When divided into groups based on the medical school's historical volume of graduates entering pathology, the schools in groups labeled Group 1 and Group 2 produced significantly higher and lower proportions of pathology residents, respectively. This study aimed to identify what medical school curriculum elements and other medical school characteristics might explain the differences observed in the AAMC data. The Dean or another undergraduate medical education contact from the Group 1 and Group 2 schools was invited to participate in an interview. Pathology Program Directors and Pathology Department Chairs were also included in communications. Thirty interviews were completed with equal numbers from each group. Interview questions probed pathology experiences, existence, and structure of a pathology interest group, options for post-sophomore fellowships, recent curriculum changes, and the extent of mentoring programs. Surprisingly, the curriculum does not appear to be a predictor of a medical school's production of students who enter pathology residency. A significantly greater percentage of Group 1 schools are public institutions compared to Group 2 schools. Other factors that may increase the number of students who go into pathology include mentoring, active learning versus observation, and post-sophomore fellowships or other opportunities to work in the capacity of a new pathology resident.

Thymosin β4 and Actin: Binding Modes, Biological Functions and Clinical Applications

Thymosin β4 (Tβ4) is the β-thymosin (Tβs) with the highest expression level in human cells; it makes up roughly 70-80% of all Tβs in the human body. Combining the mechanism and activity studies of Tβ4 in recent years, we provide an overview of the subtle molecular mechanism, pharmacological action, and clinical applications of Tβ4. As a G-actin isolator, Tβ4 inhibits the polymerization of G-actin by binding to the matching site of G-actin in a 1:1 ratio through conformational and spatial effects. Tβ4 can control the threshold concentration of G-actin in the cytoplasm, influence the balance of depolymerization and polymerization of F-actin (also called Tread Milling of F-actin), and subsequently affect cell's various physiological activities, especially motility, development and differentiation. Based on this, Tβ4 is known to have a wide range of effects, including regulation of inflammation and tumor metastasis, promotion of angiogenesis, wound healing, regeneration of hair follicles, promotion of the development of the nervous system, and improving bone formation and tooth growth. Tβ4 therefore has extensive medicinal applications in many fields, and serves to preserve the kidney, liver, heart, brain, intestine, and other organs, as well as hair loss, skin trauma, cornea repairing, and other conditions. In this review, we focus on the mechanism of action and clinical application of Tβ4 for its main biological functions.

Thymosin Beta 15 Alters the Spatial Development of Thymic Epithelial Cells

The thymus is the most sensitive organ under various pathophysiological conditions, such as aging, starvation, and infection. As a key stromal cell for T cell development, it is well-known that thymic epithelial cells (TECs) play an important role in the thymus response to the external environment. Thymosin beta 15 (Tβ15) is a G-actin binding protein secreted by TECs, it plays an important role in maintaining the dynamic balance of actin, angiogenesis, axonal formation, and wound healing, but the relationship between Tβ15 and TECs is not clear yet. Here, we show the impact of Tβ15 on the TEC's spatial development, as well as the T-cell differentiation and thymic output. As a result, TEC is the main effector cell of Tβ15 in the thymus. Tβ15 OX inhibits the chemotaxis of TECs to the medulla and subsequently blocks the positive selection of thymocytes from CD3⁺TCRβ⁺CD4⁺CD8⁺ double positive cells to CD3⁺TCRβ⁺CD4⁺CD8^- single-positive (CD4SP) cells. Tβ15-knockdown accelerates the reticular differentiation of astral TECs and medullary TECs. Importantly, mice implanted with Tβ15-knockdown iTECs show high thymic output but low peripheral T cell maturity and activity. In a word, our results explain the role of Tβ15 on the differentiation and function of TECs and provide a new perspective for understanding the process of thymus development and degeneration.

G-CSF/GM-CSF-induced hematopoietic dysregulation in the progression of solid tumors

There are two types of abnormal hematopoiesis in solid tumor occurrence and treatment: pathological hematopoiesis, and myelosuppression induced by radiotherapy and chemotherapy. In this review, we primarily focus on the abnormal pathological hematopoietic differentiation in cancer induced by tumor-released granulocyte colony stimulating factor (G-CSF) and granulocyte-macrophage colony stimulating factor (GM-CSF). As key factors in hematopoietic development, G-CSF/GM-CSF are well-known facilitators of myelopoiesis and mobilization of hematopoietic stem cells (HSCs). In addition, these two cytokines can also promote or inhibit tumors, dependent on tumor type. In multiple cancer types, hematopoiesis is greatly enhanced and abnormal lineage differentiation is induced by these two cytokines. Here, dysregulated hematopoiesis induced by G-CSF/GM-CSF in solid tumors and its mechanism are summarized, and the prognostic value of G-CSF/GM-CSF-associated dysregulated hematopoiesis for tumor metastasis is also briefly highlighted.

Evaluating the Impact of COVID-19 on the Adoption of Virtual Care in General Practice in 20 Countries (inSIGHT): Protocol and Rationale Study

BACKGROUND

In recent decades, virtual care has emerged as a promising option to support primary care delivery. However, despite the potential, adoption rates remained low. With the outbreak of COVID-19, it has suddenly been pushed to the forefront of care delivery. As we progress into the second year of the COVID-19 pandemic, there is a need and opportunity to review the impact remote care had in primary care settings and reassess its potential future role.

OBJECTIVE

This study aims to explore the perspectives of general practitioners (GPs) and family doctors on the (1) use of virtual care during the COVID-19 pandemic, (2) perceived impact on quality and safety of care, and (3) essential factors for high-quality and sustainable use of virtual care in the future.

METHODS

This study used an online cross-sectional questionnaire completed by GPs distributed across 20 countries. The survey was hosted in Qualtrics and distributed using email, social media, and the researchers' personal contact networks. GPs were eligible for the survey if they were working mainly in primary care during the period of the COVID-19 pandemic. Descriptive statistical analysis will be performed for quantitative variables, and relationships between the use of virtual care and perceptions on impact on quality and safety of care and participants' characteristics may be explored. Qualitative data (free-text responses) will be analyzed using framework analysis.

RESULTS

Data collection took place from June 2020 to September 2020. As of this manuscript's submission, a total of 1605 GP respondents participated in the questionnaire. Further data analysis is currently ongoing.

