R. D. Start

Telepathology: current status and future prospects in diagnostic histopathology

Telepathology: current status and future prospects in diagnostic histopathology

Does delay in fixation affect the number of mitotic figures in processed tissue

The effect of delay in fixation on the number of mitotic figures in tissues has received little attention, and previous studies have reached differing conclusions. The numbers of mitotic figures in the normal mucosa of six colectomy specimens were counted with delays in fixation of 30 minutes, one hour, two hours, three hours and six hours for samples from each specimen. The numbers of mitotic figures were counted in 50 whole crypts in each specimen by two observers. All phases of mitosis were counted. The number of observable mitotic figures declined by about 30% with a delay in fixation of two hours and by 50% with a delay of six hours. This observation has important implications for the handling of surgical specimens.

Reassessment of the rate of fixative diffusion.

The diffusion of fixatives is slow. Early work using plasma gels and animal tissues showed the distance penetrated by a fixative to be a simple function of the fixation time but this relation has not been established in human tissues. The rates of diffusion into whole human spleens were measured for three primary fixatives over periods ranging from one to 25 days. A positive correlation was demonstrated between penetration distance (mm) and fixation time (hours). The diffusion rates were slower than those in previous studies. These results have possible implications for the handling of surgical specimens.

Clinicians and the coronial system: ability of clinicians to recognise reportable deaths.

OBJECTIVE--To assess the ability of clinicians to recognise deaths which require referral to the coroner. DESIGN--Postal questionnaire consisting of 16 fictitious case histories, 14 of which contained a clear indication for referral to the coroner. SETTING--Large teaching hospital. Coroners office. SUBJECTS--200 clinicians from general medical and surgical firms and senior staff of the local coroners office (two coroners officers and the two deputy coroners). MAIN OUTCOME MEASURES--Number of correct assessments on questionnaire. RESULTS--The mean recognition score for the clinicians was 9.11 (range 3-14) with no difference between the clinical grades. All of the coroners senior staff recorded maximum recognition scores of 16. CONCLUSIONS--The study highlights several features of the coronial system which are poorly understood by clinicians and provides the basis for an initiative to improve the medicolegal education of all clinicians.

The use of digital imaging, video conferencing, and telepathology in histopathology: a national survey

Aims: To undertake a large scale survey of histopathologists in the UK to determine the current infrastructure, training, and attitudes to digital pathology. Methods: A postal questionnaire was sent to 500 consultant histopathologists randomly selected from the membership of the Royal College of Pathologists in the UK. Results: There was a response rate of 47%. Sixty four per cent of respondents had a digital camera mounted on their microscope, but only 12% had any sort of telepathology equipment. Thirty per cent used digital images in electronic presentations at meetings at least once a year and only 24% had ever used telepathology in a diagnostic situation. Fifty nine per cent had received no training in digital imaging. Fifty eight per cent felt that the medicolegal implications of duty of care were a barrier to its use. A large proportion of pathologists (69%) were interested in using video conferencing for remote attendance at multidisciplinary team meetings. Conclusions: There is a reasonable level of equipment and communications infrastructure among histopathologists in the UK but a very low level of training. There is resistance to the use of telepathology in the diagnostic context but enthusiasm for the use of video conferencing in multidisciplinary team meetings.

Ownership and uses of human tissue: what are the opinions of surgical in-patients?

Aims: To investigate whether patient opinion about the uses of tissue removed at therapeutic operations has changed since the adverse publicity surrounding the Alder Hey and Bristol Royal Infirmary Inquiries, and to see whether it aligns with the Human Tissue Act 2004. Methods: A questionnaire was given to 220 postoperative patients in a teaching hospital during an 11 week period. Aggregated responses to each question were ranked in frequency order. Unweighted centroid linkage hierarchical clustering analysis was performed with dendrogram display for the main data on tissue usage. Results: 203 completed questionnaires were collected (compliance rate 92.3%). 96.3% of patients indicated that they would not object to their tissue being used in research, significantly higher than in the 1996 study (89.1%) with no overlap of the 95% CIs. 29.1% of patients believed that the hospital had ownership of tissue once it has been removed during surgery, 23.2% believed they had ownership, 19.7% believed that the pathology laboratory had ownership, and 15.3% believed that nobody had ownership rights in the case of tissue samples. Conclusions: This new survey indicates that despite a turbulent decade for those involved in human tissue retention in the UK, public support for a wide range of human tissue based activities, especially biomedical research, has not diminished and that patient opinion aligns well with the Human Tissue Act 2004.

