Anatomic Pathology
Surgical Pathology / Autopsy Pathology / Conferences / Thin Needle Biopsy / Cytology / Neuropathology / Ophthalmologic Pathology / Dermatopathology / Forensic Pathology / Immunopathology / Medical School Teaching / Research
Clinical Pathology
Clinical Immunology / Clinical Microbiology / Hematology/Microscopy / Hematology/Microscopy I / Hematology/Microscopy II / Clinical Chemistry / Blood Bank
Anatomic Pathology
Staff: Stephen P. Naber, MD, PhD; Ina Bhan, MD; Maria L. Garcia-Moliner; Nora Laver, MD; Rolf Pfannl, MD; Robert N. Salomon, MD; Miguel J. Stadecker, MD, PhD; Arthur S. Tischler, MD; Angelo A. Ucci, MD, PhD; Barbara J. Weinstein, MD
Surgical Pathology: After an introductory period, each resident is assigned to a two- to six-week rotation in surgical pathology with intervening periods of autopsy pathology. During this rotation, the resident has responsibilities for the examination and description of the surgical specimens and the selection of appropriate tissue for microscopic examination. In addition the resident participates in operating room consultation, including the preparation and interpretation of frozen sections.
The resident will choose the appropriate histological sections for microscopic examination and subsequently, prepare a preliminary anatomic diagnosis in each case. The entire case, including all slides and special studies, are then reviewed with the staff pathologist in a combined teaching and diagnostic procedure; All diagnostic problems and/or cases of unusual interested are presented and reviewed by all of the staff. In addition, during this assignment, the resident reviews, with the staff, all of the referral (consult) cases submitted to the Department.
All anatomic pathology activities are carried out in a facility which was especially designed and constructed to minimize risks of infection and exposure to harmful vapors.
Autopsy Pathology: Autopsies are performed by residents in all years of the combined program as well as by those in the straight anatomic pathology program. Most autopsies are performed during the first two years, but residents maintain their skills by performed occasional autopsies during the later years of the program. Especially close supervision and assistance are provided during the first several autopsies that a resident performs, but assistance and consultation are always available.
Before beginning an autopsy, the resident carefully reviews the clinical record and then consults with appropriate clinicians as well as the assigned staff pathologist. On the day following the dissection, the organs are reviewed with the staff pathologist. A provisional anatomic diagnosis is prepared and tissue blocks are selected for microscopic examination. The resident receives the microscopic sections with a few days after submission to the Histology Laboratory, studies them, writes a preliminary microscopic description and orders special stains and studies as indicated. The case is then reviewed with the staff pathologist, and a final anatomic diagnosis is written.
Each autopsy is the subject of a full hour presentation at an autopsy conference at which the clinical, radiographic, laboratory, gross and microscopic findings are correlated. Fixed samples of the gross organs are examined and all pertinent microscopic sections are examined by all participants using a multi-headed microscope. The conference is attended by the appropriate staff pathologist(s) and all the residents.
While on autopsy and surgical service, the residents participate in a variety of morphologic techniques including routine histology and special histochemistry, immunohistochemistry, immunofluorescence, morphometrics and transmission electron microscopy. The trainees are expected to become familiar with the technical procedures as well as limitations and interpretation. These rotations include both theoretical and practical experience based on current diagnostic care material available in the department.
Conferences: Many conferences and didactic sessions provide an opportunity for the study and discussion of all interesting surgical pathology and gross and microscopic autopsy pathology. These conferences and didactic sessions include:
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Surgical Pathology Conference: Once per week
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Anatomic Pathology Didactic Conferences: Two per week
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CP Case Conference: Once per week
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Autopsy Conference: Once per week
Thin Needle Biopsy: The thin needle biopsy service is a rotation in anatomic pathology in which staff and resident consult with clinicians and begin the diagnostic process by assisting with biopsy aspiration, preparation of smears, interpretation and reporting results. Each resident is expected to become competent in aspiration biopsy slide preparation, staining, and in interpretation during the course of this rotation.
Cytology: Included in the program is an integrated experience in the cytology laboratory at the Tufts Medical Center. The resident is assigned to 2 two-month rotations in the third and fourth years and, in addition, bi-monthly seminars correlating cytology and biopsy material are presented for the entire group. There is also access to an extensive cytology teaching collection.
