First 2010 CAP Neuropathology Education CD-ROM is released.

I recently received in the mail the College of American Pathologists' excellent Neuropathology Program CD-ROM, the first of two installments for the year. I've written about this product in the past; and I recommend it to trainees, general pathologists, and neuropathologists. Each installment consists of eight cases, four of which are linked by a particular theme. The current edition's theme (the CAP uses the term "symposium") is Masses in the Cauda Equina Region. The symposium introduction is written by Drs. Bette K. DeMasters and Hillary L. Somerset of the University of Colorado Health Sciences Center.(Dr. Somerset is pictured.) Included in the symposium introduction is a handy algorithmic representation for the differential diagnosis of cauda equina lesions. Good stuff!

Best Post of October '09: Should Football Be Illegal?

The next in our series of "Best Posts of the Month" is from October 21, 2009:

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.

2010 AANP Annual Meeting Program Announced

The preliminary program for the 2010 annual meeting of the American Association of Neuropathologists has been released. The meeting, to be held June 10-13 in Philadelphia, will feature a special day-long course entitled Hereditary Tumor Syndromes of the Nervous System: Clinical, Pathological, and Biological Updates. Of the topics to be covered in that course, I most eagerly anticipate the presentation by Dr. Alexander Judkins (pictured) entitled  "INI1: Syndromes and Diagnostic Neuropathological Applications". Since the World Health Organization has only in recent years recognized Rhabdoid Tumor Predisposition Syndrome and its association with the INI1 gene, it will be interesting to hear Judkins -- a recognized leader in this area of research -- talk about the evolution of this syndrome as a distinct nosologic entity. Also on the agenda is a Presidential Symposium entitled "Big Science" Neuro-Oncology: How can Neuropathologists Play Roles in Large-Scale Clinical, Translational and Basic Research? The Transition to Personalized Medicine. Its heartening to see the AANP addressing one of the key areas of transformation in pathology in the coming decades: personalized medicine. And, of course, the always-popular Diagnostic Slide Session of unknowns makes its return. So far, it looks as though we're in for a stimulating meeting!

Perry Rocks: Arie releases neuropathology music CD

When I first heard about this, I said to myself: "No way. This has got to be a spoof." But its true! Neuropathologist Arie Perry (pictured) has released a music CD called Neuropathology Songs, which can be purchased at his website, which includes free samples of several songs. The song list includes such soon-to-be classics as Acute Meningitis, Craniopharyngioma, and Leukodystophies. Perhaps my favorite tune is Schwannoma, which features the following chorus:

Schwannomas are no mystery; you look for Antoni A and Antoni B

And Verocay bodies will clinch the diagnosis for me
Hyalinized vessels is another clue,
And good encapsulation is a key feature too
To make the diagnosis when the surgeon’s leaning over you
To make the diagnosis when the surgeon’s leaning over you

In the current issue of the journal Brain Pathology, Perry has this to say about the new CD: "For many years, I’ve employed these songs for teaching medical students about common neurological disorders. As word of this practice spread however, I’ve been increasingly asked to include such songs in invited lectures and even to the lay public in a local 'Mini Medical School Course', all associated with extremely positive feedback. I’ve even received requests to share these songs with educators and students from other medical centers, in part prompting me to record these songs professionally."

I blogged about Perry back in September regarding his impending move from Wash U in St. Louis, where he has spent the last 12 years, to the University of California at San Francisco. Perry starts as UCSF's neuropathology chief this summer. I assume they'll be giving him time off to collect his award at the Grammys.

Best Post of September '09 - A Case of Cerebral Baylisascariasis

The next in our series of "Best Posts of the Month" is from September 28, 2009:

A loyal reader sent in this wonderful photomicrograph from a recent case of cerebral Baylisascariasis (click on the picture to see it up close). A cause of eosinophilic meningoencephalitis, infection with Baylisascaris procyonis is typically characterized by necrosis and eosinophilic inflammation. Larvae are often encapsulated within fibrous tissue (reference 1). Although not particularly neurotropic, the larvae may reach the central nervous system and cause major tissue damage.

