Evidence-based cellular pathology: a systematic framework for pathological diagnosis and clinical decisions

With few exceptions the diagnostic role of pathology has not been systematically researched, especially the link between histopathological diagnosis and patient outcomes. However, histopathology can be evaluated in the same way as any other diagnostic test using the measurements of reproducibility, sensitivity and specificity. Using the example of liver biopsy, we show the gradual reduction in diagnostic uncertainty using information from all the different tests. A staged approach to pathological diagnosis and clinical decision making is described. The stages for each test are: establishing the biological basis, assessing the performance in clinical practice, determining the impact on clinical outcomes, assessing the psychological and social impact, determining the cost-effectiveness, deciding on test use, and implementing change and audit of outcomes. This evidence-based systematic approach will help standardize and optimize the clinical practice of cellular pathology.     

Evidence-based pathology: umbilical cord coiling

The generation of a pathology test result must be based on criteria that are proven to be acceptably reproducible and clinically relevant to be evidence-based. This review de-constructs the umbilical cord coiling index to illustrate how it can stray from being evidence-based. Publications related to umbilical cord coiling were retrieved and analysed with regard to how the umbilical coiling index was calculated, abnormal coiling was defined and reference ranges were constructed. Errors and other influences that can occur with the measurement of the length of the umbilical cord or of the number of coils can compromise the generation of the coiling index. Definitions of abnormal coiling are not consistent in the literature. Reference ranges defining hypocoiling or hypercoiling have not taken those potential errors or the possible effect of gestational age into account. Even the way numerical test results in anatomical pathology are generated, as illustrated by the umbilical coiling index, warrants a critical analysis into its evidence base to ensure that they are reproducible or free from errors.     

Evidence-based decision making and asthma in the internet age: the tools of the trade

At the dawn of the Information Age, the practice of evidence-based decision making (EBDM) is still hindered by many important barriers related to the decision makers, to the evidence per se or to the health system. Some of these barriers, particularly those related to the distillation, dissemination and packaging of research evidence, could be overcome by recent and ongoing developments in portable/wearable computers, internet appliances, multimedia and wireless broadband internet traffic. This article describes specific EBDM-related tools, with emphasis on internet-enabled "how to" books; and tools to improve the quality of reporting research, to formulate questions; to search for evidence; to access journals, systematic reviews and guidelines; to interact with organizations promoting EBDM; and to tailor evidence to individual cases. However, thinking that all barriers to the practice of EBDM could be solved by fancy information technology is naïve. Barriers related to the generation, interpretation, integration and use of the evidence demand more complex and perhaps unfeasible solutions, as overcoming them will require substantial changes in the structure of the health system, in the politics of science and in the way in which humans think and behave.     

循证医学与临床医学图书馆员

本文阐述了临床医学图书馆员参与循证医学的重要作用、工作方式以及应具备的业务素质，同时还介绍了当今国内外一些主要的循证医学证据检索工具，如有关的医学期刊与数据库。     

A Review of Online Evidence-based Practice Point-of-Care Information Summary Providers

Background

Busy clinicians need easy access to evidence-based information to inform their clinical practice. Publishers and organizations have designed specific tools to meet doctors’ needs at the point of care.

Objective

The aim of this study was to describe online point-of-care summaries and evaluate their breadth, content development, and editorial policy against their claims of being “evidence-based.”

Methods

We searched Medline, Google, librarian association websites, and information conference proceedings from January to December 2008. We included English Web-based point-of-care summaries designed to deliver predigested, rapidly accessible, comprehensive, periodically updated, evidence-based information to clinicians. Two investigators independently extracted data on the general characteristics and content presentation of summaries. We assessed and ranked point-of-care products according to: (1) coverage (volume) of medical conditions, (2) editorial quality, and (3) evidence-based methodology. We explored how these factors were associated.