CONCLUSIONS

The study will provide a comprehensive overview of the availability of virtual care technologies, perceived impact on quality and safety of care, and essential factors for high-quality future use. In addition, a description of the underlying factors that influence this adoption and perceptions, in both individual GP and family doctor characteristics and the context in which they work, will be provided. While the COVID-19 pandemic may prove the first great stress test of the capabilities, capacity, and robustness of digital systems currently in use, remote care will likely remain an increasingly common approach in the future. There is an imperative to identify the main lessons from this unexpected transformation and use them to inform policy decisions and health service design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30099.

Positive Job Search Experience for New Pathologists Seeking First Employment Between 2017-2019

CONTEXT.—

An aging population calls for an adequate response in the workforce of medical professionals. The field of pathology has seen a downward trend in numbers of graduating US allopathic medical students choosing the specialty. Concerns about the job market after residency and fellowship graduation may be a contributing factor.

OBJECTIVE.—

To provide an update on the trends emerging from a survey of pathology graduates' job search experience for their first nonfellowship position.

DESIGN.—

Data from an annual job search survey sent by The College of American Pathologists Graduate Medical Education Committee between 2017 and 2019 to The College of American Pathologists junior members and fellows in practice 3 years or less, actively looking for a nonfellowship position, was analyzed. Various indicators of the job search experience were compared year to year and with the previously published 2012 to 2016 benchmark data.

RESULTS.—

Analysis revealed positive trends between the 2017 to 2019 data and the 2012 to 2016 benchmark data, including participants' perceiving more ease in finding a position, improved availability of jobs in their subspecialty choice, and higher ratings of satisfaction with the position accepted, as well as a greater proportion of respondents finding a position within 6 months of initiating their job search.

CONCLUSIONS.—

The job market for pathology residents and fellows looking for their first nonfellowship position has improved with respect to multiple indicators, such as ease of finding a position, length of job search, and satisfaction with the position accepted when comparing 2017 to 2019 data with the 2012 to 2016 benchmark data.

Reevaluation of the US Pathologist Workforce Size

IMPORTANCE

There is currently no national organization that publishes its data that serves as the authoritative source of the pathologist workforce in the US. Accurate physician numbers are needed to plan for future health care service requirements.

OBJECTIVE

To assess the accuracy of current pathologist workforce estimates in the US by examining why divergency appears in different published resources.

DESIGN, SETTING, AND PARTICIPANTS

This study examined the American Board of Pathology classification for pathologist primary specialty and subspecialties and analyzed previously published reports from the following data sources: the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), a 2013 College of American Pathologists (CAP) report, a commercially available version of the American Medical Assoication (AMA) Physician Masterfile, and an unpublished data summary from June 10, 2019.

MAIN OUTCOMES AND MEASURES

Number of physicians classified as pathologists.

RESULTS

The most recent AAMC data from 2017 (published in 2018) reported 12 839 physicians practicing "anatomic/clinical pathology," which is a subset of the whole. In comparison, the current AMA Physician Masterfile, which is not available publicly, listed 21 292 active pathologists in June 2019. The AMA Physician Masterfile includes all pathologists in 15 subspecialized training areas as identified by the ACGME. By contrast, AAMC's data, which derive from the AMA Physician Masterfile data, only count physicians primarily associated with 3 general categories of pathologists and 1 subspecialty category (ie, chemical pathology). Thus, the AAMC pathology workforce estimate does not include those whose principal work is in 11 subspecialty areas, such as blood banking or transfusion medicine, cytopathology, hematopathology, or microbiology. An additional discrepancy relates to the ACGME residency (specialties) and fellowship (subspecialties) training programs in which pathologists with training in dermatopathology appear as dermatologists and pathologists with training in molecular genetic pathology appear as medical geneticists.

CONCLUSIONS AND RELEVANCE

This analysis found that most sources reported only select categories of the pathologist workforce rather than the complete workforce. The discordant nature of reporting may pertain to other medical specialties that have undergone increased subspecialization during the past 2 decades (eg, surgery and medicine). Reconsideration of the methods for determining the pathologist workforce and for all workforces in medicine appears to be needed.

Rapidly fatal pneumonitis from immunotherapy and concurrent SARS-CoV-2 infection in a patient with newly diagnosed lung cancer

Immune checkpoint inhibitors (ICIs) are used for the treatment of numerous cancers, but risks associated with ICI-therapy during the COVID-19 pandemic are poorly understood. We report a case of acute lung injury in a lung cancer patient initially treated for ICI-pneumonitis and later found to have concurrent SARS-CoV-2 infection. Post-mortem analyses revealed diffuse alveolar damage in both the acute and organizing phases, with a predominantly CD68+ inflammatory infiltrate. Serum was positive for anti-SARS-CoV-2 IgG, suggesting that viral infection predated administration of ICI-therapy and may have contributed to a more fulminant clinical presentation. These data suggest the need for routine SARS-CoV-2 testing in cancer patients, where clinical and radiographic evaluations may be non-specific.

Identification and functional study of immortalized mouse thymic epithelial cells

As the key cells in a three-dimensional scaffold within the thymus, Thymic epithelial cells (TECs) play critical roles in the homing, migration and differentiation of T cell precursors through adhesive interactions and the release of various cytokines. In this study, primary cultures of mouse TECs were isolated and identified with TEC-specific antibodies CK5 and CK8. These TECs were immortalized by retroviral transduction of simian virus (SV) 40 large T antigen. We then compared the functions of TECs and immortalized TECs (iTECs). Cell morphology and the proliferative capacity of TECs and iTECs were observed by inverted microscope photography and crystal violet assay after passage. A soft agar assay was then performed to observe their clone formation ability. The expression levels of epithelial cell related factors, such as IL-7, Lptin, Pax-9, Sema3A and et al., were detected by IF and qPCR. TECs were co-cultured with human acute monocytic leukemia cells (THP-1), and the effect of TECs on promoting THP-1 proliferation was observed with flow cytometry and CFSE labeling. Senescence-associated β-galactosidase assay was measured to detect the anti-aging capabilities of the cells. Cell cycle distribution was analyzed by propidium iodide (PI) staining, and paclitaxel (PTX)-induced apoptosis was detected by Annexin V-PI staining to evaluate the anti-apoptotic ability of the cells. Throughout, we found that the immortalized TECs still retain the characteristics of primary TECs, such as the morphology, function and epithelial characteristics; however, iTECs have stronger capabilities in proliferation and anti-aging. Our research suggests that the iTECs were successfully immortalized by SV40 large T antigen, and that the biological characteristics and functions of iTECs were similar to the original TECs. This immortalized cell can be used as an efficient cell model in functional research of the thymus substituting primary TECs with iTECs.