Neuropathology: Dr. Rolf Pfannl is responsible for the Brain, Muscle, and Nerve Biopsy Service and the resident training in neuropathology. There is a four-month rotation in neuropathology, as well as weekly brain-cutting and weekly didactic conferences covering all aspects of neuropathology.
Ophthalmologic Pathology: The Ophthalmologic Pathology Laboratory is under the direction of Nora Laver, MD who has had special training in ocular pathology. Ophthalmology and Pathology residents are trained in gross and histologic analysis of all intraocular, orbital and peri-ocular specimens. Didactic conferences are held once a month. Teaching slide collections are available for review.
Dermatopathology: Experience in dermatopathology will be provided by dermatologist Miguel J. Stadecker, MD through daily sign-out sessions of skin specimens from the Tufts Medical Center and community dermatologists.
Forensic Pathology: A series of monthly lectures in forensic pathology is given by selected speakers. In addition, residents participate in a one-month rotation at the Suffolk County Medical Examiner’s Office during their third (AP only residents) or fourth (AP/CP residents) year of training.
Immunopathology: Formal rotations in immunopathology are available during elective time. The goals of this rotation are: 1) to introduce residents to tissue immunological techniques; and 2) to review applications of these methodologies in the diagnosis and classification of immunologically mediated diseases involving the skin, kidneys and other sites and for the immunophenotypic analyses of malignant lymphomas and other tumors. Each resident will have the opportunity to perform immunofluorescence and immunoperoxidase analyses, to review indications for these tests and to review their pitfalls. The rotation in immunopathology will also cover the pathology of transplantation (heart, liver, kidney and bone marrow) and will be coordinated with HLA typing and flow cytometry presented during the immunology rotation. The laboratory rotations will be supplemented by basic readings covering both basic and applied immunopathology.
Molecular Biology: The formal rotation period in the Molecular Biology Laboratory will be for a period of 1 month. The goals of this rotation are: 1) to introduce residents to molecular biological technology; and 2) to review applications of these technologies to selected problems in diagnostic pathology. Residents will have the opportunity to perform filter (Southern, Northern, dot/slot blot, hybridizations, PCR-based analyses) as well as isotopic and non-isotopic in situ hybridization techniques for selected infectious disease processes (cytomegalovirus, herpes and human papilloma virus subtyping). The laboratory rotation will be supplemented by readings covering both basic and applied molecular biology.
Cytogenetics: Residents have a two-week rotation in cytogenetics under the direction of Dr. Janet Cowan. The cytogenetics laboratory examines amniotic fluid, peripheral blood, bone marrow, and solid tumor specimens using both routine karyotype analysis and fluorescent in situ hybridization. Additional training may be scheduled based on the interest of the resident.
Medical School Teaching: Residents participate in teaching of the laboratory sections (15 to 20 students) in the general pathology course in the fall of the second year at Tufts University School of Medicine and in laboratory sections in the systemic pathology course (winter and spring of the second year). Stipends are provided for these teaching activities. Residents also participate in the teaching of the laboratories in the pathology course at Tufts University School of Dental Medicine.
Research: In the course of training, each resident is encouraged to participate in a research project under the supervision of one of the department’s staff members. The resident may choose from a variety of projects recommended by the staff or may elect to participate in a project of their own interest (see below; Elective).
Fourth Year Rotation in Anatomic Pathology
Chief Resident: During a six- or 12-month period of the fourth or fifth year, the resident may act as chief resident. The duties of this position include supervisory and administrative roles in day-to-day departmental operations. The chief resident acts as a member of the junior staff participating in the signout rotations in surgical pathology. In addition, the Chief Resident is responsible for the selection and presentation of material at a monthly interdepartmental conference, the Radiology/Pathology Conference, and at monthly Surgical Oncology Service with surgical residents and staff.
Elective: For a six- or 12-month period, there will be an elective for research or special pathology tailored for each resident, dependent upon their career goals. One important element of this program consists of research opportunities under the guidance of an established investigator on the Pathology staff. This includes an opportunity for development of research experience in such fields as immunopathology, immunochemistry, histochemistry and immunocytochemistry, genetics, immunohematology, viral oncology and ultrastructural analysis. Some of the current research projects, many of which are supported by U.S. Public Health Service Grants, are summarized in Supplement II. Residents may also participate in basic research projects in Pathology or in other departments at Tufts Medical Center or Tufts University School of Medicine.
