Perspective: Can emotional intelligence training serve as an alternative approach to teaching professionalism to residents?

Of the Accreditation Council for Graduate Medical Education's six general competencies, professionalism has posed the greatest challenges for medical educators to define and teach. Currently, professionalism is largely taught experientially through role modeling, which has many shortcomings as a sole teaching strategy. Namely, role modeling does not involve an explicit curriculum, the skill is difficult to teach or develop, and physicians may be reluctant to talk about lapses in their own behaviors regarding professionalism.In this article, the authors propose instead using the model of emotional intelligence (EI) to define key elements of professionalism and as the basis for their proposed curriculum for teaching professionalism. EI is a well-developed construct and consists of four types of abilities: emotional self-awareness, self-management, social awareness, and relationship management. EI is grounded in effective performance and leadership success rather than in moral right or wrong. The authors propose that the EI abilities suggest specific curricula which, when successfully taught by faculty and learned by physicians-in-training, would allow trainees' professionalism to be recognized and measured in ways that are not currently possible with existing hidden curricula. The authors hope that those who develop policies regarding professionalism and those who train physicians will find this construct a useful way of developing curricula for the critical professionalism competency.     

Ki-67 immunocytochemistry in liquid based cervical cytology: useful as an adjunctive tool?

AIMS: To test the ability of Ki-67 to detect cytological lesions in a screening setting and its use as a surrogate marker of human papillomavirus (HPV) infection. METHODS: A study of liquid based cytology, HPV DNA testing by MY09/MY11 consensus polymerase chain reaction (PCR), type specific PCRs, and Ki-67 immunocytochemistry on a randomly selected series of 147 patients. RESULTS: Comparison of the number of Ki-67 immunoreactive cells/1000 cells in the different cytological groups showed that the HSIL group yielded a significantly higher mean count than did the other groups. The number of Ki-67 immunoreactive cells/1000 cells was significantly higher in HPV-16 positive samples than in samples containing infections with other high risk types. Receiver operating characteristic curves indicated a test accuracy (area under curve) of 0.68, 0.72, and 0.86 for atypical squamous cells of undetermined significance (ASCUS), low grade squamous intraepithelial lesions (LSIL), and high grade squamous intraepithelial lesions (HSIL), respectively. Thresholds for 95% sensitivity were 0.07, 0.08, and 0.15 Ki-67 immunopositive cells/1000 cells for ASCUS, LSIL and HSIL, respectively. The threshold for 95% specificity was 1.9 Ki-67 immunopositive cells/1000 cells. CONCLUSIONS: Ki-67 immunocytochemistry can be applied to liquid based cytology. The accuracy and diagnostic indices of the test are good when compared with those of other techniques. As part of a panel of screening procedures, it could be used as an adjunct to liquid based cytology to identify HSIL, and as a surrogate marker of HPV-16 infection.     

Cystic hepatic metastases in treatment naïve neuroendocrine tumor: Cytomorphology clubbed with cell block immunocytochemistry clinches the diagnosis

Cystic hepatic lesions encompass a vast spectrum of infectious, non-neoplastic, and neoplastic entities. Most hepatic cysts are benign and asymptomatic, requiring no active intervention. However, symptomatic and malignant cysts need proper evaluation and specific treatment. An accurate preoperative diagnosis is pivotal for patient management. At times, these lesions may mimic, especially symptomatology and radiology, leading to a diagnostic ordeal. We herein present a case of a patient with cystic liver lesions in a treatment naïve neuroendocrine tumor that was a diagnostic dilemma on radiology. Low cellularity of cytology smears made the diagnosis challenging, and cell block immunocytochemistry finally clinched the diagnosis. A timely diagnosis provided on cytology fuelled further work-up, the discovery of primary tumor, and initiation of appropriate therapy.     

Can palmar creases serve as landmarks for the deeper neuro-vascular structures?

Purpose

The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures.

Methods

Four creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases.