Chinese Herbal Medicine and Its Regulatory Effects on Tumor Related T Cells

Traditional Chinese medicine is an accepted and integral part of clinical cancer management alongside Western medicine in China. However, historically TCM physicians were unaware of the chemical constituents of their formulations, and the specific biological targets in the body. Through HPLC, flow cytometry, and other processes, researchers now have a much clearer picture of how herbal medicine works in conjunction with the immune system in cancer therapy. Among them, the regulation of tumor-related T cells plays the most important role in modulating tumor immunity by traditional Chinese medicine. Encouraging results have been well-documented, including an increase in T cell production along with their associated cytokines, enhanced regulation of Tregs and important T cell ratios, the formation and function of Tregs in tumor microenvironments, and the promotion of the number and function of normal T Cells to reduce conventional cancer therapy side effects. Chinese herbal medicine represents a rich field of research from which to draw further inspiration for future studies. While promising agents have already been identified, the vast majority of Chinese herbal mechanisms remain undiscovered. In this review, we summarize the effects and mechanisms of specific Chinese herbs and herbal decoctions on tumor related T cells.

Salivary Gland NUT Carcinoma with Prolonged Survival in Children: Case Illustration and Systematic Review of Literature

NUT (midline) carcinoma is a rare, highly aggressive, poorly differentiated carcinoma that characteristically harbors a rearrangement of the NUTM1 gene. Most of these tumors occur in adolescents and young adults, arise from the midline structures of the thorax, head, and neck, and are associated with extremely poor outcomes. Rare cases originating from salivary glands have been reported with clinicopathologic features comparable to NUT carcinoma of other sites. Outcome studies regarding this subgroup are currently lacking. We report a case of NUT carcinoma arising in a submandibular gland of a 12-year-old boy. Diagnosis was confirmed by fluorescence in situ hybridization demonstrating fusion of the BRD4 (19p13.12) and NUTM1 (15q14) gene loci. A systematic review of all previously reported salivary gland NUT carcinomas (n = 15) showed exclusive occurrence of pediatric cases (n = 6) in males compared to adult patients (n = 9, male: female = 1:2; p < 0.05). The median survival was 24 and 4 months for pediatric and adult patients, respectively (95% confidence interval was 8-24 and 1-7 months, respectively; p < 0.01). The 1-year overall survival was 67% for pediatric and 11% for adult patients. Among all NUT carcinomas, pediatric salivary gland tumors may represent a distinct clinical subset associated with male predilection and comparatively prolonged survival.

Entry of Graduates of US Pathology Residency Programs Into the Workforce: Cohort Data Between 2008 and 2016 Remain Positive and Stable

The pathologist workforce in the United States is a topic of interest to the health-care community as a whole and to institutions responsible for the training of new pathologists in particular. Although a pathologist shortage has been projected, there has been a pervasive belief by medical students and their advisors that there are “no jobs in pathology.” In 2013 and again in 2017, the Program Directors Section of the Association of Pathology Chairs conducted surveys asking pathology residency directors to report the employment status of each of their residents graduating in the previous 5 years. The 2013 Program Directors Section survey indicated that 92% of those graduating in 2010 had obtained employment within 3 years, and 94% of residents graduating in 2008 obtained employment within 5 years. The 2017 survey indicated that 96% of those graduating in 2014 had obtained employment in 3 years, and 97% of residents graduating in 2012 obtained positions within 5 years. These findings are consistent with residents doing 1 or 2 years of fellowship before obtaining employment. Stratification of the data by regions of the country or by the size of the residency programs does not show large differences. The data also indicate a high percentage of employment for graduates of pathology residency programs and a stable job market over the years covered by the surveys.

The State of the Job Market for Pathologists: Evidence From the College of American Pathologists Practice Leader Survey

CONTEXT.—

Disagreement exists within the pathology community about the status of the job market for pathologists. Although many agree that jobs in pathology were harder to come by earlier this decade, recent evidence suggests improvement is occurring.

OBJECTIVE.—

To assess the state of the job market for pathologists.

DESIGN.—

We analyzed data from the 2018 College of American Pathologists Practice Leader Survey. This survey contains data from 253 practice leaders on practices' hiring (and retrenchments) in 2017, the skills and level of experience being sought, success in filling those positions, and expectations for hiring in the next 3 years.

RESULTS.—

Among the surveyed practice leaders, 115 (45.5%) sought to hire at least 1 pathologist in 2017, and together tried to fill 246 full-time equivalent positions that year, of which 93.5 full-time equivalents (38%) were newly created. This hiring was not limited to larger, academic-based practices, but also occurred among smaller practices and practices based in nonacademic hospitals, independent laboratories, and other settings. Although some practices retrenched (60 full-time equivalents in 2017), the net increase was a healthy 187 full-time equivalents. Practices most frequently sought pathologists who had at least 2 years of experience, but the level of experience identified with the "optimal" candidate varied by desired areas of subspecialty expertise. Practice leaders also reported expected growth in hiring, with the number of positions they hope to fill in the next 3 years exceeding those vacated by retirement.

CONCLUSIONS.—

Our findings support the proposition that the demand for pathologists is strong, at least at the current time.

Gender Parity in Gainful Employment and Other Gender Trends in the Job Market for Recent Pathology Graduates

Context.—

Gender-based barriers to equal salary, career advancement, and leadership still exist in medicine. Herein we provide the first report of data comparing the experiences of men and women seeking their first nonfellowship position in pathology.

Objective.—

To identify gender trends regarding pathologists taking their first job after training and the relationship to various demographic factors, job search satisfaction, and outcome.

Design.—

Aggregate data from the College of American Pathologists Graduate Medical Education Committee Job Market surveys (2015–2018) were analyzed across multiple domains including residency focus, number and subspecialty of fellowships completed, and extent to which expectations were met in regard to work duties, geographic preference, benefits, and salary. These data were examined in the context of assessing gender-based differences.