Results

We retrieved 30 eligible summaries. Of these products, 18 met our inclusion criteria and were qualitatively described, and 16 provided sufficient data for quantitative evaluation. The median volume of medical conditions covered was 80.6% (interquartile range, 68.9% - 84.2%) and varied for the different products. Similarly, differences emerged for editorial policy (median 8.0, interquartile range 5.8 - 10.3) and evidence-based methodology scores (median 10.0, interquartile range 1.0 - 12.8) on a 15-point scale. None of these dimensions turned out to be significantly associated with the other dimensions (editorial quality and volume, Spearman rank correlation r = -0.001, P = .99; evidence-based methodology and volume, r = -0.19, P = .48; editorial and evidence-based methodology, r = 0.43, P =.09).

Conclusions

Publishers are moving to develop point-of-care summary products. Some of these have better profiles than others, and there is room for improved reporting of the strengths and weaknesses of these products.     

浅议循证医学与医学教育的关系

循证医学(EBM)思想来源于临床实践,目前已广泛深入到各种临床实践和基础研究。循证医学思想不仅对医药、卫生的各个领域产生了重大影响,也对医学教育、教学改革产生了影响。分析循证医学与医学教育的关系对于促进医学教育改革和推动循证医学发展都具有重要的现实意义。笔者从循证医学的发展概况及其基本内涵对循证医学与医学教育的关系作简要分析。     

Artificial intelligence in digital pathology: a roadmap to routine use in clinical practice

The use of artificial intelligence will transform clinical practice over the next decade and the early impact of this will likely be the integration of image analysis and machine learning into routine histopathology. In the UK and around the world, a digital revolution is transforming the reporting practice of diagnostic histopathology and this has sparked a proliferation of image analysis software tools. While this is an exciting development that could discover novel predictive clinical information and potentially address international pathology workforce shortages, there is a clear need for a robust and evidence-based framework in which to develop these new tools in a collaborative manner that meets regulatory approval. With these issues in mind, the NCRI Cellular Molecular Pathology (CM-Path) initiative and the British In Vitro Diagnostics Association (BIVDA) have set out a roadmap to help academia, industry, and clinicians develop new software tools to the point of approved clinical use. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Pathologists are from Mercury, clinicians are from Uranus: the perverted prospects for perceptual pathology

Clinicians and pathologists do their work, of course, in quite different ways. Because both groups are trained as physicians, however, this training commonality makes all involved seem basically to be on the same “medical team.” There are, nevertheless, some fundamental differences between the 2 groups that can on occasion cause significant difficulties in mutual understanding; there are reasons to believe that such differences are becoming more pronounced. Although the differences in viewpoints are often subtle and, therefore, seemingly not very important, these differences have very profound causes and can be profound in their effects. This narrative examines the underlying broad historical-sociological-philosophical bases for these differences with the aim of illuminating their importance to medicine and their prospective importance to pathology in particular.     

Ethics codes and medical decision making

ObjectiveThe objective of this study is to analyze guidance about medical decision making contained in ethics codes. The primary question we address is which of the main decision-making models - informed decision making (IDM), shared decision making (SDM), or paternalism - is promoted by these codes.MethodsWe manually searched codes of medical ethics for guidance on medical decision making. Our analysis focused on the major international code, the World Medical Association International Code of Medical Ethics (ICME), and national codes of the US, Canada, Australia, New Zealand, the UK, Ireland, Germany, France and Norway.ResultsThe ICME does not promote any specific model of medical decision making. 10 of the 11 analyzed national codes contain guidance about IDM, while only four refer to SDM. Some codes contain articles which are imprecise with regard to the question of medical decision making.ConclusionsAll of the analyzed national codes should be updated or amended. In particular, given the great importance of SDM in medicine, codes which do not contain relevant guidance should be updated.Practice implicationsRelevant amendments introduced to ethics codes could contribute to promoting of adequate standards of medical decision making (especially those regarding SDM) among doctors.     

Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Recurrent miscarriage (RM; > or =3 consecutive early pregnancy losses) affects around 1% of fertile couples. Parental chromosomal anomalies, maternal thrombophilic disorders and structural uterine anomalies have been directly associated with recurrent miscarriage; however, in the vast majority of cases the pathophysiology remains unknown. We have updated the ESHRE Special Interest Group for Early Pregnancy (SIGEP) protocol for the investigation and medical management of RM. Based on the data of recently published large randomized controlled trials (RCTs) and meta-analyses, we recommend that basic investigations of a couple presenting with recurrent miscarriage should include obstetric and family history, age, BMI and exposure to toxins, full blood count, antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies), parental karyotype, pelvic ultrasound and/or hysterosalpingogram. Other investigations should be limited to particular cases and/or used within research programmes. Tender loving care and health advice are the only interventions that do not require more RCTs. All other proposed therapies, which require more investigations, are of no proven benefit or are associated with more harm than good.     

Software-assisted decision support in digital histopathology

Tissue diagnostics is the world of pathologists, and it is increasingly becoming digitalised to leverage the enormous potential of personalised medicine and of stratifying patients, enabling the administration of modern therapies. Therefore, the daily task for pathologists is changing drastically and will become increasingly demanding in order to take advantage of the development of modern computer technologies. The role of pathologist has rapidly evolved from exclusively describing the morphology and phenomenology of a disease, to becoming a gatekeeper for novel and most effective treatment options. This is possible based on the retrieval and management of a wide range of complex information from tissue or a group of cells and associated meta-data. Intelligent and self-learning software solutions can support and guide pathologists to score clinically relevant decisions based on the accurate and robust quantification of multiple target molecules or surrogate biomarker as companion or complimentary diagnostics along with relevant spatial relationships and contextual information from digital H&E and multiplexed images. With the availability of multiplex staining techniques on a single slide, high-resolution image analysis tools, and high-end computer hardware, machine and deep learning solutions now offer diagnostic rulesets and algorithms that still require clinical validation in well-designed studies. Before entering the clinical practice, the ‘human factor’ pathologist needs to develop trust in the output coming from the ‘digital black box of computational pathology’, including image analysis solutions and artificial intelligence algorithms to support critical clinical decisions which otherwise would not be available. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Curriculum content and evaluation of resident competency in clinical pathology (laboratory medicine): a proposal

Ten years have passed since the Graylyn Conference Report on Laboratory Medicine Clinical Pathology training was issued. Over that period, the Accreditation Council for Graduate Medical Education substantially revised the requirements for training programs; the American Board of Pathology amended both the requirements and the periods needed for certification; and the discipline itself, along with the broader discipline of pathology, evolved significantly. Recently, a curriculum proposal in anatomical pathology was published as a potential template to be used by training programs to help meet these new and evolving needs. Toward the same end, the Academy of Clinical Laboratory Physicians and Scientists has now developed a template for a curriculum in clinical pathology (laboratory medicine), taking into account newly designated and revised areas of residency core competency, the alterations in training requirements promulgated by the Accreditation Council for Graduate Medical Education and American Board of Pathology, and the rapidly developing nature of the discipline itself. The proposed clinical pathology curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by pathology residency training programs.     

Identifying subfertile ovulatory women for timely tubal patency testing: a clinical decision rule based on medical history

BACKGROUND: The aim of tubal testing is to identify women with bilateral tubal pathology in a timely manner, so they can be treated with IVF or tubal surgery. At present, it is unclear for which women early tubal testing is indicated, and in whom it can be deferred. METHODS: Data on 3716 women who underwent tubal patency testing as a part of their routine fertility workup were used to relate elements in their medical history to the presence of tubal pathology. With multivariable logistic regression, we constructed two diagnostic models. One in which tubal disease was defined as occlusion and/or severe adhesions of at least one tube, whereas in a second model, tubal disease was defined as the presence of bilateral abnormalities. RESULTS: Both models discriminated moderately well between women with and women without tubal disease with an area under the receiver-operating characteristic curve (AUC) of 0.65 (95% CI: 0.63-0.68) for any tubal pathology and 0.68 (95% CI: 0.65-0.71) for bilateral tubal pathology, respectively. However, the models could make an almost perfect distinction between women with a high and a low probability of tubal pathology. A decision rule in the form of a simple diagnostic score chart was developed for application of the models in clinical practice. CONCLUSIONS: In conclusion, the present study provides two easy to use decision rules that can accurately express a woman's probability of (severe) tubal pathology at the couple's first consultation. They could be used to select women for tubal testing more efficiently.     