Results

Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases.

Conclusions

These anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.     

Microencapsulation of tumor lysates and live cell engineering with MIP-3α as an effective vaccine

The combination of several potential strategies so as to develop new tumor vaccines is an attractive field of translational medicine. Pulsing tumor lysates with dendritic cells (DCs), in-vivo attraction of DCs by macrophage inflammatory protein 3α (MIP-3α), and reversion of the tumor suppressive microenvironment have been tested as strategies to develop tumor vaccines. In this study, we generated an alginate microsphere (named PaLtTcAdMIP3α) that encapsulated tumor lysates, live tumor cells engineering with a recombinant MIP-3α adenovirus and BCG. We used PaLtTcAdMIP3α as a model vaccine to test its antitumor activities. Our results showed that PaLtTcAdMIP3α expressed and excreted MIP-3α, which effectively attracted DCs ex vivo and in vivo. Injection of PaLtTcAdMIP3α into tumor-bearing mice effectively induced both therapeutic and prophylactic antitumor immunities in CT26, Meth A, B16-F10 and H22 models, but without any ensuing increase in adverse effects. Both tumor-specific cellular and humoral immune responses, especially the CD8⁺ T cell-dependent cytotoxic T immunity, were found in the mice injected with PaLtTcAdMIP3α. The anti-tumor activity was abrogated completely by depletion of CD8⁺ and partially by CD4⁺ T lymphocytes. In addition, the number of IFN-γ-producing CD8⁺ T cells in spleen and tumor tissues was significantly increased; but the number of CD4⁺CD25⁺FOXP3⁺ regulatory T cells (Treg) in tumor tissues was decreased. These data strongly suggest that a combination of multi-current-using strategies such as the novel approach of using our PaLtTcAdMIP3α microspheres could be an effective tumor model vaccine.     

Mesenchymal neoplasms: Is it time for cytology? New perspectives for the pre-operative diagnosis of soft tissue tumors in the molecular era

Soft tissue tumors comprise a great variety of common and rare entities with overlapping features. Their diagnosis is based on the evaluation of several histological parameters which are difficult to assess on small incisional biopsies. Useful diagnostic markers in the field of soft tissue tumors include: 1) molecular biomarkers detecting pathogenetically relevant, distinctive alterations; 2) immunohistochemical surrogate biomarkers of pathogenetically relevant, distinctive molecular alterations; 3) highly specific immunohistochemical biomarkers indicating tumor differentiation. Their introduction in clinical practice has revolutionized the pre-operative diagnosis of soft tissue tumors. Cytology has long been considered inadequate as a first-line approach in this setting. However, since the implementation of new immunohistochemical and molecular tests with high diagnostic specificity, fine needle aspiration cytology (FNAC) is starting to gain acceptance for the pre-operative assessment of soft tissue tumors. FNAC represents a versatile, poorly expensive and well-tolerated diagnostic strategy with relevant advantages over histological biopsies. Moreover, evidences suggest that, in expert hands, FNAC can also aim at a definite diagnosis, especially if a cell block is prepared, allowing the application of multiple ancillary techniques.     

Can neurografts from mice with chromosome 16 trisomy serve as a model of Alzheimer disease?

Basal forebrain regions were transplanted from mouse embryos with chromosome 16 trisomy into the lateral brain ventricle of healthy adult mice. After 1–12 months, the grafts contained immunoreactive choline- and GABAergic neurons and astroglial cells. Quantitative analysis revealed no neurodegenerative changes in these grafts compared to diploid ones. Pronounced infiltration with T and B cells and activation of micro- and astroglia were found in the grafts with chromosome 16 trisomy and in control specimen. Translated fromByulleten' Eksperimental'noi Biologii i Meditsiny, Vol. 128, No. 11, pp. 559–564, November, 1999     

Can hematopoietic stem cells be an alternative source for skin regeneration?

