Finally, a simple cartoon depicting the anatomic location of the transentorhinal cortex

In our teaching and in our autopsy reports, we neuropathologists often make reference to the transentorhinal cortex as it is -- in the Braak and Braak staging system -- the region where the earliest Alzheimer pathology appears. I have found it difficult to find a clear illustration of the anatomic location of the transentorhinal cortex in texts or on the internet. However, I came across a nice cartoon of the divisions of the parahippocampal gyrus, including the transentorhinal cortex, in an online presentation by Prof. Jillian Kril of the Pathology Department at the University of Sydney, NSW. Prof. Kril kindly emailed me a copy of the illustration, which is depicted above with the addition of a label for the presubiculum.  Feel free to use this cartoon for teaching purposes with the following credit: Adapted from Harding AJ, Halliday GM, Kril JJ. Variation in hippocampal neuron number with age and brain volume. Cerebral Cortex (December, 1998) 8:710-718.

Neuropathology Blog Initiates Job Listing Feature

I am today initiating an open position list on Neuropathology Blog. In the column to the right, I will be adding neuropathology positions as I become aware of them. I have inaugurated the process by listing three open positions, along with contact information. First, Rush University Medical Center is looking for a neuropathologist to replace the illustrious Dr. Liz Cochran, who has moved to the Medical College of Wisconsin. Secondly, the esteemed Dr. Mark Cohen is looking for a neuropathology colleague at Case Western Reserve University. Finally, Genentech in South San Francisco, CA is looking for a neuropathologist. If you hear of other positions that are available, please write in so that I can add to the list. Good luck to the job seekers. And thanks to Dr. Peter Cummings for suggesting this feature!

Epidermal nerve fiber density assessment: probably not worth doing in-house

About a month ago, I addressed the issue of skin biopsies for patients with peripheral neuropathy to assess for nerve fiber density. Since that post, I have heard that this test is not something to be taken lightly. Dr. Tom Smith (pictured) of the University of Massachusetts had this to say about the test: "Basically, to assess fiber density correctly in these skin biopsies, you need a considerable investment in technology (e.g. a confocal microscope, morphometric software program, etc) and technician training -- do you really have time to sit and count fibers?" Dr. Smith went on to say that in his opinion, there is a rather high initial investment for a relatively small volume of cases. Since a few university labs and Therapath already offer this service, its probably wise for most institutions of small or medium size to outsource this particular test. Finally, might these skin biopsies ultimately turn out to be a fad? Do these biopsies really provide useful information beyond what one could gain from clinical and electrophysiologic exam? Given these concerns, I'll likely recommend Therapath to any clinician looking for an epidermal nerve fiber density assessment.

Announcing the Forensic Neuropathology Initiative 2010

Today I feature a guest post from Dr. Peter Cummings (pictured), an emerging power player in the field of forensic neuropathology. Dr. Cummings appeared on this blog in July in connection to a People Magazine article about his investigation of a 1980 murder case. Today Dr. Cummings reappears as he attempts to harness the power of Web Pathology 2.0 to create a network among those who practice the tiny-but-important sub-sub-specialty of forensic neuropathology. Take it, Pete:

"The field of forensic neuropathology has expanded exponentially over the past few years and has seen the publication several new text books and the development of a one-year fellowship position in some medical examiner offices. With this growth the practicing neuropathologist who handles forensic brains needs to keep up with current research. In light of this, I proposed to Dr. David Louis (the current president of the American Association of Neuropathologists) that the upcoming AANP meeting have a dedicated forensic neuropathology session. Dr. Louis agreed and charged me with the task of drumming up interested individuals. Even though the area of forensic neuropathology has seen tremendous growth, it seems as though those of us practicing the 'dark art' are out of touch with each other. I have managed to get in touch with a few folks and have hopes of finding more of us forensic NPer's. My goal is to get people interested in submitting forensic-related abstracts for the June 2010 AANP meeting in Philadelphia. The submission deadline is February 5, 2010, so there is plenty of time. According to the powers-that-be at AANP, right now I have enough people for a dedicated poster session. If more people are interested, we could get a platform session. A formal decision will not be made regarding a poster or platform session until all of the abstracts are submitted. So, if you are interested, get in touch with me (at pathologypete@hotmail.com) so I can get a head count (no pun intended, but appreciated if you thought it was punny). Also, if you are practicing forensic neuropathology to any degree, still get in touch with me even if you don't want to prepare an abstract. I would like to hear from you. OK, lets get those abstracts cooking, there is power in numbers!!"