Results.—

Comparable results were identified in all measured outcomes according to gender. There were no differences between gender and medical school type, relocation, residency training focus, number of fellowships completed, overall satisfaction with position accepted, salary, or extent to which the position met expectations. Similarly, there were also no discrepancies between gender and the geographic region in which positions were accepted, practice setting, practice subspecialty, partnership track, length of job search, or difficulty finding a position.

Conclusions.—

Analysis from 4 years of job market survey data shows equivalent results between men and women looking for their first nonfellowship position in pathology. There were no significant differences with regard to difficulty finding a position, overall satisfaction with the position accepted, salary, benefits, or access to partnership track.

Will I Need to Move to Get My First Job?: Geographic Relocation and Other Trends in the Pathology Job Market

Context.—

There is an ongoing perception that the pathology job market is poor, which may be discouraging medical students from pursuing the specialty. Academic pathologists believe that jobs are available but relocation may be necessary.

Objective.—

To identify trends regarding the geographic relocation of pathologists taking their first job after training.

Design.—

The College of American Pathologists (CAP) Graduate Medical Education Committee has sent an annual job search survey from 2012–2016 to CAP junior members and fellows in practice for 3 years or less and seeking their first job. Data were analyzed across demographics and geographic domains consisting of the following: stayed at same institution/city, relocated within the same region, or relocated to a different region. Standard statistical methods were used.

Results.—

Of 501 respondents, 421 reported completing combined anatomic pathology (AP)/clinical pathology (CP) training, while 80 reported AP- or CP-only training. Of the 421 AP/CP respondents, 109 (26%) stayed at the same institution or city, while of the 80 AP- or CP-only respondents, 36 (45%) stayed at the same institution or city. One hundred ninety-nine respondents completed surgical pathology fellowships with 124 (62%) general/oncologic surgical pathology and 75 (38%) subspecialty surgical pathology trainees. Job seekers who completed general surgical pathology/surgical oncologic pathology fellowship accounted for 34 of 52 (65%) of those remaining at the same institution or city, while those with subspecialty training accounted for 40 of 77 (52%) of those relocating to a different region. Relocation did not demonstrate any significant trends in regard to other demographics studied.

Conclusions.—

The pathology job market appears stable with no precedent for geographic hardship.

Position Paper From the Association of Pathology Chairs: Surgical Pathology Residency Training

Training in surgical pathology specimen dissection and microscopic diagnosis is an integral part of pathology residency training, as surgical pathology is one of the defining activities of most pathologists. The Accreditation Council for Graduate Medical Education and the American Board of Pathology policies delineate guidelines and requirements for residency training. Both the ACGME and ABP require that residents are ready for “independent practice” upon completion of training (ACGME) and for board eligibility (ABP). This position paper, developed through a consensus process involving the Association of Pathology Chairs, including the Program Directors and Graduate Medical Education committee, expands on these guidelines and the importance of gross dissection as a part of training.

Position Paper From the Association of Pathology Chairs: Assessing Autopsy Competency in Pathology Residency Training

Declining numbers of hospital autopsies performed in US pathology residency training programs and perceived declining practice of autopsy by many pathologists has caused stakeholder organizations to reassess the role of autopsy training in pathology residency. A working group convened by the stakeholder organizations has delivered the results of a detailed study of current practice of autopsy education in US pathology programs, along with recommendations for the future of autopsy education. Accepting the report of the Working Group, the Association of Pathology Chairs here publishes its position paper on the proposed recommendations.

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.

Development of Professionalism in Graduate Medical Education: A Case-Based Educational Approach From the College of American Pathologists' Graduate Medical Education Committee

Professionalism and physician well-being are important topics in academic medicine. Lapses in professional judgment may lead to disciplinary action and put patient's health at risk. Within medical education, students and trainees are exposed to professionalism in the institution's formal curriculum and hidden curriculum. Development of professionalism starts early in medical school. Trainees entering graduate medical education already have developed professional behavior. As a learned behavior, development of professional behavior is modifiable. In addition to role modeling by faculty, other modalities are needed. Use of case vignettes based on real-life issues encountered in trainee and faculty behavior can serve as a basis for continued development of professionalism in trainees. Based on the experience of program directors and pathology educators, case vignettes were developed in the domains of service, research, and education and subdivided into the areas of duty, integrity, and respect. General and specific questions pertaining to each case were generated to reinforce model behavior and overcome professionalism issues encountered in the hidden curriculum. To address physician burnout, cases were generated to provide trainees with the skills to deal with burnout and promote well-being.

The Recent Pathology Residency Graduate Job Search Experience: A Synthesis of 5 Years of College of American Pathologists Job Market Surveys

CONTEXT

- Pathology residents and fellows tailor their training and job search strategies to an actively evolving specialty in the setting of scientific and technical advances and simultaneous changes in health care economics.

OBJECTIVE

- To assess the experience and outcome of the job search process of pathologists searching for their first non-fellowship position.

DESIGN

- The College of American Pathologists (CAP) Graduate Medical Education Committee has during the past 5 years sent an annual job search survey each June to CAP junior members and fellows in practice 3 years or less who have actively searched for a non-fellowship position.

RESULTS

- Job market indicators including job interviews, job offers, positions accepted, and job satisfaction have remained stable during the 5 years of the survey. Most survey respondents who had applied for at least 1 position had accepted a position at the time of the survey, and most applicants who had accepted a position were satisfied or very satisfied. However, most attested that finding a non-fellowship position was difficult. Despite a perceived push toward subspecialization in surgical pathology, the reported number of fellowships completed was stable. Respondent demographics were not associated with job search success with 1 significant exception: international medical school graduate respondents reported greater perceived difficulty in finding a position, and indeed, fewer reported having accepted a position.

CONCLUSIONS

- Pathology residents and fellows seeking their first position have faced a relatively stable job market during the last 5 years, with most accepting positions with which they were satisfied.