Alternatively, the fourth or fifth year elective may take the form of an extended in-depth experience in one or more of the subspecialties of anatomic pathology which are represented in the Department, including neuropathology, endocrine pathology, renal pathology, hematopathology, gastrointestinal pathology, gynecologic pathology, orthopedic pathology, and dermatopathology.
Teaching: The chief residents share responsibility for teaching a laboratory section in general pathology. They also are involved in teaching third and fourth year medical students who may rotate through the Department in one-month pathology electives at the hospital.
Resident Evaluation: Performance of residents will be evaluated in two ways. Bi-annual evaluations are completed by all staff on each resident and a composite evaluation is constructed by the residency program director, which is discussed with each resident. Residents are also asked to evaluate the staff performance on a bi-annual basis. The resident will also participate in the National Resident In-Service Examination annually.
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Clinical Pathology
Staff: Igor B. Rozenvald, MD; Arthur R. Rabson, MD, Director of Laboratories;
Integrated Program: Residents receiving training in all branches of clinical pathology including clinical immunology, medical microscopy, hematology, clinical microbiology, clinical chemistry and blood banking. In addition, residents will develop consultative and managerial skills across the subspecialty borders in an integrated training program. Residents training in particular clinical pathology subspecialty will spend most of their time in that area, although they will receive training in elements from all the clinical pathology laboratories.
In this integrated program, residents will be trained to serve as consultants to physicians regarding cost-effective test strategy and interpretation of results. In addition, they will be trained to use the techniques of medical informatics to acquire, manage and translate data into clinically useful information, to communicate that information in support of patient care and to play an influential role in medical staff and Healthcare delivery activities that reach beyond the confines of the laboratory.
The residents, under the guidance of all CP Directors, will seek intralaboratory and clinical consultations. As their knowledge base expands, they will be provided with the opportunity to assume increasing responsibility for clinical and consultative service. Residents will become familiar with the Laboratory Information System. One of their service roles will include the retrieval and interpretation of both clinical and management data designed to assess quality and promote cost-effective utilization of laboratory resources.
Faculty: Arthur Rabson, MD, Medical Director and Staff
Objective: The aim of this program is to give the resident a working knowledge of immunological principles and experience in performing and interpreting the wide variety of tests carried out in a modern, active, clinical immunology laboratory. In particular, the resident will be instructed in the clinical application and interpretation of the various tests, and how they assist in the diagnosis of autoimmune, allergic, and immunodeficiency disorders. With the establishment of tissue typing, the resident will develop an understanding of the support services provided by an immunology laboratory to the various transplant programs in the hospital. The techniques employed will introduce the resident to methods for assessing cell mediated immune function in the normal state or in-patients with various disorders.
Program: The resident will learn the various procedures by observing and performing the appropriate techniques under close supervision. The resident will meet with the director for an hour each day to discuss the performance and interpretation of various tests. In addition, he/she will be encouraged to interact with the clinical staff and to attend appropriate rounds in Allergy, Infectious Disease, Rheumatology, and other programs.
Week 1 – Introduction to Clinical Immunology: During this week, the resident will be introduced to various techniques routinely employed in an immunology laboratory. These include assays for classical and alternative complement pathway activity, various complement components including C2, C3 and C4, cryoglobulins, circulating immune complexes and Coomb’s tests. The diagnosis of auto-immune disease includes experience with immunofluorescent and ELISA tests for antibodies to nuclear antigens, smooth muscle, mitochondrial and parietal cell antigens, DNA, antibodies to various extractable nuclear antigens including RO, La, SM, RNP, SCL-79, the measurement of cardiolipin antibodies and anti-thyroid and anti-microsomal antigens. Residents will be encouraged to perform, read, and interpret these tests and relate the results to the clinical evaluation of the patient.