In the past few years, the plasticity of adult cells in several post-natal tissues has attracted special attention in regenerative medicine. Skin is the largest organ in the body. Adult skin consists of epidermis, dermis and appendages such as hair and glands that are linked to the epidermis but project deep into the dermal layer. Stem cell biology of skin has been a focus of increasing interest in current life science. Committed stem cells with a limited differentiation potential for regeneration and repair of epidermis have been known for decades. Recent studies further found that adult skin tissues contain cell populations with pluripotent characteristics. Multipotent stem cells from skin with and without hair follicles, both in epidermal and dermal tissues, can differentiate and generate multiple cell lineages. Especially, the hematopoietic system in epidermal and dermal tissue, like skin, may be a local, acceptable reservoir of various adult stem cell populations. Given their easy accessibility, such stem cells can provide an experimental model not only for skin biology but also for studying the epithelial–mesenchymal cell interactions of organs other than the skin. This review presents an overview of recent advances in research into skin repair and regeneration involving stem cells from epidermis, dermis, and bone marrow. In particular, we focus on the possible use of blood stem cells as an alternative resource for research advances in skin biology.     

The approach of scratch‐imprint cytology: Is it an alternative to frozen section for intraoperative assessment of pulmonary lesions?

To address the diagnostic performance of scratch‐imprint cytology (SIC), in this study we compared intraoperative diagnoses of pulmonary lesions between SIC and frozen section histology (FSH) for accuracy with respect to the final pathological diagnosis. We histologically divided 206 pulmonary lesions (resected surgically) into two groups (benign and malignant) and compared each intraoperative diagnosis by SIC and FSH with the final pathological diagnoses. We also examined the radiological existence of pure ground‐glass opacity (GGO) nodules in each group. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 91.5%, 100%, 100%, 63.6%, and 92.6%, respectively for SIC, and 98.2%, 100%, 100%, 92.1% and 98.5%, respectively, for FSH. Thus, we concluded that diagnosis by SIC is reliable for malignancy, but not for benign lesions. All pure GGO nodules (19; 9.2%) were noninfectious and malignant with a high accuracy of FSH diagnosis (100%), in comparison with those of low accuracy with a SIC diagnosis (57.9%). SIC can be an appropriate intraoperative diagnostic tool where multiple cytotechnologists observe intraoperative SIC preparations scratched evenly across the whole lesion including the peripheral area of the mass.     

TNF-blocking therapies: an alternative mode of action?

Despite expanding use of drugs blocking tumour necrosis factor (TNF), their precise mechanisms of action remain unclear. Early assumptions that they act by direct neutralization of the toxic inflammatory effects of TNF might be too simplistic because they explain neither the range of effects observed nor the varying properties of different TNF-blocking agents. Recent studies have demonstrated a key role for mast cell-derived TNF in the increase in lymph node size and the organizational complexity that accompanies a developing immune response. Regulation of this phenomenon might comprise a novel mode of action for TNF-directed therapy: by preventing this lymph node hyperplasia, TNF blockade could modulate immune responses, ameliorating pathology in autoimmune diseases, such as rheumatoid arthritis.     

Ossifying fibromyxoid tumor: modified myoepithelial cell tumor? Report of three cases with immunohistochemical and electron microscopic studies