Mapping the evidence base of pathology

Evidence-based medicine (EBM) is a paradigm that is beginning to exert an influence in related fields such as surgery, general practice, psychiatry, and now pathology. For example, a survey has shown that 70 per cent of therapeutic interventions in clinical haematology delivered in a district general hospital were based on research-derived evidence. A prerequisite to evidence-based pathology is availability of, and access to, the evidence base. As a discipline, pathology has certain characteristics that makes information retrieval more challenging. Nevertheless, a number of evidence-seeking techniques can be utilized to maximize the chances of success: focusing the question, use of an evidence-seeking protocol, and application of methodological filters. A number of key information sources are reviewed for their usefulness and a comparison is made with the yield from the World Wide Web. Conclusions are drawn from an example of the evidence-seeking process based on a clinical scenario involving immune thrombocytopenic purpura. Copyright © 1999 John Wiley & Sons, Ltd.     

Combining multi-criteria decision analysis and mini-health technology assessment: A funding decision-support tool for medical devices in a university hospital setting

BackgroundAt the hospital level, decisions about purchasing new and oftentimes expensive medical devices must take into account multiple criteria simultaneously. Multi-criteria decision analysis (MCDA) is increasingly used for health technology assessment (HTA). One of the most successful hospital-based HTA approaches is mini-HTA, of which a notable example is the Matrix4value model.ObjectivesTo develop a funding decision-support tool combining MCDA and mini-HTA, based on Matrix4value, suitable for medical devices for individual patient use in French university hospitals – known as the IDA tool, short for ‘innovative device assessment’.MethodsCriteria for assessing medical devices were identified from a literature review and a survey of 18 French university hospitals. Weights for the criteria, representing their relative importance, were derived from a survey of 25 members of a medical devices committee using an elicitation technique involving pairwise comparisons. As a test of its usefulness, the IDA tool was applied to two new drug-eluting beads (DEBs) for transcatheter arterial chemoembolization.ResultsThe IDA tool comprises five criteria and weights for each of two over-arching categories: risk and value. The tool revealed that the two new DEBs conferred no additional value relative to DEBs currently available.ConclusionsFeedback from participating decision-makers about the IDA tool was very positive. The tool could help to promote a more structured and transparent approach to HTA decision-making in French university hospitals.     

循证医学方法在神经病教学中的应用

目的 探讨将循证医学方法引入神经病学教学的意义.方法 剖析传统神经病学教学的弊端,分析将循证医学方法引入神经病学教学的优势和必要性;通过举例,简要说明循证医学的方法和步骤.结果 将循证医学方法引入神经病学教学,可以整合神经病学、临床流行病学、医学统计学和文献检索等课程,激发学生学习的积极性.结论 将循证医学方法引入神经病学教学,有利于加强课程间的横向联系,使学生学习效果最大化.     

整合医学理念在病理PBL教学改革中的应用

以问题为向导教学法PBL在病理学教学中已广泛开展,但其在实施中仍然存在局限性,而整合医学理念可以在很大程度上提高PBL的教学效果。本文通过分析整合医学思维在病理PBL教学中应用的必要性,提出了以整合医学思维为指导的PBL教学优化原则,包括整体化与网络化原则、解包和拓扑原则及在实践中完善"典型病例选择与PBL机制的不足"。文章最后提出通过深入理解整合医学与PBL相辅相成的关系,建立易于理解、可操作、易于把握的医学场景,从而促进病理教学改革的不断前进。     

An aggregation of PRO and CON evidence for medical decision support systems

One promising way to increase the classification accuracy of medical decision support systems is to implement heuristic combinations of pattern recognition and artificial intelligence tools. A parallel between “cognition” model and differential diagnostic task is sketched accentuating the aggregation of activating and restraining inputs and corresponding PRO and CON evidence in medicine. On the basis of this paradigm a trainable model of a fuzzy neuron is proposed which resembles some elements from the physician's decision process. An example from aviation medicine is presented which demonstrates the enhanced performance.