Week 2 – Immunoelectrophoresis: Experience will be obtained in setting up and interpreting serum and urinary protein electrophoretic patterns and immunofixation technology for the diagnosis of monoclonal gammopathy. The classification and diagnosis of monoclonal gammopathy and the application of gene rearrangements to diagnostic immunopathology will be discussed. During this week, residents will gain experience in the use of a modern densitometer and a nephelometry system for the measurement of immunoglobulins. ELISA technology is employed to measure IgE antibodies, and immunoprecipitation plates are used for the measurement of IgD antibodies, and IgG subsets. In addition, residents will be introduced to practical and theoretical aspects of diagnostic techniques employed in assessing immunodeficiency. This will include lymphocyte subset enumeration, lymphocyte proliferation, and lymphokine assays. Residents will be introduced to various aspects of lymphocyte culture, and biology, and general assessment of cell mediated immunity. In addition, various aspects of neutrophil and macrophage biology will be discussed.
Week 3 – Tissue Typing and Immunogenetics: During this week, instruction will be given on the techniques involved in supporting a renal or bone marrow transplantation service. The resident will therefore gain experience in the performance and interpretation of cross-matching techniques and their relationship to results of HLA typing. The resident will gain experience in the use of PCR for detecting both Class I and Class II MHC proteins. Discussions on the preparation of sera for tissue typing and the immunological monitoring of transplant patients will take place, as well as the basic principles involved in paternity determination.
Week 4 – Flow Cytometry: The laboratory is equipped with a Becton-Dickinson FACScan and a Coulter Epics XL-MCL. Residents will be trained in their use and the general application of flow cytometry. Training will include the interpretation of cytometric data in cases of leukemia and lymphoma and quantitation and subset analysis on rare leukemia and lymphoma cases are available for resident review. Residents will be shown how flow cytometry aids in DNA analysis of malignant cells and how this data should be interpreted.
General Objectives: Training in hematology/microscopy is divided into two time blocks. The first rotation takes place during either the first or second years and is integrated with rotations in other clinical laboratory areas, as well as in anatomic pathology. The initial rotation aims to give the resident solid grounding in hematologic morphology, clinical laboratory testing in the areas of hematology, coagulation and clinical interpretation. The training program is coordinated and integrated with the activities of the Clinical Hematology/Oncology Service.
The second rotation takes place during the third or forth year. This provides opportunity to further develop skills covered in the initial rotation but also provides elective opportunities for more advanced training in hematologic techniques. During this period, the resident also has opportunities to carry out projects of limited scope related to development of new methodology or management problems.
Opportunities for clinically related research activities are made available during the fifth year. These activities are planned with residents early and would be oriented to clinical sub-specialization or research in hematopathology.
Orientation: There is a formal orientation scheduled at the beginning of each academic year. This experience introduces the resident to the organization, staffing and procedures of the laboratory. This experience also includes didactic presentation introducing the areas of hematologic morphology and hemostasis/thrombosis.
Hematology/Microscopy I, 8 weeks
Staff: Igor B. Rozenvald, MD, Director, Hematology/Microscopy Laboratory; Rouette C. Hunter, M.T. (ASCP), Supervisor, Hematology/Microscopy Laboratory; Clinical Staff, Hematology/Oncology Service
Although training will place major emphasis on morphology and clinical laboratory testing methods, it is planned to encompass those areas which represent major roles the pathologist plays as medical director of a clinical laboratory. These roles (i.e., administrative, technical director, clinical consultation and clinical interpretation, teaching and research) and how the program addresses them is outlined below.
Administrative: To expose the resident to administrative problems and their management, the resident will be exposed to discussion of personnel, fiscal management, workload and work-flow management, equipment purchase and maintenance, test trouble-shooting, critical values, quality assurance and clinical liaison.
Although the resident may not be given primary responsibility and authority in these areas and will participate primarily as an observer, wherever possible, the resident will participate especially in promoting communication.
The resident will carry a call beeper during the daytime hours and will be available to the supervisory staff and technical staff for consultation.
Technical:
Coagulation: The resident will be introduced to coagulation testing by spending scheduled time at the workbench with technologists.
This experience will involve exposure to the BBL fibrometer, Biomerieux MAX, Biomerieux MDA II Diagnostic Stage ST4, BioData Aggregometer, and Protopath.