Should football be illegal?

Two neuropathologists are prominently spotlighted in an article by Malcolm Gladwell in the October 19 issue of The New Yorker. The article explores a provocative question raised by autopsy results on football players: namely, should football be illegal? Featured are Dr. Ann McKee (pictured), neuropathologist at the Veterans Hospital in Bedford, Massachusetts and Dr. Bennet Omalu, forensic neuropathologist and San Joaquin Valley (CA) chief medical examiner. Drs. McKee and Omalu have done some interesting autopsy work which suggests that the tau-positive chronic traumatic encephalopathy suffered by football players is much more common, even among high school players, than previously realized. As an example, McKee provides photomicrographs from a case of an 18-year-old high school football player and says: "He's got all this tau. This is frontal and this is insular.... This is completely inappropriate. You don't see tau like this in an 18-year-old. You don't see tau like this in a fifty year old."

You might counter that this is simply the result of a few bad-luck hits on the field, but research involving the University of North Carolina football team suggests otherwise. Players at UNC wear impact sensors in their helmets throughout the season. Results from these investigations suggests that even routine hits during practice can add up to cause concussions and, theoretically, set the stage for chronic traumatic encephalopathy. (On the first day of training camp one UNC lineman was recorded as having been hit in the head thirty-one times!)

Back in 1905, Gladwell reports, the question of whether football should be played in our nation's schools was raised to the level of the White House, when President Theodore Roosevelt called an emergency summit to discuss the issue. At the time, a professor at the University of Chicago called football a "boy-killing, man-mutilating, money-making, education-prostituting, gladiatorial sport". And in December of 1905, presidents of twelve prominent colleges met in New York and came within one vote of abolishing the sport at their institutions.

What does this mean for football in America? Nothing. Fans are willing to spend a lot of money to see men slam into each other's heads on the field. But, as a parent, you can do something. You can forbid your son from playing football.

Dr. C. Everett Koop turns 93 today

Happy birthday, Dr. Koop! C. Everett Koop, MD turns 93 years old today. Surgeon General of the United States under President Reagan from 1982 t0 1989, Koop (pictured circa 1974) was probably the most influential figure to have ever filled that office. I met with Dr. Koop during his open office hours on April 19, 1995 at Dartmouth Medical School's Koop Institute. I found Dr. Koop to be a really nice guy -- definitely more gentle than his stern appearance initially suggests. Since I was applying to medical school at that time, Koop and I talked a bit about our respective experiences with the admissions process. Koop told me that he had been rejected from Columbia Medical School, an institution that he had looked forward to attending since his childhood in Brooklyn. He described the rejection as a "major blow". But Koop got the last laugh. Decades later, he told me, at an event honoring his accomplishments, Koop was introduced to the dean of the Columbia Medical School and said, "See, if you had only accepted me, I would have made something of myself."

Is anyone assessing epidermal nerve fiber density in skin biopsies?

I recently received an advertising pamphlet from Therapath, a New York company offering to evaluate skin punch biopsy specimens in patients with suspected small fiber neuropathy. The pamphlet trumpets Therapath's proficiency, including "board certified neuropathologists meticulously reviewing cases". Although I have heard of this test, no clients of my practice have yet requested such a test. According to Therapath, the result is "reported as the average number of nerve fibers that cross the basement membrane at the dermal epidermal border, over a length of 1 mm. Making the correct diagnosis explains the symptoms, guides the evaluation for the underlying cause, and helps decide treatment". See the photomicrograph from Therapath's website of normal skin with small fibers (arrow) traversing the basement membrane (arrowhead) and coursing through the epidermis. Accompanying the pamphlet is a letter from "neuropathologist and laboratory director" William Harrington, MD in which he states that the American Academy of Neurology has added a practice guideline to include skin biopsy in the scope of practice when evaluating for polyneuropathies. He goes on to say that "skin biopsy for the determination of epidermal nerve fiber density is the most sensitive test for small fiber neuropathy". Therapath provides the clinician with a kit for biopsy collection and shipping to their facility at no extra charge. Eight to 12 days later, Therapath provides a full-color, quantitative laboratory report with images. If anyone has had experience with evaluating such biopsies, please comment on this post and provide us with your insights regarding the utility and technical requirements of this test. I'm not sure whether I would have to use a service such as Therapath's, or perform the service in-house. Thanks!