Sudden death in a pediatric heart transplant recipient with peripheral eosinophilia and eosinophilic myocardial infiltrates

Eosinophilia has been rarely reported in pediatric heart transplant recipients and has been suggested to play a role in graft rejection. We report a case of a young female patient with peripheral blood eosinophilia who died suddenly 2 years following ABO-incompatible heart transplantation. She was found at autopsy to have myocardial infiltration of not only T-lymphocytes and macrophages expected in acute cellular rejection but also of eosinophils, B-lymphocytes, and plasma cells indicating myocarditis.

Perceptions of Unprofessional Attitudes and Behaviors: Implications for Faculty Role Modeling and Teaching Professionalism During Pathology Residency

CONTEXT

- Changes occurring in medicine have raised issues about medical professionalism. Professionalism is included in the Core Competencies and Milestones for all pathology residents. Previous studies have looked at resident professionalism attitudes and behaviors in primary care but none have looked specifically at pathology.

OBJECTIVE

- To examine behavior and attitudes toward professionalism within pathology and to determine how professionalism is taught in residency programs.

DESIGN

- Surveys were sent to all College of American Pathologists junior members and all pathology residency program directors, and responses were compared.

RESULTS

- Although no single behavior received the same professionalism rating among residents and program directors, both groups identified the same behaviors as being the most unprofessional: posting identifiable patient information or case images to social media, making a disparaging comment about a physician colleague or member of the support staff on social media or in a public hospital space, and missing work without reporting the time off. Faculty were observed displaying most of these behaviors as often or more often than residents by both groups. The most common means to teach professionalism in pathology residencies is providing feedback as situations arise and teaching by example. Age differences were found within each group and between groups for observed behaviors and attitudes.

CONCLUSIONS

- As teaching by example was identified as a common educational method, faculty must be aware of the role their behavior and attitudes have in shaping resident behavior and attitudes. These results suggest a need for additional resources to teach professionalism during pathology residency.

Abstract 588: Advanced molecular characterization of severe autoimmune toxicities associated with checkpoint inhibitor therapies

Immune checkpoint inhibitors (ICIs) have made a profound impact on the treatment of a variety of cancers. However, as with any systemic treatment, toxicities are inevitable. With most classes of cancer therapies, toxicities are relatively predictable based on clinical trial safety data and therefore can be handled with prophylactic or supportive care measures. However, ICIs are unique in their ability to cause rare but severe auto-immune toxicities. The molecular underpinnings of these toxicities, as well as unique features of the patient, tumor, or affected tissue, have not been extensively explored. We recently reported a small case series of two patients with myocarditis resulting in death arising following combination ICI therapy (Johnson et al, N Engl J Med, 2016). High lymphocytic infiltration, coupled with PD-L1 expression was present in the affected myocardium and skeletal muscle. Common T cell clones were identified between the affected tissue and tumor, and abnormal expression of muscle-specific transcripts was identified in the associated tumor, suggesting release of peripheral tolerance to tumor-expressed self-antigens.To expand upon our reported study, we collected healthy and afflicted tissue from a series of cancer patients with immune-related colitis, myocarditis (MC), and encephalopathy following ICI treatment. We hypothesize that molecular analysis of these tissues will identify causal factors in the etiology of these toxicities, and how to better predict, prevent, and treat them. Thus, we performed molecular characterization of the immune infiltrate and diseased tissue microenvironment. A total of 20 affected (colon, cardiac, brain) and non-diseased control specimens were examined by spatial digital profiling (nanoString). This process generates a spatial heatmap of digital counts of 20 selected immunology and cellular markers and proteins across each specimen. Using this technology, the landscape of inflammation in ICI-affected organs can be resolved for insights into the mechanism whereby ICI-mediated auto-immunity occurs. Targeted RNAseq for selected immuno-oncology mRNA targets was also performed. In initial RNA sequencing analyses of MC cases, affected myocardium, skeletal muscle, and patient-matched tumors all demonstrated expression of immune activation markers (e.g. interferon-gamma and granzyme B), expression of PD-L1, and muscle-specific genes. In the expanded population, including colitis, digital spatial profiling analyses and targeted NGS (RNAseq) are underway. Although data analyses are incomplete at the time of this abstract, this work will be the largest and most comprehensive analysis of the molecular underpinnings of ICI-mediated auto-immune toxicity reported to date. These data should offer clarity in the mechanisms and features of these adverse events, how to prevent or predict them with precision medicine, and how to treat them when they do occur.

Citation Format: Justin M. Balko, Daniel Y. Wang, Yu Wang, Rami Al-Rohil, Margaret Compton, Jeffery A. Sosman, Igor Puzanov, Bret Mobley, Robert D. Hoffman, Yaomin Xu, Javid J. Moslehi, Chanjuan Shi, Douglas B. Johnson. Advanced molecular characterization of severe autoimmune toxicities associated with checkpoint inhibitor therapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 588. doi:10.1158/1538-7445.AM2017-588

Entrustable Professional Activities for Pathology: Recommendations From the College of American Pathologists Graduate Medical Education Committee

Competency-based medical education has evolved over the past decades to include the Accreditation Council for Graduate Medical Education Accreditation System of resident evaluation based on the Milestones project. Entrustable professional activities represent another means to determine learner proficiency and evaluate educational outcomes in the workplace and training environment. The objective of this project was to develop entrustable professional activities for pathology graduate medical education encompassing primary anatomic and clinical pathology residency training. The Graduate Medical Education Committee of the College of American Pathologists met over the course of 2 years to identify and define entrustable professional activities for pathology graduate medical education. Nineteen entrustable professional activities were developed, including 7 for anatomic pathology, 4 for clinical pathology, and 8 that apply to both disciplines with 5 of these concerning laboratory management. The content defined for each entrustable professional activity includes the entrustable professional activity title, a description of the knowledge and skills required for competent performance, mapping to relevant Accreditation Council for Graduate Medical Education Milestone subcompetencies, and general assessment methods. Many critical activities that define the practice of pathology fit well within the entrustable professional activity model. The entrustable professional activities outlined by the Graduate Medical Education Committee are meant to provide an initial framework for the development of entrustable professional activity–related assessment and curricular tools for pathology residency training.