The following laboratory methods will be covered:
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Prothrombin Time
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Activated partial thromboplastin time
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Thrombin time
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Reptilase time
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Stypven time
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Fibrinogen
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Fibrin/fibrinogen degradation products
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Mixing studies
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Factor assays
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Circulating anticoagulant
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Platelet neutralization procedure
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Euglobin lysis time
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Clot solubility
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Bleeding time
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Clot retraction
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Platelet aggregation
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Platelet adhesiveness
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Ristocetin aggregation
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Factor VIII antigen
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Antithrombin III
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Plasminogen level
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Bleeding time
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Screen for heparin associated antibody
Blood and Bone Marrow Morphology: The medical director and laboratory supervisor will provide supervised study of normal and abnormal blood smears and bone marrow specimens. This will be accomplished by utilizing the teaching microscope in the Clinical Hematology Laboratory.
The resident will attend the weekly Hematopathology Microscopic Conference during which current case materials will be studied (see description #5).
In addition to these more structured teaching experiences, the resident will learn morphology through case material which is generated from the daily load of blood smears in the Clinical Laboratory, from clinical ward rounds, as well as from the Surgical Pathology Service.
Hematology/Microscopy: Throughout the period of training, time will be scheduled for the resident to work with technologists at the workbench. This experience will introduce the resident to practical testing methods, instrumentation, use of standards and calibrators, quality control, machine maintenance and trouble-shooting. The methods to be covered include:
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RBC chamber count
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WBC chamber count
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Phase platelet count
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Platelet estimate on blood smear
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Reticulocyte count
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Manual hemoglobin
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Microhematocrit
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Erythrocyte sedimentation rate
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Eosinophil count
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Sickle cell screen
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Automated particle counting: the SYSMEX SE 9500 Alpha
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Alkaline cellulose acetate electrophoresis for hemoglobin
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Acid citrate electrophoresis for hemoglobin
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Chromatographic column method for hemoglobin A2
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Immunodiffusion method for hemoglobin F
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Hemoglobin H preparation
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Isopropanol precipitation methods for unstable hemoglobin
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G-6-PD screen
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Pyruvate kinase screen
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Heinz body preparation
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Osmotic fragility
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PNH screen
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Leukocyte alkaline phosphatase
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Blood parasite identification
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Clinical microscopy, routine urinalysis, analysis of body fluids
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Urine qualitative porphobilinogen
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Urine hemosiderin
Resident Conferences and Clinical Round Schedule during Hematology/Microscopy Rotation:
Weekly Conferences
Hematology/Oncology Clinical Conference: Thursday, 8:00 a.m.; South 7 Conference Room. NOTE: Hematopathology Morbidity/Mortality, fourth Thursday of month.
Lymphoma/Bone Marrow Transplantation Conference: Monday, 1:00 p.m., South 7 Conference Room.
Hematopathology Microscopic Conference: Wednesday, 9:00 a.m., Ziskind 5 Teaching Microscope.
Hematology/Oncology Microscopic Conference: Wednesday, 8:00 a.m., Ziskind 5 Teaching Microscope.
Daily Conferences
Clinical Laboratory Rounds: Hematology/Microscopy Laboratory, 10-12 noon. Includes bone marrow sign-out, review of smears, hemoglobins and coagulation problems.
Hematopathology Microscopic Conference: The Hematopathology Microscopic Conference is conducted weekly at the multi-headed microscope adjacent to the Resident’s library. All clinical laboratory trainees are required to attend weekly during the entire period of clinical laboratory training.
The purpose of this conference is to provide all trainees with continuous and reinforced exposure to hematologic and lymphoreticular morphology during the entire two years of training in the Clinical Laboratory. The resident rotating in Hematology and the Medical Director are responsible for providing material for study.
The content consists of active case material and of material from the teaching files. The latter, especially, allows for a systematic and comprehensive presentation of normal and abnormal hematologic and lymphoreticular morphology. Emphasis is placed on blood and bone marrow morphology.
Teaching: The resident is responsible for formal case presentations at the Hematology/Oncology/Pathology Conferences. The resident will be afforded opportunity to teach technologists by presenting an in-service program as part of the laboratory’s continuing education program.
Research: The time allotted allows undertaking only short projects. For example, the resident may participate in the development, evaluation and implementation of new laboratory procedures, the critical evaluation of existing procedures, and the development of reference ranges.