Ossifying fibromyxoid tumors (OFMT) are rare soft tissue tumors of uncertain histogenesis and clinical behavior. Since Enzinger, Weiss, and Liang first described 59 examples in 1989 (Am Surg Pathol. 13:817-827), approximately 150 cases have been reported. Their clinicopathologic features are fairly well characterized and their histogenesis remains unknown. Three examples of soft tissue tumors with typical histopathologic characteristics of OFMT were studied: case 1, a 43-year-old female with a 2.5-cm tumor of the back; case 2, a 56-year-old man with an 8-cm thigh mass; and case 3, an 81-year-old female with a 13.5-cm buttock tumor. For immunohistochemistry, formalin-fixed, paraffin-embedded tissue sections were stained with antibodies against cytokeratin, smooth muscle actin, desmin, vimentin, S-100 protein, EMA, and collagen type IV using standard ABC-peroxidase methods. For electron microscopy, tissue samples fixed in EM-grade buffered formalin were processed according to routine methods. Immunohistochemistry showed that the tumor cells were positive for vimentin and S-100 protein in all 3 cases. Stains for collagen type IV revealed diffusely positive staining in the stroma with a tendency for stronger staining around the cell borders in 2 out of 3 cases. Desmin was positive in one and actin was positive in one other case. By electron microscopy, tumor cells were characterized by centrally located round to oval nuclei with varying amounts of cytoplasm containing scanty cytoplasmic organelles. There were rare profiles of rough-surfaced endoplasmic reticulum (RER) and rare mitochondria with areas of condensed intermediate filaments. No tonofilaments or actin filaments were present. There were multiple short web-like processes, some of which were attached to that of neighboring cells by primitive cell junctions. In all 3 cases, lesional cells showed external lamina (EL), which was abundant in case 1, forming redundant scrolls frequently. In case 2, EL was less prominent and incomplete, and interrupted portions of EL were present only along the periphery of cell columns or nests bordering the stroma. In case 3, which behaved as a malignant tumor, the tumor cells were less differentiated spindle cells with primitive cellular features, and EL was rarely found along the short span of tumor cell borders. In this study, tumor cells in OFMT were polygonal to stellate often with multiple short cytoplasmic processes. The tumor cells were found to form cell clusters attached by primitive intercellular junctions between cytoplasmic processes forming intercellular bridges. The cell borders facing the stroma around cell clusters tended to be flat and had incomplete EL, while no EL was present along the cell borders facing the inner aspect of cell clusters. These ultrastructural findings together with immunophenotypic expression of S-100 protein presented closer resemblance to those of modified myoepithelial cells in pleomorphic adenomas of salivary glands and skin appendages rather than peripheral nerve sheath tumors. The authors conclude that these findings render more support to the hypothesis of myoepithelial histogenesis of OFMT. They also conclude that ultrastructural study not only helps accurate diagnosis, but also may aid in predicting malignant behavior by the degree of deviation from the typical examples of OFMT.     

Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study

Background  

Despite the importance of collecting individual data of socioeconomic status (SES) in epidemiological oral health surveys with children, this procedure relies on the parents as respondents. Therefore, type of school (public or private schools) could be used as an alternative indicator of SES, instead of collecting data individually. The aim of this study was to evaluate the use of the variable type of school as an indicator of socioeconomic status as a substitute of individual data in an epidemiological survey about dental caries in Brazilian preschool children.     

Küttner's tumor of the submandibular glands: report of five cases with fine-needle aspiration cytology

Küttner's tumor (KT) is a benign tumor-like lesion of the salivary gland that mimics neoplasm clinically because of presentation as a hard mass. Recently, the histomorphological and immunohistochemical findings of this lesion have been analyzed, and differential diagnostic problems relating to salivary gland lymphoma have been discussed. However, currently there is little information on the cytological findings of those lesions. We present cytological findings from five such cases using fine-needle aspiration cytology (FNAC). FNAC of this lesion may present a diagnostic challenge to the cytologist as lesions share some cytologic features with inflammatory process containing numerous lymphoid cells. Smears obtained from two cases contained moderate to large numbers of lymphoid cells without definite cytological atypia, scattered ductal structures, and acinar cell clusters. The remaining three cases showed low cellularity probably attributable to fibrosis that made it difficult to aspirate the cellular element. FNAC findings of scattered ductal structures surrounded by collagens and infiltrated by a mixed population of lymphoid cells, not specific for KT, are highly suggestive of the diagnosis with the appropriate clinical findings. However, a portion of cytological specimens of KT containing relatively large numbers of lymphoid cells should be differentiated from malignant lymphoma arising from the submandibular gland.