Baylisascaris procyonis is an intestinal roundworm endemic to the US raccoon population. Humans are infected by ingestion of worm eggs in raccoon feces. The median age for human infection is just over one year old, consistent with the propensity of young children to explore their environment orally (surprising that this behavior has not been naturally selected out of humans over the millenia!). I came across only one report of clinical recovery after infection (reference 2). Otherwise, cerebral Baylisascariasis results in either severe neurologic damage or death. That being said, subclinical infection has been suggested by a study in Chicago, which found 30 (8%) of 389 children 1–4 years of age were seropositive for B. procyonis, although none had experienced symptoms (reference 3).

The most common cause of eosinophilic meningitis in the United States is the presence of a ventriculoperitoneal shunt; but worldwide it is infection by Angiostrongylus cantonensis. In addition to Bayliscaris procyonis, other infectious causes of eosinophilic meningitis include Toxocara spp., Gnathostoma spinigerum, and neurocysticercosis (source: reference 2).

References:
1. Love S, et al, eds. Greenfield's Neuropathology, 8th edition. p. 1479.
2. Pai et al. Full recovery from Baylisascaris procyonis eosinophilic meningitis. Emerging Infectious Disease 13(6) p 928-30. June 2007
3. Brinkman WB, Kazacos KR, Gavin PJ, Binns HJ, Robichaud JD, O'Gorman M, et al. Seroprevalence of Baylisascaris procyonis (raccoon roundworm) in Chicago area children. In: Program and abstracts of the 2003 Annual Meeting of the Pediatric Academic Societies, Seattle, Washington; 2003 May 3–6. Abstract 1872. [cited 2007 Mar 29]. Available from http://www.abstracts2view.com/pasall/authorindex.php

The College of American Pathologists unveils updated patient website today

The College of American Pathologists (CAP) unveiled today new resources and features on MyBiopsy.org to help patients better understand their disease. Neuropathological diagnoses discussed on the site include: anaplastic astrocytoma, glioblastoma, pilocytic astrocytoma, and oligodendroglioma. If one of your patients has questions about one of these pathological diagnoses, you can refer them to this website, which is part of a larger Transforming Pathology initiative by the CAP.

An Abundance of Job Opportunities Exist in Neuropathology

Since starting the job listings feature of this blog (see column on right) , the number of entries to the list has exploded! Right now, I count TWENTY JOB OPENINGS, an impressive number for such a tiny subspecialty. A special thanks to Sherry Miller (wife of U Missouri neuropathologist Doug Miller, MD, PhD) for providing the majority of listings.

A Message from the President of the CAP Foundation regarding the Haiti Relief Effort

Dr. Jennifer Hunt ask me to publish the following open letter to pathologist colleagues regarding the College of American Pathologists Foundation Haiti Relief Effort. I urge readers to participate in this important initiative:

Dear Colleagues,

All of us are reading and watching the devastating news and seeing the wrenching pictures from Haiti in the aftermath of the terrible earthquake earlier this week. As a physician, I read the news and looked at the images with grief, with shock, and with a strong desire to reach out to the struggling people, injured and terrified. But, as a pathologist, I also realize that there is little I would be qualified to do in Haiti today, besides comfort those who are alive and have suffered loss and provide rudimentary first aid.

The CAP Foundation does have a way that you can help Haiti in this hour of need.

Our Humanitarian Grant program has sponsored several pathologists who have done wonderful laboratory outreach work in Haiti in the past. We are working with these pathologist-humanitarians to identify the areas where the CAP Foundation can help Haiti with short-term immediate support and the longer term struggles ahead. I urge you to join me in donating to the CAP Foundation, where pathologists will be part of providing laboratory services, humanitarian efforts, and medical aid during Haiti's moment of crisis and beyond.