Hematology/Microscopy II, 2 months
Program: During the second rotation, the resident will continue to study morphologic material, and participate in the continuing education program and share in responsibility for carrying both the Hematology call beeper and the 24-hour Physician-on-call beeper. The latter is used to provide physician back up 24 hours per day, seven days per week. Problems or questions originating both in the laboratory and from patient units are handled via this call system.
Time constraints limit the scope of research possible during this rotation. A trainee truly interested in research must commit at least one full year to this endeavor if a meaningful experience is to be achieved. Nonetheless, the resident will be required to carry on a project under the supervision of the medical director. When possible, this will relate to ongoing research activities of the medical director. If such an experience is not elected, research and development of laboratory methods will be used as a basis for this experience.
In addition, there will be elective opportunities in the following areas to expose the resident to more advanced techniques. Each experience will be for a period of two weeks or more if desired.
Hematologic cytochemistry (Hematology/Microscopy Laboratory, Dr. Igor B. Rozenvald): The resident will learn cytochemical methods and their interpretation. These will include peroxidase, Sudan Black B, P.A.S., non-specific esterase with and without fluoride inhibition, chloroacetate esterase and acid phosphatase with and without tartrate inhibition.
Cell surface markers (Immunology Laboratory, Dr. Arthur Rabson): The resident will learn methods to detect cell surface markers on suspensions of cells separated on a Ficoll-Hypaque gradient.
Immunocytochemical methods (Immunoperoxidase Laboratory):
Hematologic ultrastructure (Electron Microscopy Laboratory, Dr. Angelo Ucci) The resident will learn specimen collection technique, specimen preparation and processing technique and basic interpretation of hematologic ultrastructure.
Anticoagulation and thrombolytic therapy (Hematology/Microscopy Laboratory, Dr. Igor B. Rozenvald): This experience will include a review of basic coagulation theory and will specifically emphasize the use of heparin and its laboratory monitoring, the use of Warfarin and its laboratory monitoring, and the use of thrombolytic agents and their laboratory monitoring.
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First Clinical Pathology Year, 2 months
Staff: Arthur Rabson, MD, Cody MeiSsner, MD, David Snydman, MD, Linda K. Perry, M.T. (ASCP), Jayne Tirrell, M.T. (ASCP)
Objectives: The eight-week basic course in medical microbiology is intended to introduce the resident to the various procedures, techniques, media, stains, equipment and thought processes which underlie modern diagnostic microbiology. Laboratory experience will cover diagnostic procedures, interpretation of results, problem solving, quality control, nosocomial infections and laboratory administration relating to the disciplines of bacteriology, mycology, parasitology, virology, mycobateriology and immunoserology. The resident will not achieve the expertise of an experienced microbiology technologist, but will gain a substantial understanding of the technical work and will be able to anticipate and solve problems as well as make decisions.
Ancillary to the laboratory experience in diagnostic microbiology, the resident also will have the opportunity to participate in conference and consult rounds of the Adult Infectious Disease Service in the Department of Medicine.
Program
Introduction to Bacteriology, 1 week: Introduction to accessioning and processing of specimens; selection and inoculation of appropriate media for different specimens, including special cases in which additional or unusual primary isolation media may be appropriate; isolation techniques.
Introduction to the laboratory filing system and information retrieval; review of proper requisition requirements; review of specimen labeling. Introduction to the use of the Gram stain.
Urine Cultures and Antimicrobial Susceptibility Testing, 2 weeks: Bench instruction in the interpretation of quantitative urine cultures, subculturing to diagnostic media and evaluation of results to establish bacteriological diagnoses; review and discuss proper handling of urine specimens, both in patient-care areas and in the laboratory safety protocol.
Bench instruction in the use of the Vitek method of antimicrobial susceptibility testing and special susceptibility problems of synergy, serum cidal levels, and their interpretation.
Introduction to bacterial taxonomy, and to the reference literature of medical bacteriology.
Blood Culture, 1 week: Bench instruction in the interpretation of blood cultures; review of methods of obtaining blood cultures; discuss pitfalls of blood culturing; review the literature of blood culturing; introduction to pour plate methodology.