Estimating mitotic activity in tumours

Counting mitotic activity is still the most commonly used method of assessing proliferative activity in human tumours in the setting of diagnostic and prognostic histopathology. The method is available to any pathologist as it does not require any special stains or equipment. The paper by Jannink et al. in this issue reporting the heterogeneity of mitotic activity in breast cancer adds valuable information to the extensive literature in this area.

Evaluating the reliability of causes of death in published clinical research

Deaths during clinical trials or outcome review studies could be due to the disease being studied; adverse complications of interventions in the study; intercurrent disease unrelated to the initial condition or interventions; or unnatural events. Accurate ascertainment of the causes of deaths is therefore required to establish whether treatment has prevented deaths from the investigated disease without concomitant increases in death or morbidity from other causes. We assessed the methods used to evaluate causes of death in published clinical research. All 879 papers published in 1994 in the Lancet , BMJ , Annals of Internal Medicine , and New England Journal of Medicine were reviewed; the methods used to evaluate the causes of death in each paper were recorded using 11 categories (table 1). Death was an outcome measure in 223 papers (25%). …

Have declining clinical necropsy rates reduced the contribution of necropsy to medical research

AIMS--To examine trends in necropsy based research output for a period of 27 years during which there has been a progressive decline in clinical necropsy rates. METHODS--The numbers of necropsy based research papers published between 1966 and 1993 were determined using the CD-Plus Medline computed literature database. RESULTS--The number of necropsy based research papers containing necropsy or a synonym in the title increased by 220% between 1966 and 1993. When papers including necropsy or a synonym in the abstract, but not in the title, were included, the proportion of all indexed papers increased from 0.35% in 1975, when abstracts were first included, to 0.53% in 1993. Analysis of the subject material indicated that necropsy based research has constantly reflected trends and advances in clinical medicine. Neuroscience related research represented the largest subject category which may reflect the difficulties in obtaining human tissue from sources other than necropsy. CONCLUSIONS--The modern necropsy continues to provide valuable information for all clinical and laboratory based disciplines. The decline in clinical necropsy rates would not yet appear to have undermined the contribution of the necropsy to research.

Analysis of necropsy request behaviour of clinicians.

AIM: To develop a necropsy related audit system to record accurate information in relation to necropsy requests, necropsy rates and coronial referrals. METHODS: A simple audit form was used to record detailed necropsy related data via an integrated questionnaire design and data entry system based on available optical image scanning technology. The system recorded the numbers and locations of deaths, referrals to the coroner, clinical necropsy requests, hospital and medicolegal necropsies, the grade of clinician involved in these processes, and the identity of the consultant in charge of the case. The overall, hospital and medicolegal necropsy rates were calculated by individual consultant, specialty and for the whole hospital. Necropsy request rates and coronial referral rates were also calculated and these data were related to the grade of clinician. All data were available on a monthly or an accumulative basis. RESULTS: Of 1398 deaths, 534 (38%) were discussed with the local coroners office and 167 of these were accepted for further investigation. House officers and senior house officers referred over 80% of all cases, whereas consultants referred only 2%. There were no significant differences in case acceptance rates by grade of clinician. Clinicians made 307 hospital necropsy requests (overall hospital necropsy request rate 22%). House officers made 65% of all necropsy requests. Consultant necropsy requests represented 13% of all requests. There were no significant differences in necropsy request success rates by grade of clinician. CONCLUSIONS: The referral of cases to coroners and clinical necropsy requests are still being inappropriately delegated to the most junior clinicians. This study illustrates the type of useful information which can be produced for individual clinicians, specialty audit groups and pathology departments using a simple necropsy related audit system.