I know that each and every one of you would go to Haiti, comfort the survivors, give medical care, and help laboratories cope with the medical situation. And, if you are a pathologist who is planning to join an established relief mission to Haiti, please contact the CAP Foundation and tell us your story. But, we are also acutely aware that there will be incredible needs, short and long term, that will require funding, supplies, and equipment, for health care and laboratory services. By donating to the CAP Foundation Haiti Relief Effort, pathologists can contribute what is needed most, when it is needed most, to provide these desperately needed services.

To help the CAP foundation provide support to the impoverished nation of Haiti, use this link and donate today.

Sincerely,

Jennifer Hunt, MD, MEd, FCAP
Interim President
CAP Foundation

Can that brain you left in storage since 1996 still be assessed immunohistochemically?

The current issue of the Journal of Neuropathology and Experimental Neurology features an article about the effect of prolonged fixation time on the immunoreactivity of brain tissue being assessed for neurodegenerative disease. Dr. Irina Alafuzoff from Uppsula University in Sweden is the senior author on this study which looked at 20 post-mortem brains to determine whether prolonged fixation time has a deleterious effect on typical immunohistochemical stains used for neurodegenerative disease diagnosis.  A panel of commercial antibodies to amyloid-[beta], ubiquitin, p62/sequestosome, tau, and [alpha]-synuclein was assessed using tissue microarray with several antigen retrieval methods. Short-term fixation was defined as a time period of up to 70 days before paraffin embedment. Long-term fixation was defined as 71 days to 14 years in formalin. The bottom line is that brains that are stored in 10% formalin for periods far exceeding a decade do indeed lose some immunoreactivity. But with proper antigen retrieval techniques (which are outlined in detail in the article) immunoreactivity can be maintained in these long-fixed tissues. Keep this article in mind to avoid false-negative results in brain autopsy specimens that have fixed for prolonged periods of time.

POSTSCRIPT: In an email to me regarding this article, Dr. Alafuzoff wanted to add this: "[A]s new antibodies are produced almost monthly and some of them work better than others on archived material (ex. synuclein), maybe we all working in this field should try out new antibodies at regular intervals."

Eight states still do not mandate reporting of CJD cases to public health authorities

Neuropathologists are obligated to keep generally up to date on Creutzfeldt-Jakob disease (CJD) research as they are called upon to perform autopsies on patients whose dementia may have been caused by a prion disease. The most overlooked players in the CJD research arena are patient advocates. Many patient advocates are fiercely motivated, often having been inspired to act by the CJD-related death of a loved one. One such advocate is Theresa Matthews (pictured on a 2006 lobbying visit to Washington with her teenage daughter Mary and Illinois Senator Durbin and then Senator Obama). Patient advocates often raise worthy questions about issues surrounding CJD research. One such question is whether adequate epidemiological data on CJD is being collected in every state. Ms. Matthews informs me that currently there are eight states that do not require physicians to report CJD cases. She testified about this issue at a June 2009 meeting of the FDA's Transmissible Spongiform Encephalopathies Advisory Committee. Here's an excerpt from her testimony:

"Accurate disease reporting is a basic and fundamental step of epidemiology... This cannot possibly be done if you are not even counting the cases. The current state of CJD epidemiology in this country is a joke and it is no laughing matter."

Strong words. But Ms. Matthews makes a good point. Mandated reporting is the first step in reliable epidemiological research. Every state should mandate reporting of CJD cases, whether discovered pre-mortem or only at autopsy. Here are the states that fail to mandate reporting: Washington, Nevada, New Mexico, Iowa, Indiana, Alabama, Kentucky, and West Virginia. If you are a resident of one of these states, contact your governor or state legislator to get this situation corrected!

Doctor Creates Centralized Pathology Web Resource

Bertalan Mesko, MD (pictured) has created a nice collection of pathology web resources called PeRSSonalized Pathology, which features the best medical journals, news sites, blogs and tweeters dedicated to pathology. Needless to say, Neuropathology Blog is included! "If you have any suggestions," says Dr. Mesko, "feel free to send those to me so I can improve the resource." Dr. Mesko can be emailed at info@webcina.com.