General Bacteriology and Anaerobic Bacteriology, 2 weeks: Bench instruction in the interpretation of cultures obtained from nose, throat, sputum, wound, stool and body fluid specimen.
Introduction to Lancefield grouping of streptococci, serotyping of Salmonella, Shigella and identification of Hemophilus influenza, using satellite plates, X and V factors; coagulase testing of staphylococci.
Review of bacterial taxonomy, introduction to various test systems for identification of gram-negative enteric bacilli, introduction to various identification schemes for the non-fermentative gram-negative bacilli.
Observation of planning and performing quality control.
Bench instruction in the examination of Gram-stained smears of urethral and/or cervical discharges to search for gram-negative, intra-cellular diplococci; inoculation of media selective for the pathogenic Neisseria (gonococcus and meningococcus); interpretation of cultures for gonococci; review of the taxonomy of the pathogenic Neisseria; review and discuss transport systems for Neisseriac cultures.
Isolation and identification techniques for anaerobes.
Mycobacteriology, 1 week: Introduction to mycobacteriology; acid-fast staining of clinical specimens and mycobacteria; auramine-fluorescent staining procedure for tubercle bacilli; selection of specimens for digestion prior to culture; digestion procedures; use and maintenance of the safety hood and ultraviolet lamp; review of safety measures in the TB laboratory, including appropriate precautionary measures in the patient care areas.
Parasitology, 1 week: Introduction to processing stool for examination for ova and parasites. A teaching collection will be utilized for study of common pathogens.
Second Clinical Pathology Year
The second year will serve to expand the knowledge of the clinical pathology resident. The two month period will be concentrated in areas of virology, immunoserology, mycology, special susceptibility testing and rapid diagnostic methods.
Virology, 2 weeks: The resident will observe cell culture techniques, primarily focusing on the Herpes group viruses, respiratory syncytial virus, enteroviruses, and adenoviruses. The resident will learn about immunologic identification of viral pathogens, processing of specimens for viral culture and maintenance of culture media.
Immunoserology, 2 weeks: The resident will observe immunoserologic techniques including latex agglutination, enzyme-linked immunosorbent assay (ELISA), and counterimmunoelectrophoresis. The immunoserologic techniques for screening or diagnoses of Herpes group viruses, toxoplasmosis, rubella, and rotavirus will be emphasized. Testing for human immunodeficiency virus (HIV) by ELISA and Western blot method will be taught.
Rapid Bacterial Diagnosis, 1 week: Antigen detection for bacterial diagnosis will be emphasized using available latex agglutination and counterimmunoelectrophoresis methods. Detection of S. pneumoniae, H. influenza Group B streptococcus, N. meningitidis and K. pneumoniae in spinal fluid will be emphasized. Use of cell culture and rapid diagnosis of C. difficile associated diarrhea and chlamydia will be taught.
Mycology, and Special Susceptibility Testing, 1 week: Differentiation of pathogenic fungi will be emphasized. Emphasis will be placed on need for special susceptibility tests including clinical situations which dictate need for minimum inhibitory concentrations, minimum bactericidal concentrations, and synergy.
Hospital Epidemiology, 1 week: The resident will gain exposure to epidemiologic methods, problem solving in hospital epidemiology, and statistical analysis. The resident will attend infection control meetings and problem solving sessions.
Resident Conference and Clinical Round Schedules – Clinical Microbiology
Clinical Laboratory Rounds (daily): Clinical Microbiology Laboratory, 11:30 a.m. to 12 noon.
Infectious Disease Consult Rounds (daily): 2:30 p.m., Tupper 6 Conference Room.
Infectious Disease Clinical Conference (weekly): 4:00 p.m. to 5:30 p.m., Proger 5 South Conference Room.
Infection Control Committee (monthly): 3rd Thursday of the month, 12:00 noon to 1:00 p.m., Ziskind 1 Conference Room.
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Clinical Chemistry: First rotation, 2 months during PGY 1 or 2
Location: Tufts Medical Center Clinical Chemistry Laboratory
Staff: Arthur R. Rabson, MD, Director.
