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PubMed2002

[Postgraduates' training as laboratory physicians/clinical pathologists in Japan--board certification of JSLM as a mandatory requirement for chairpersons of laboratory medicine].

The educational committee of the Japanese Society of Laboratory Medicine(JSLM) proposed a revised laboratory medicine residency curriculum in 1999 and again in 2001. The committee believes that present undergraduate clinical training is insufficient and that Japanese medical graduates need clinical training for two years after graduation. This two years training should be a precondition for further postgraduate training in laboratory medicine and should include fundamental clinical skills(communication skills, physical examination and common laboratory procedures such as Gram's stain, Wright-Giemsa stain and urinalysis). After the two years training, the minimal training period of laboratory medicine should be three years, and should include: 1) Principles, instrumentation and techniques of each discipline including clinical chemistry, clinical hematology, clinical microbiology, clinical immunology, blood banking and other specific areas. 2) The use of laboratory information in a medical setting. 3) Interaction of the laboratory physician with laboratory staff, physicians and patients. With good on-the-job training and 24 hours on-call duties, laboratory physicians are expected to perform their tasks, including laboratory management, effectively. They should have appropriate educational background and should be well motivated. The background and duties of the laboratory physicians often reflect the institutional needs and personal philosophy of the chairperson of their department. At the moment, few senior physicians in Japan have qualifications in laboratory medicine and are unable, therefore, to provide the necessary guidance to help the laboratory physicians in their work. I therefore believe that the board certification of JSLM should be regarded as mandatory for chairpersons of laboratory medicine. Our on-call service system can enhance the training in laboratory medicine, and improve not only laboratory quality assurance but patients' care as well.

Certification↗
PubMed1996

Duplicate laboratory orders: a College of American Pathologists Q-Probes study of thyrotropin requests in 502 institutions.

OBJECTIVE: To examine the frequency and cause of duplicate thyrotropin (TSH) testing. METHODS: Five hundred two institutions, ranging in size from fewer than 100 to more than 600 beds, examined consecutively processed TSH assays to identify duplicate orders. Duplicates were defined as two or more TSH tests performed within 7 days. All together, participants submitted data on 221,476 TSH orders. RESULTS: The median institution reported that 1.5% of TSH tests duplicated a TSH order that had been received from the same patient within the previous 7 days. Ten percent of institutions reported that 4.5% or more of their TSH tests were duplicates. Institutions with higher duplicate rates tended to be larger (ie, they had a greater number of occupied beds) and to have duplicate tests that were more likely to be ordered by a physician other than the one who ordered the initial test. Participants reported that for 19% of duplicate orders, physicians were unaware that the first test had been ordered. Physicians also indicated that duplicate assays were ordered to see if a previous result had changed (15%) or to check on the accuracy of a previous result (13%). Participants reported that 11% of duplicate TSH assays that their laboratory performed had apparently never been ordered. CONCLUSIONS: A large number of institutions are performing duplicate TSH tests that, in most cases, appear to be medically unnecessary. Institutions aiming to reduce the frequency of duplicate testing should consider policies that decrease the opportunity for different physicians to order tests on a single patient and should increase the accuracy with which physician orders are transmitted to the laboratory.

Clinical Laboratory Techniques↗
PubMed2002

[Medical supports for the diagnosis of infectious diseases; the role and responsibilities of clinical pathologist and microbiology technologist. Acute purulent meningitis; the position of the technologists in microbiology laboratory].

The features and limitations of microbiology processes for the diagnosis of bacterial meningitis were summarized. Requests for physicians were also emphasized. The microbiology laboratory should be responsible for providing highly reliable and concordant data with a variety of clinical settings. Technologists in a microbiology laboratory should perform following subjects: i) Direct smear examination: Presumptive identification by the observers with abundant experience and sufficient training. ii) Rapid bacterial antigen detection tests: Active utilize alone in combination with the direct microscopy. iii) Culture: Cost effective utilize for appropriate media and culture condition based on the bacteriological statistics. Report with bacteriological interpretations and with additional proper comments, if necessary. iv) Antimicrobial susceptibility tests: Determination of penicillin resistance among the strains of penicillin-resistant or-intermediate Streptococcus pneumoniae (PI or PRSP) should be confirmed by MIC procedures; Detection of beta-lactamase producing Haemophilus influenzae (BLP) could detect by beta-lactamase tests, but not clearly identify for beta-lactamase-negative ampicillin-resistant isolates (BLNAR). In addition, a laboratory should provide appropriate information by using the accumulated routine clinical microbiology data, which may help to physicians in selecting an empiric therapy and to the microbiology technologists in processing the routine microbiology. In recent status, the most common organisms isolated from patients with bacterial meningitis continue to be S. pneumoniae and H. influenzae. Among S. pneumoniae strains, penicillin-intermediate(PISP) and--resistant(PRSP) strains had exceeded 50%, and the strains of beta-lactamase producing H. influenzae (BLP) had decreased with less than 10% and beta-lactamase negative ampicillin-resistant strains (BLNAR) have increasing. To providing rapid and accurate results, a laboratory should require the clinical information, including patient's age, major presenting symptoms, and receive antimicrobials prior to specimen collection.

