[Show abstract][Hide abstract] ABSTRACT: Background: Microbiology rounds are an integral part of infectious disease consultation service. During microbiology rounds we highlight microbiology principles using vignettes. We created case-based, interactive, microbiology online modules similar to the vignettes presented during microbiology rounds since internal medicine residents rotating on our infectious disease elective have limited time to participate in rounds and learn microbiology. Objective: Evaluate the use of the microbiology online modules by internal medicine residents. Design: We asked residents to complete 10 of 25 online modules during their infectious disease elective. We evaluated which modules they chose and the change in their knowledge level. Results: Forty-six internal medicine residents completed assessments given before and after accessing the modules with an average of 11/20 (range 6-19) and 16/20 (range 9-20) correct questions, respectively (average improvement 5; p=0.0001). The modules accessed by more than 30 residents included those related to Clostridium difficile, anaerobes, Candida spp., Streptococcus pneumoniae, influenza, Mycobacterium tuberculosis, and Neisseria meningitidis. Summary: We demonstrated improved microbiology knowledge after completion of the online modules. This improvement may not be solely attributed to completing the online modules as fellows and faculty may have provided additional microbiology education during the rotation.
[Show abstract][Hide abstract] ABSTRACT: The role pathology plays in establishing or excluding infectious diseases has been established. However, as the practice of pathology has become subspecialized, there is not enough infectious disease specimen volume to have a pathologist dedicated full time to this cross-cutting subspecialty. So, what are the myths and realities of a practicing infectious disease pathologist in the hospital setting? Infectious disease clinicians tend to consult pathologists when there are questions regarding terminology used in pathology reports, when there is the need to perform additional studies on formalin-fixed, paraffin-embedded tissues, and when there is an interest in seeing biopsies or resections obtained from their patients and obtaining photographs for presentations. Pathologists consult infectious disease pathologists when there is a need to review diverse inflammatory reactions, for identification of fungi, parasites or unknown structures, to define the need to use special stains and other techniques to identify organisms in tissues that have been formalin fixed, and to help with terminology to be used in reports. This review will explore in more detail why and how these consultations occur.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 06/2014;
[Show abstract][Hide abstract] ABSTRACT: Objectives: To describe the implementation and evaluation of a case-based microbiology curriculum during daily microbiology rounds. Methods: Vignettes consist of short cases with images and questions that facilitate discussion among microbiologists, pathologists, infectious disease physicians, and trainees (residents and fellows). We performed a survey to assess the value of these vignettes to trainees. Results: Motivation to come to rounds on time increased from 60% to 100%. Trainees attending rounds after implementation of the vignettes perceived the value of microbiology rounds to be significantly higher compared with those who attended rounds before implementation (P = .04). Pathology residents found that vignettes were helpful for retaining knowledge (8.3 of 10 points). Conclusions: The vignettes have enhanced the value of microbiology rounds by serving as a formalized curriculum exposing trainees from multiple specialties to various microbiology topics. Emphasis on interdisciplinary interactions between clinical and laboratory personnel was highlighted with this case-based curriculum.
American Journal of Clinical Pathology 03/2014; 141(3):318-22. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fungal infections are a frequent occurrence in medical practice due to increasing numbers of immunosuppressed patients. New antifungal medications have been developed and it has become evident that different fungi require different treatments as some are intrinsically resistant to these drugs. Thus, it is imperative that pathologists recognize the limitations of histopathologic diagnosis regarding speciation of fungal infections and advocate for the use of different techniques that can help define the genus and species of the fungus present in the specimen they are studying. In this review we present the use of in situ hybridization as an important adjunct for the diagnosis of fungal diseases, the different techniques that have been used for fungal identification, and the limitations that these techniques have.