Objectives and Program: The objective of the core rotation in clinical chemistry is to develop an understanding of the analytical methods and instruments, quality control procedures, and logistic and data processing systems used to maintain the timely output of consistently accurate laboratory results. This will be accomplished through hands-on experience at each of the laboratory workstations, tutorial sessions with the instructors, and active involvement in problem solving. The resident will gain experience, while helping provide laboratory services, by being responsible for review and interpretation of tests where interpretation is included in the report; for review and approval of requests for certain special tests; for in vivo procedures involving administration of radioisotopes; and for being on-call to handle special requests, answer questions and deal with problems. Specifically, the rotation will provide:
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A review of basic chemical and physiological concepts and principles
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Knowledge of the chemical and physical basis for assays that are typical of the most commonly encountered in clinical chemistry
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An understanding of the principles and operations of the analytical systems and instrumentation we use
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Experience in performing typical assay procedures and working with, maintaining, calibrating, and "trouble-shooting" the instruments employed
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An appreciation of the factors inherent in an analytical method or system such as chemical specificity and sensitivity, susceptibility to interference, accuracy and precision, that must be taken into account in correctly interpreting chemistry measurements
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An appreciation of the factors that must be controlled in various tests to insure reliability; i.e., timing, temperature, specimen handling, etc.
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Understanding the use of blanks, standards, standard curves, and controls
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Experience in calculating results, the statistical analysis of laboratory data, estimating errors, and determining confidence limits
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Experience in methods evaluation and comparison
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An introduction to the clinical chemistry literature
The laboratory sections through which the resident will rotate are:
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General Chemistry: Electrolytes, proteins, metabolites, and enzymes measured by manual procedures and on a wide range of automated systems.
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Immunoassay: Therapeutic drug monitoring by abused-drug screening, hormones, B12 and folate, manual RIA, and a wide range of automated systems.
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Blood gasses and pH:
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Special Procedures: Isoenzymes, serum and urine proteins and lipoproteins by agarose gel electrophoresis, glycohemoglobin by affinity chromatography.
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In Vivo Procedures: RBC mass, and plasma and blood volumes by isotope dilution, RBC survival.
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Second Rotation, 2 months during PGY 3 or 4
Location: NEMC Clinical Chemistry Laboratory
Staff: Arthur R. Rabson, MD, Medical Director;
Objectives and Program: Develop an understanding of how the laboratory is organized, managed and maintained to accomplish its mission effectively. The aim is to provide the conceptual framework required if one were required, de novo, to assess the requirements of a hospital for laboratory services, then direct the equipping, staffing, organization and operation of a clinical chemistry laboratory to meet these requirements. This will be accomplished through tutorials, problem solving assignments and being available to field questions. Specific areas that we will focus on are:
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Organization of workflow
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Operation and management of the laboratory computer system for data processing and communication
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Quality control and quality assurance programs: Monitoring quality control records; reviewing proficiency surveys; preventive maintenance; investigating problems; regulatory and accreditation requirements
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Methods and instrument comparison: Statistical analysis of data; functional analysis
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Personnel management: Scheduling and deployment; productivity and workload analysis; performance review
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Fiscal management: Budget report review; purchasing and inventory management
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Develop the role of clinical consultant so that, given the clinical question to be evaluated, the resident will be able to recommend an effective test strategy, or, given test results, will be able to provide the interpretation. This will be accomplished through tutorials, being on-call and handling questions, review for approval of special send-out tests, participation in clinical conferences and rounds, and involvement in our emergency drug testing and toxicology programs.
Opportunity also will be provided to carry out a limited project, e.g., evaluation of a new procedure or instrument, correlation of clinical and laboratory findings, reference range studies, or biochemical investigations.
Training Program in Clinical Pathology – Blood Bank, 9 weeks
Staff: Medical Director and Blood Bank Staff
Program:
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Review blood group immunology, typing, compatibility testing and antibody identification (including panels, absorptions, elutions)
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Monitor problem cases and transfusion reactions
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Apheresis of normal donors; therapeutic apheresis; use of cell separators (CS3000, Model 30 Model 50, Cobe 2887)
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Blood collection (including autologous donors), component preparation, storage and preservation of blood
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Transfusion therapy (hazards, use of components, hepatitis, HIV and CMV
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Red cell freezing and cryobiology
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Hemolytic disease of the newborn
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Outpatient transfusion
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Bone marrow processing and freezing
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Blood irradiation-transplantation
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Intra-operative cell salvage
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