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!

Pathology 2.0: The Time Has Come

You may not realize it, but by reading this blog post you are participating in "Pathology 2.0". What is Pathology 2.0? For that, read an edited transcript of remarks made by Dr. Keith J. Kaplan (pictured) at the College of American Pathologists Foundation June 12-14 "Futurescape of Pathology" conference in Rosemont, Illinois. Speaking of things 2.0, today is the opening day of the Health 2.0 conference in San Francisco. Subtitled "User-Generated Healthcare", the conference focuses on the ways in which Web 2.0 technology is being applied to healthcare today. Conference organizers define Health 2.0 on their website as follows: "Our definition is currently focusing on user-generated aspects of Web2.0 within health care but not directly interacting with the mainstream health care system. That means, a) search, b) communities, c) tools for individual and group consumer use. But clearly there are blurring boundaries between all these, and the question of connecting Health 2.0 user-generated content to the wider health care system—which hasn’t exactly adopted Web 1.0 with a flourish—is coming into closer focus as more clinicians and organizations start to use these technologies to communicate with consumers."

Online Biomedical Lectures for the Blue-Collar Neuropathologist

If you consider yourself a blue-collar neuropathologist, a nice resource has appeared on the web for you. Henry Stewart Talks, based in London, is providing free access to a wide variety of on-line biomedical lectures in the form of The Biomedical and Life Sciences Collection. One series of these talks focuses on neurodegenerative disease, which would be of particular interest to the practicing neuropathologist engaged in brain autopsy work. The talks are geared toward an audience looking for a more in-depth presentation than would be appropriate for a general pathologist or neurologist, but not so loaded with basic science as to be of no practical use. For now, Henry Stewart Talks is offering institutions, such as mine, free access to the talks on a trial basis. Alternatively, you can request a free trial as an individual by visiting the site. I recently watched a very nice lecture on the clinicopathologic aspects of frontotemporal dementia by Dr. John Hodges of Cambridge University (53 minutes) and a helpful talk by Dr. Peirluigi Gambetti of Case Western Reserve University on prion diseases (53 minutes). Hats off to Henry Stewart Talks for providing this resource!