Advances in anatomic pathology 05/2013; 20(3):168-74. · 3.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Teaching microbiology to medical students is usually done by basic science microbiologists or infectious diseases physicians with minimal input from the laboratory specialists who validate, implement and perform these assays, and ensure quality control in clinical microbiology laboratories. In 2012, Emory Medical School developed, implemented, and evaluated a 4-hour clinical microbiology elective offered during the final 4-week module of medical school. A tour of the clinical microbiology laboratory occurred the day before. We selected 8 case-based vignettes with questions that emphasized laboratory techniques required to establish the diagnosis. An infectious diseases clinician and a clinical microbiologist or pathologist discussed the vignettes with groups of 6 to 8 medical students. Twenty-four of 30 students that participated in the elective answered a 14 question multiple-choice test before and after the session. The average score before the elective and at completion was 53% (range 36 - 71%) and 85% (64 - 100%) respectively. The average improvement was 4.75 (mode 4) correct questions with a minimum of 3 and a maximum improvement of 7. Although the assessment measured a limited amount of recently acquired knowledge, it is encouraging that students improved in their knowledge after this activity. The combination of the tour of the clinical microbiology laboratory and case-based discussions can give learners a better understanding of the function of the clinical laboratories, the complexity of microbiologic testing and the value of interacting with the professionals in the laboratory to enhance clinical care and guide appropriate antimicrobial selection.
Journal of Medical Microbiology 04/2013; · 2.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The frequency of fatalities due to acute bacterial meningitis has decreased significantly due to vaccinations, early diagnoses, and treatments. We studied brain tissues of patients with fatal neutrophilic meningitis referred to the Centers for Disease Control for etiologic diagnosis from 2000-2009 to highlight aspects of the disease that may be preventable or treatable. Demographic, clinical, and laboratory data were extracted from records. Of 117 cases in the database with a diagnosis of meningitis or meningoencephalitis, 39 had neutrophilic inflammation in the meninges. Inflammatory cells infiltrated the superficial cortex in 16 of 39 (41%) cases. Bacteria were found using Gram and bacterial silver stains in 72% of cases, immunohistochemistry in 69% (including two cases where the meningococcus was found outside the meninges), and PCR in 74%. Streptococcus pneumoniae was the cause of the meningitis in 14 patients and Neisseria meningitidis in 9. In addition, Streptococcus spp. were found to be the cause in six cases, while Staphylococcus aureus, Staphylococcus spp., Enterococcus spp., and Fusobacterium were the cause of one case each. There were six cases in which no specific etiological agent could be determined. The mean age of the patients with S. pneumoniae was 39 years (range 0-65), with N. meningitidis was 19 years (range 7-51), whereas that for all others was 31 years (range 0-68). In summary, our study shows that S. pneumoniae continues to be the most frequent cause of fatal neutrophilic bacterial meningitis followed by N. meningitidis, both vaccine preventable diseases.Modern Pathology advance online publication, 5 April 2013; doi:10.1038/modpathol.2013.30.
[Show abstract][Hide abstract] ABSTRACT: Haemophilus influenzae rarely causes acute endometritis and the few published cases have always been associated with intrauterine devices (IUD). A 48-year-old female presented to the emergency department with a 3-day history of lower abdominal pain and fever. On physical examination she was tachycardic, hypotensive and had fundic tenderness to palpation. Imaging showed uterine leiomyomas and no IUD. Blood cultures grew a non-typable H. influenzae. Endometrial biopsy demonstrated acute endometritis. Tissue Gram stains and cervico-vaginal cultures were negative; however, polymerase chain reaction (PCR) determined presence of H. influenzae on the formalin-fixed, paraffin-embedded tissue biopsy. Evidence of H. influenzae in the endometrium demonstrates that the uterus can be the nidus for sepsis when invasive H. influenzae is found with no distinct usual primary focus. This case underscores the importance pathologic diagnosis and molecular testing.
Diagnostic microbiology and infectious disease 03/2013; · 2.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Deep eosinophilic granulomatous abscesses, as distinguished from eosinophilic subcutaneous abscesses, are rare. Most reports are from the Far-East and India where the most commonly attributed cause is Toxocara. Sulaimaniyah in Northeastern Iraq has experienced an outbreak of eosinophilic granulomatous liver and gastrointestinal (GI) abscesses beginning in 2009. The purpose of this study was to determine the etiology and guide treatment.
The study was an ongoing investigation of patients having a histopathologic diagnosis of eosinophilic granulomatous abdominal abscesses in Sulaimaniyah hospitals from May 2009 to August 2012. Tissues were examined for organisms, and Enzyme Linked Immunoabsorbent Assays (ELISA) were performed for serum antibodies to Fasciola hepatica, Toxocara, and Echinococcus granulosus.