Fulminant Myocarditis with Combination Immune Checkpoint Blockade

Immune checkpoint inhibitors have improved clinical outcomes associated with numerous cancers, but high-grade, immune-related adverse events can occur, particularly with combination immunotherapy. We report the cases of two patients with melanoma in whom fatal myocarditis developed after treatment with ipilimumab and nivolumab. In both patients, there was development of myositis with rhabdomyolysis, early progressive and refractory cardiac electrical instability, and myocarditis with a robust presence of T-cell and macrophage infiltrates. Selective clonal T-cell populations infiltrating the myocardium were identical to those present in tumors and skeletal muscle. Pharmacovigilance studies show that myocarditis occurred in 0.27% of patients treated with a combination of ipilimumab and nivolumab, which suggests that our patients were having a rare, potentially fatal, T-cell-driven drug reaction. (Funded by Vanderbilt-Ingram Cancer Center Ambassadors and others.).

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.

Which positive factors determine the GP satisfaction in clinical practice? A systematic literature review

Background

Looking at what makes General Practitioners (GPs) happy in their profession, may be important in increasing the GP workforce in the future. The European General Practice Research Network (EGPRN) created a research team (eight national groups) in order to clarify the factors involved in GP job satisfaction throughout Europe. The first step of this study was a literature review to explore how the satisfaction of GPs had been studied before. The research question was “Which factors are related to GP satisfaction in Clinical Practice?”

Methods

Systematic literature review according to the PRISMA statement. The databases searched were Pubmed, Embase and Cochrane. All articles were identified, screened and included by two separate research teams, according to inclusion or exclusion criteria. Then, a qualitative appraisal was undertaken. Next, a thematic analysis process was undertaken to capture any issue relevant to the research question.

Results

The number of records screened was 458. One hundred four were eligible. Finally, 17 articles were included. The data revealed 13 subthemes, which were grouped into three major themes for GP satisfaction. First there were general profession-related themes, applicable to many professions. A second group of issues related specifically to a GP setting. Finally, a third group was related to professional life and personal issues.

Conclusions

A number of factors leading to GP job satisfaction, exist in literature They should be used by policy makers within Europe to increase the GP workforce. The research team needs to undertake qualitative studies to confirm or enhance those results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0524-x) contains supplementary material, which is available to authorized users.

Dealing with ambiguity: Israeli physician's attitudes and practices regarding pre-exercise certificates: a questionnaire study

Background

It has become clear in recent years that a healthy lifestyle, including physical exercise is crucial for health maintenance. Nevertheless, most people do not exercise regularly. Physician intervention is beneficial in increasing patient exercise. In Israel, the 1994 “Sports Law” regarding exercising in a gymnasium requires a physician’s written authorization, but does not direct the physicians what they should ascertain before issuing the certificate. This pre-exercise certificate has been widely discussed in Israel over the last year as the law is to be revised to enable using a modification of the PAR-Q+ (Physical Activity Readiness questionnaire) patient questionnaire as a screening tool. This will leave the requirement for a pre-exercise certificate for a less healthy population, yet without clear instructions to the primary care physician on criteria for ascertaining fitness. Our aim was to evaluate how primary care physicians deal with the ambiguity of defining health criteria for issuing exercise authorization/certificate.

Methods

We used an anonymous ten-item attitude/knowledge multiple choice questionnaire with an additional 13 personal/education and employment questions. We assessed each potential predictor of physician attitude and knowledge in univariate models.

Results

135 useable questionnaires were collected. Of these, 43.7 % of the doctors will provide the pre-exercise certificate to all their patients; 63 % were aware of their HMO/employers guidelines for issuing certificates; 62 % stated they complied with these guidelines, and 16 % stated they did not follow them. In addition, 70 % of the physicians reported regular exercise themselves, an average of 4.12 h/week. These physicians tended to provide the pre-exercise certificate to all patients unconditionally, as compared to physicians that did not exercise regularly. (46 % vs. 14.5 %, p < 0.01)

Conclusions

Most Israeli primary care physicians will provide the required certificate allowing their patients to exercise in the gym. There is a wide variation as to what physicians check before providing the certificate. The modification of the law has made the need for standardization of the nature of what is expected of primary care physicians more urgent. A large portion of physicians exercise on a regular basis – and exercising physicians are more positive regarding pre-exercise certificates.

Our study clearly shows a gap in knowledge transfer; and we call for a standardized approach to pre-exercise certificates utilizing computerized patient medical files.

Employer Expectations for Newly Trained Pathologists: Report of a Survey From the Graduate Medical Education Committee of the College of American Pathologists

CONTEXT

-Multiple sources have identified challenges that training programs face in preparing graduates for the "real world" practice of pathology, and many training programs have sought to decrease the gap between skills acquired during training and those required in practice. However, there exists the possibility that some of the difficulty experienced by newly trained pathologists and employers might arise from differences between employer expectations of new hires and what applicants expect from their first job.

OBJECTIVE

-To define the constellation of skills and attributes employers prioritize when hiring newly trained pathologists.

DESIGN

-A survey of fellows of the College of American Pathologists in practice for 5 or more years in the United States was administered and the results were analyzed.

RESULTS

-A total of 630 pathologists who were responsible for hiring a new-in-practice pathologist completed the survey. Regardless of practice setting, certain skills and attributes were rated critically important in new hires, including ethics/integrity, work ethic, and professionalism. Seventy-one percent reported having some difficulty hiring entry-level pathologists and cited inadequate training/experience during residency, and applicants having unrealistic expectations regarding work load/hours as the most common reasons.

CONCLUSIONS

-Prospective employers not only expect well-developed diagnostic skills in their job applicants, but also require evidence of a strong work ethic and outstanding professionalism. Successful applicants must display willingness to assume responsibilities and flexibility regarding existing and new responsibilities. A secondary but important finding of this survey was that most jobs are garnered through word-of-mouth recommendations; therefore, it is crucial for pathologists-in-training to hone their networking skills.