Acute Disease↗
PubMed2002

[Genetic pathways in colorectal cancer: interest for the pathologist].

Molecular biology studies have led to the identification of two different types of colorectal carcinomas. The first group, called LOH (for loss of heterozygosity), represents 80% of colorectal cancers and is characterised by aneuploidy, allelic losses and a location in the distal colon. The second group displays phenotypic microsatellite instability (MSI-positive tumours), has a near-diploid karyotype and a relatively low frequency of allelic losses. It accounts for 15% of all colorectal cancers and for about 30% of right-sided cancers. Four different pathways have been identified as responsible for tumour progression: the WNT/Wingless, the K-ras, the Transforming growth factor (TGF) and the P53 pathways. The involvement of these pathways depends on the tumour type. In LOH-positive tumours, the WNT/Wingless pathway is activated through an APC mutation, whereas MSI+ tumours do so through a catenin stabilising mutation. The TGFb growth inhibitory pathway is altered either by mutations in the signal transduction molecules SMAD2 and SMAD4 in LOH positive tumours or by mutations of TGFbRII in MSI+ tumours. In the p53 pathway, mutations in BAX may contribute to the adenoma-carcinoma transition just as p53 mutations may do in LOH positive tumours. Until now, cancer phenotype determination has had no clinical implications. However, the predictive value of the MSI status was recently stressed as a predictive factor for response to chemotherapy. Immunohistochemistry could represent a complementary strategy to molecular biology in assessing MSI status. This simple test would allow to screen all colorectal carcinomas for MSI status, which would provide valuable management information in addition to the histological assessment for tumour stage and grade.

Aneuploidy↗
PubMed2002

Medical malpractice claims and quality improvement program as viewed by a forensic pathologist.

This is a review article dealing with the half-century evolution of the quality assurance program to improve patient care in the United States. The author attempted to point out some differences in approach to solving the medical error and medical malpractice problems between Japan and the U.S. In the 1970s, an increase in the medical malpractice claims resulted in such high premiums for medical liability insurance that it threatened the healthcare system in the U.S. Urgent legislative remedy, the Medical Injury Compensation Reform Act (MICRA) was put into place in the State of California. This act was the beginning of the definitive quality improvement in our health care system. It was followed by other improvement programs, such as the National Practitioner Data Bank (NPDB) for tracking physicians with malpractice judgments or settlements against them, or who have problems with the medical licensing Board or other impairments. By comparison, in recent years, in Japan, there has been a rash of medical malpractice claims, similar to the situation in the U.S. in the 1970's. The two pronged approach to maintaining and assuring quality health care are: (1) Set standards by inspection and accreditation of hospitals and healthcare facilities and (2) by credentialing and peer review program to assure the competency of the physicians and other healthcare personnel. Clinical medicine has made a major effort in setting up a quality assurance program and so has forensic medicine. Similar approaches have been used in both programs. The current emphasis in forensic medicine is on inspection and accreditation of the medical examiner and coroner's offices by the National Association of Medical Examiners (NAME) and re-certification for the medical license and specialty board and credentialing and peer review activities.

California↗
PubMed2002

[Persistent hyperinsulinemic hypoglycemia of infancy: the pathologist's experience].

Persistent hyperinsulinemic hypoglycemia of Infancy (PHHI) is characterized by episodes of severe hypoglycemia exposing the child to serious neurological sequelae. The morphologic pancreatic anomalies observed consist in either a focal lesion which can be totally cured by a selective surgical resection, or a diffuse and poorly understood lesion of pancreatic tissue, which may appear at first glance to be both macroscopically and microscopically normal, the treatment of which, requires a near-total pancreatectomy. The studies presented concentrate on several pathogenic hypotheses of this latter form of PHHI. We first demonstrate that nesidioblastosis, long considered as the original lesion for the diffuse form of hyperinsulinism, does indeed exist although it is not specific to this disease and does not correspond to a permanent proliferation of endocrine cells. We then dismiss the hypothesis of an enhanced B cell mass, as the volume density of B cells is not systematically increased in hyperinsulinemic children compared to controls. The third hypothesis looking to a decreased D cell mass has to be approached with circumspection as the difference in volume density of somatostatin cells, which tends to be slightly lower in hypoglycemic children, is small and inconsistent. The fourth hypothesis concerns an intrinsic functional lesion of the B cells, and is supported by an increased quantity of proinsulin detected in the Golgi area as well as by the observation of voluminous nuclei and a particularly abundant cytoplasm in certain B cells. These histological anomalies are detected on per-operative frozen sections and guide the surgical treatment.

Humans↗
PubMed2003

Pathologists who attained fame without using microscopy.

Morgagni, Baillie, and Rokitansky were three giants in pathology. They established the foundations for classification of diseases. Their combined contributions to clinical knowledge outweighed all that had been learned in medicine in the prior history of the human race. It is remarkable that their achievements were made without using microscopy.

Anatomy↗