Fourteen patients had granulomatous inflammation surrounding a central necrotizing eosinophilic exudate identified in surgical pathology specimens from abdominal surgeries. Two children and four adults had abscesses that formed GI masses. These patients included a 39 year old male with oropharyngeal and transverse colon disease, and a 48 year old male with liver and GI abscesses. All sites demonstrated a Zygomycete fungus surrounded by eosinophilic Splendori-Hoeppli material consistent with basidiobolomycosis. Five of the six patients with fungal disease were treated by surgery and 4 to 7 months of itraconozol. One child died of intestinal perforation while receiving IV amphotericin B; two adults required additional surgery for recurrent GI obstruction. Eight patients had isolated liver abscesses with no organisms identified by histopathology: ELISA results for F. hepatica were positive for five, borderline for one, and negative for two patients. These eight patients were treated for fascioliasis by surgical resection of localized abscesses and albendazol. One patient serologically positive for F. Hepatica was found to have a common duct fluke two years after initial diagnosis. Serological testing for Toxocara and Echinococcus granulosus was negative in all 14 patients.
Basidiobolomycosis and F. hepatica are implicated as the cause of abdominal eosinophilic granulomatous abscesses in 12 of 14 patients identified over a period of 40 months in northern Iraq. Treatment was complicated by chronic biliary tract disease in fascioliasis and perforation and recurrent intestinal obstruction with basidiobolomycosis.
[Show abstract][Hide abstract] ABSTRACT: Context.-Laboratory medicine is an integral component of patient care. Approximately 60% to 70% of medical decisions are based on laboratory results. Physicians in specialties that order the tests are teaching medical students laboratory medicine and test use with minimal input from laboratory scientists who implement and maintain the quality control for those tests. Objective.-To develop, implement, and evaluate a 1.5-day medical student clinical laboratory experience for fourth-year medical students in their last month of training. Design.-The experience was devised and directed by laboratory scientists and included a panel discussion, laboratory tours, case studies that focused on the goals and objectives recently published by the Academy of Clinical Laboratory Physicians and Scientists, and medical-student presentations highlighting salient points of the experience. The same knowledge quiz was administered at the beginning and end of the experience and 84 students took both quizzes. Results.-A score of 7 or more was obtained by 16 students (19%) on the initial quiz, whereas 34 (40%) obtained the same score on the final quiz; the improvement was found to be statistically significant (P = .002; t = 3.215), particularly in 3 out of the 10 questions administered. Conclusions.-Although the assessment can only measure a small amount of knowledge recently acquired, the improvement observed by fourth-year medical students devoting a short period to learning laboratory medicine principles was encouraging. This medical student clinical laboratory experience format allowed teaching of a select group of laboratory medicine principles in 1.5 days to an entire medical school class.
Archives of pathology & laboratory medicine 11/2012; 136(11):1423-9. · 2.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Helicobacter pylori causes gastritis, duodenal ulcers, and gastric cancer. Although household crowding, low socioeconomic status (SES), and poor sanitation are associated with infection elsewhere, risk factors of infection in the Republic of Georgia (ROG), a country with a high prevalence rate (>70%), remain unknown. In this study we explored potential risk factors of infection among symptomatic patients in ROG.
During 2007-2008, we prospectively recruited 390 subjects with gastrointestinal symptoms referred to five tertiary care centers for diagnostic upper endoscopy. We administered a questionnaire on potential risk factors and tested patients using three diagnostic tests: gastric biopsies underwent histological evaluation and rapid urease test (CLO test), and an ELISA was used to detect IgG against H. pylori in serum. We defined a case as having two or more positive results from the three available tests. Univariate and multivariate logistic regression analyses were performed.
Overall, 217 (56%) patients met the study case definition. Subjects diagnosed with cancer had the highest rate of H. pylori infection (62%), followed by those with gastritis (55%), and ulcer (54%). Age >30 years (adjusted odds ratio (aOR 2.6, 95% confidence interval (CI) 1.6-4.3) and residing in the capital city (aOR 0.6, 95% CI 0.4-0.9) were significantly associated with infection.
In this large cohort with gastrointestinal symptoms, only age >30 years and living in the capital were significant factors associated with infection. Lower SES, less education, and crowding did not confer an increased risk, in contrast to the findings of previous studies. Population-based studies are needed to identify potential routes and risk factors of H. pylori infection in ROG.