Assessment and Management of Professionalism Issues in Pathology Residency Training: Results From Surveys and a Workshop by the Graduate Medical Education Committee of the College of American Pathologists

Professionalism issues are common in residency training and can be very difficult to recognize and manage. Almost one-third of the milestones for pathology recently instituted by the Accreditation Council for Graduate Medical Education encompass aspects of professionalism. Program directors are often unsure of how and when to remediate residents for unprofessional behavior. We used a case-based educational approach in a workshop setting to assist program directors in the management of unprofessional behavior in residents. Eight case scenarios highlighting various aspects of unprofessional behavior by pathology residents were developed and presented in an open workshop forum at the annual pathology program director’s meeting. Prior to the workshop, 2 surveys were conducted: (1) to collect data on program directors’ experience with identifying, assessing, and managing unprofessional behavior in their residents and (2) to get feedback from workshop registrants on how they would manage each of the 8 case scenarios. A wide range of unprofessional behaviors have been observed by pathology program directors. Although there is occasionally general agreement on how to manage specific behaviors, there remains wide variation in how to manage many of the presented unprofessional behaviors. Remediation for unprofessional behavior in pathology residents remains a difficult and challenging process. Additional education and research in this area are warranted.

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.

Recurrent tissue-specific mtDNA mutations are common in humans

Mitochondrial DNA (mtDNA) variation can affect phenotypic variation; therefore, knowing its distribution within and among individuals is of importance to understanding many human diseases. Intra-individual mtDNA variation (heteroplasmy) has been generally assumed to be random. We used massively parallel sequencing to assess heteroplasmy across ten tissues and demonstrate that in unrelated individuals there are tissue-specific, recurrent mutations. Certain tissues, notably kidney, liver and skeletal muscle, displayed the identical recurrent mutations that were undetectable in other tissues in the same individuals. Using RFLP analyses we validated one of the tissue-specific mutations in the two sequenced individuals and replicated the patterns in two additional individuals. These recurrent mutations all occur within or in very close proximity to sites that regulate mtDNA replication, strongly implying that these variations alter the replication dynamics of the mutated mtDNA genome. These recurrent variants are all independent of each other and do not occur in the mtDNA coding regions. The most parsimonious explanation of the data is that these frequently repeated mutations experience tissue-specific positive selection, probably through replication advantage.

DNA mutations are expected to be formed randomly, thus any reproducible pattern of DNA somatic mutations across multiple individuals or even across organs within each individual is highly unexpected. Using next generation sequencing of multiple tissues from the same individuals we found several somatic mutations in mitochondrial DNA that appear in a heteroplasmic state in all individuals examined, but only in particular tissues. These mutations were only found in known regions of replication control for the mitochondrial DNA. These data imply the presence of tissue-specific positive selection for these variants.

Pathology subspecialty fellowship application reform, 2007-2010

The specialty of pathology and laboratory medicine has entered a phase in which the 4-year sequence of residency training is almost universally followed by 1 or more years of subspecialty fellowship training. Such training may occur in an American Board of Pathology-recognized subspecialty or any number of "subspecialty fellowships" that do not lead to subspecialty board certification. Unlike the application process for first-year pathology residency, which is run through the National Resident Matching Program, applications for subspecialty pathology fellowships have no consistent coordination. Responding to widespread dissatisfaction voiced in 2007 by national pathology resident organizations, the Association of Pathology Chairs began evaluation and potential intervention in the fellowship application process. After 3 years of effort, the Council of the Association of Pathology Chairs has recommended implementation of a pathology subspecialty fellowship matching program starting in the 2011-2012 recruiting year for applicants matriculating in fellowship programs in July 2013. We report on the data that informed this decision and discuss the pros and cons that are so keenly felt by the stakeholders in this as-yet-incomplete reform process.

Ex vivo characterization of human atherosclerotic iliac plaque components using cryo-imaging

We characterized atherosclerotic plaque components with a novel cryo-imaging system in lieu of standard histological methods commonly used for imaging validation and research endpoints. We aim to accurately identify plaque tissue types from fresh cadaver specimens rapidly (less than 5 h) in three dimensions for large specimens (up to 4 cm vessel segments). A single-blind validation study was designed to determine sensitivity, specificity and inter-rater agreement (Fleiss' Kappa) of cryo-imaging tissue types with histology as the gold standard. Six naïve human raters identified 344 tissue type samples in 36 cryo-image sets after being trained. Tissue type sensitivities are as follows: greater than 90% for adventitia, media-related, smooth muscle cell ingrowth, external elastic lamina, internal elastic lamina, fibrosis, dense calcification and haemorrhage; greater than 80% for lipid and light calcification; and greater than 50% for cholesterol clefts. Specificities were greater than 95% for all tissue types. The results demonstrate convincingly that cryo-imaging can be used to accurately identify most tissue types. If the cryo-imaging data are entered into visualization software, three-dimensional renderings of the plaque can be generated to visualize and quantify plaque components.

The safety of autologous intracoronary stem cell injections in a porcine model of chronic myocardial ischemia

BACKGROUND

Intracoronary mononuclear cell therapy may produce angiogenesis in chronic myocardial ischemia. Potential complications include periprocedural infarction secondary to: reduced coronary blood flow; hyperviscosity from the cell preparation; or microvascular dysfunction. To date, no studies to evaluate these potential complications have been reported. The objective of this report was to study the safety and feasibility of intracoronary injections of autologous bone marrow mononuclear cells in a porcine chronic myocardial ischemia model.

METHODS

Domestic pigs (n = 5) underwent ameroid cuff placement of the left circumflex artery. Bone marrow-derived mononuclear cells [15 x 10(6) cells] labeled with CM dioctadecyl tetramethylindocarbocyanine were given by intracoronary injection. Animals were sacrificed, and hearts and vital organs were inspected grossly and by histopathology, and bone marrow underwent immunofluorescence microscopy.

RESULTS

Troponin I levels, gross inspection and histopathology did not reveal evidence of myocardial infarction. Labeled cells were observed in perivascular structures in myocardium at the injection site in all animals and in the spleen from one animal. Bone marrow aspirates indicated labeled cells.

CONCLUSIONS

Intracoronary injection of autologous mononuclear cells in a porcine chronic myocardial ischemia model appears safe. Intracoronary injection resulted in cell localization in the perivascular areas of myocardium supplied by the injected vessel. Cell localization was observed only in the spleen in just one animal. Labeled cells were identified in bone marrow aspirates from three animals following injection, suggesting a role for bone marrow engraftment and repopulation as a possible mechanism for progenitor cell localization in myocardium.

Strain-dependent beta-adrenergic receptor function influences myocardial responses to isoproterenol stimulation in mice

Recently, we showed that compared with the A/J inbred mouse strain, C57BL/6J (B6) mice have an athlete's cardiac phenotype. We postulated that strain differences would result in greater left ventricular (LV) hypertrophy in response to isoproterenol in B6 than A/J mice and tested the hypothesis that a differential response could be explained partly by differences in beta-adrenergic receptor (beta-AR) density and/or coupling. A/J and B6 mice were randomized to receive daily isoproterenol (100 mg/kg sc) or isovolumic vehicle for 5 days. Animals were studied using echocardiography, tail-cuff blood pressure, histopathology, beta-AR density and percent high-affinity binding, and basal and stimulated adenylyl cyclase activities. One hundred twenty-eight mice (66 A/J and 62 B6) were studied. Isoproterenol-treated A/J mice demonstrated greater percent increases in echocardiographic LV mass/body weight (97 +/- 11 vs. 20 +/- 10%, P = 0.001) and in gravimetric heart mass/body weight versus same-strain controls than B6 mice. Histopathology scores (a composite of myocyte hypertrophy, nuclear changes, fibrosis, and calcification) were greater in isoproterenol-treated A/J vs. B6 mice (2.8 +/- 0.2 vs.1.9 +/- 0.3, P < 0.05), as was quantitation of myocyte damage (22.3 +/- 11.5 vs. 4.3 +/- 3.5%). Interstrain differences in basal beta-AR density, high-affinity binding, and adenylyl cyclase activity were not significant. However, whereas isoproterenol-treated A/J mice showed nonsignificant increases in all beta-AR activity measures, isoproterenol-treated B6 mice had lower beta-AR density (57 +/- 6 vs. 83 +/- 8 fmol/mg, P < 0.05), percent high-affinity binding (15 +/- 2 vs. 26 +/- 3%, P < 0.005), and GTP + isoproterenol-stimulated adenylyl cyclase activity (10 +/- 1.1 vs. 5.8 +/- 1.5 pmol cAMP.mg(-1).min(-1)) compared with controls. High-dose, short-term isoproterenol produces greater macro- and microscopic cardiac hypertrophy and injury in A/J than B6 mice. A/J mice, unlike B6 mice, do not experience beta-AR downregulation or uncoupling in response to isoproterenol. Abnormalities in beta-adrenergic regulation may contribute to strain-related differences in the vulnerability to isoproterenol-induced cardiac changes.

Influenza surveillance during winter 1997-1998 in Israel

BACKGROUND

Each winter influenza activity is a major cause of morbidity and mortality both in Israel and worldwide.

OBJECTIVES

To identify the influenza viruses active in Israel during the winter season and to assess the extent of influenza morbidity.

METHODS

Information was collected on a population of 18,684 individuals enrolled in two community clinics in central Israel. It included the total number of visits for acute respiratory infection--including influenza and influenza-like illness (ARI/flu-like)--during a 20 week surveillance period (23 November 1997 to 27 March 1998) and the percent of influenza virus isolates in nasopharyngeal specimens from a sample of patients with ARI/flu-like collected on a weekly basis during the same period.

RESULTS

A total of 5,947 visits for ARI/flu-like were recorded among 18,684 enrolled patients in two community clinics (18.1%). The progressive increase in the number of visits for ARI/flu-like reached a peak on week 2/98 with 597 visits and a rate of 31.95 visits per 1,000 population. After this, a decrease to the initial values was evident by week 12/98. Most affected patients were in the age groups 5-14 and 65 years and over, with a rate of 733.5 and 605.3 visits per 1,000 population, respectively. Influenza virus was isolated from 92 of the 426 nasopharyngeal specimens (21.6%). The most commonly detected strain was A/Sydney/5/97 (H3N2) like (77.2%). The peak rate of isolates was recorded at the beginning of January (01/98).

CONCLUSIONS

A/Sydney/5/97 (H3N2) like-strain was the dominant influenza virus. Its presence did not prevent the simultaneous activity of influenza A/H1N1 virus. The dynamic of the clinical disease as expressed by the weekly visit rate for ARI/flu-like was similar to the temporal pattern of the virological findings. The extent of morbidity suggests moderate epidemic activity.

The role of antibiotics in the management of elective and post-traumatic hand surgery

The use of prophylactic antibiotics in elective and emergency hand surgery is an unsettled issue. Although their benefit in general surgical cases and certain orthopedic cases is well established, the lower infection rates in elective and emergency hand surgery have made attempts to prove the efficacy of prophylaxis more difficult. Valid arguments can be made for the use of antibiotics in human and animal bites. Prophylactic antibiotic use is efficacious in the following scenarios: (1) soft-tissue reconstructive procedures with large flaps, (2) total elbow or wrist implant arthroplasty, (3) procedures of long duration, and (4) complex open hand trauma with wound contamination and extensive soft-tissue and bony injury. Antibiotic prophylaxis does not appear warranted in clean, elective procedures lasting fewer than 2 hours. The duration of antibiotic use should be as short as possible to minimize complications and the development of bacterial resistance. The selection of a particular antibiotic regimen remains the surgeon's choice, but many inexpensive and relatively safe antibiotic agents are available. Although uncommon, potentially serious hazards exist with the use of antibiotics. Definitive guidelines on the use of antibiotics in hand surgery are not available; hand surgeons should apply basic principles of prophylaxis and be aware of the existing controversies.

A primer on lower extremity outcome measurement instruments

Tracing the roots of lower extremity outcome scales is an interesting and somewhat bemusing journey. A large number of different grading methods can be found with limited reliability and/or validity testing. The usefulness of these instruments in the assessment of patient outcomes after lower extremity interventions is worrisome. This article focuses on the most commonly used scales and demonstrates an alarming and incestuous pattern of cross-validation with moderate to weak associations between potentially unreliable and crudely validated original instruments.

Spontaneous calf hematoma: a report of two cases diagnosed with MRI

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Role of cytokines in periodontal diseases

The known actions of cytokines suggest that these molecules hold a great potential for modulating the host immune response and enhancing tissue regeneration. These molecules would be useful in controlling the adverse effects of the host immune response and/or augmenting the regenerative potential of cytokines. Once the technology is optimized, it may be possible for dentists to apply cytokine therapy to resolve periodontal infections. Such therapeutic measures hold promise not only in the resolution of periodontal infections, but also in the treatment of other diseases of the oral cavity.