International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases 08/2012; 16(9):e697-702. · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Turnaround time of laboratory results is important for customer satisfaction. The College of American Pathologists' checklist requires an analytic turnaround time of 2 days or less for most routine cases and lets every hospital define what a routine specimen is. The objective of this study was to analyze which factors impact turnaround time of nonbiopsy surgical pathology specimens. We calculated the turnaround time from receipt to verification of results (adjusted for weekends and holidays) for all nonbiopsy surgical specimens during a 2-week period. Factors studied included tissue type, number of slides per case, decalcification, immunohistochemistry, consultations with other pathologists, and diagnosis. Univariate and multivariate analyses were performed. A total of 713 specimens were analyzed, 551 (77%) were verified within 2 days and 162 (23%) in 3 days or more. Lung, gastrointestinal, breast, and genitourinary specimens showed the highest percentage of cases being signed out in over 3 days. Diagnosis of malignancy (including staging of the neoplasia), consultation with other pathologists, having had a frozen section, and use of immunohistochemical stains were significantly associated with increased turnaround time in univariate analysis. Decalcification was not associated with increased turnaround time. In multivariate analysis, consultation with other pathologists, use of immunohistochemistry, diagnosis of malignancy, and the number of slides studied continued to be significantly associated with prolonged turnaround time. Our findings suggest that diagnosis of malignancy is central to significantly prolonging the turnaround time for surgical pathology specimens, thus institutions that serve cancer centers will have longer turnaround time than those that do not.
Human pathology 03/2012; 43(9):1501-5. · 3.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Granuloma is an organized aggregate of immune cells that under the microscope appear as epithelioid macrophages. A granuloma can only be diagnosed when a pathologist observes this type of inflammation under the microscope. If a foreign body or a parasite is not observed inside the granuloma, stains for acid-fast bacilli and fungi are ordered since mycobacteria and fungi are frequently the cause of this type of inflammation. It is calculated that 12 to 36% of granulomas do not have a specific etiology and many have wondered if with new molecular methods we could reduce this number. This paper will summarize the frequently known causes of granulomas and will present the recent literature regarding the use of molecular techniques on tissue specimens and how these have helped in defining causative agents. We will also briefly describe new research regarding formation and function of granulomas and how this impacts our ability to find an etiologic agent.
[Show abstract][Hide abstract] ABSTRACT: Clostridial toxic shock, caused by Clostridium sordellii or Clostridium perfringens, is a rare and largely fatal syndrome among reproductive-aged women with genital tract infection, and may occur following various pregnancy outcomes or without pregnancy. Clinicians should be aware of common clinical features of this very rapidly-progressing syndrome including abdominal pain, tachycardia, hypotension, third-space fluid accumulations, hemoconcentration, and marked leukemoid response, often with lack of fever. In this review, we summarize known cases through mid-2011 and information on clinical presentation, diagnosis, treatment, and results of recent investigations regarding pathogenesis, including germination, toxins, and host response that may have important implications for development of preventive or therapeutic interventions.
Current Infectious Disease Reports 09/2011; 13(6):561-70.
[Show abstract][Hide abstract] ABSTRACT: As the clinical implications of Helicobacter pylori infection in children and adolescents continue to evolve, ESPGHAN and NASPGHAN jointly renewed clinical guidelines using a standardized evidence-based approach to develop updated recommendations for children and adolescents in North America and Europe.
An international panel of 11 pediatric gastroenterologists, 2 epidemiologists, 1 microbiologist, and 1 pathologist was selected by societies that developed evidence-based guidelines based on the Delphi process with anonymous voting in a final face-to-face meeting. A systematic literature search was performed on 8 databases of relevance including publications from January 2000 to December 2009. After excluding nonrelevant publications, tables of evidence were constructed for different focus areas according to the Oxford classification. Statements and recommendations were formulated in the following areas: whom to test, how to test, whom to treat, and how to treat. Grades of evidence were assigned to each recommendation based on the GRADE system.
A total of 2290 publications were identified, from which 738 were finally reviewed. A total of 21 recommendations were generated, and an algorithm was proposed by the joint committee providing evidence-based guidelines on the diagnostic workup and treatment of children with H pylori infection.
These clinical practice guidelines represent updated, best-available evidence and are meant for children and adolescents living in Europe and North America, but they may not apply to those living on other continents, particularly in developing countries with a high H pylori infection rate and limited health care resources.
Journal of pediatric gastroenterology and nutrition 05/2011; 53(2):230-43. · 2.18 Impact Factor