Practice Of Dermatopathology Research Articles

Reforms, Errors, and Dermatopathology Malpractice: Then and Now: A Comprehensive Retrospective.

Medical malpractice occurs when a hospital, doctor, or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare, or health management. To be considered medical malpractice under the law, the claim must violate the standard of care, the injury must be caused by the negligence and, last but most certainly not least, the injury must result in significant damages. This review is an overview of medicolegal issues specific to the practice of Dermatopathology with the caveat that most are likely pertinent to other specialties of pathology as well. The safety of patients remains the priority in pathology as it does in any medical undertaking, and this is no different in the practice of Dermatopathology. The review is broadly divided in 2 parts-we begin with an overview of tort reforms, advocated by physicians to reduce costs associated with malpractice defense. In the second part we address practical issues specific to the practice of pathology and dermatopathology. These include among others, errors-related to the biopsy type, inadequacy of clinical information regarding the lesion that is biopsied, role of interstate dermatopathology as well as examples of select entities commonly misdiagnosed in dermatopathology. In the last decade, artificial intelligence (AI) has moved to the forefront of technology. While research into the uses of AI in pathology is promising, the use of AI in diagnostic practice is still somewhat uncommon. Given that AI is not fully integrated routinely as a diagnostic adjunct, its' impact on pathology-specific medicolegal issues cannot, as yet at least, be defined. Restriction of medical malpractice is of particular relevance in the COVID-19 era, a period that is anything but normal. The response of states with specific pandemic-related guidelines is addressed with the caveat that this particular issue is only covered in select states. Furthermore, given that the COVID pandemic is only a year old, while it does not appear to have had an immediate impact on pathology-specific medicolegal matters, it is possible that the role of COVID on this issue, if any at all, will and can only be fully defined a few years down the line.

Dermatopathology practice in the era of COVID-19.

Coronavirus disease 2019 (COVID-19) pandemic has affected almost all aspects of our life including health care services. A lot of dermatopathology laboratories have stopped working during this pandemic. This article aims at reviewing the challenges and effects of COVID-19 on the practice of dermatopathology in view of the current guidelines.

Pearls and Updates in Dermatopathology for the General Surgical Pathologist: Experts Weigh In on What You Need to Know.

Pearls and Updates in Dermatopathology for the General Surgical Pathologist: Experts Weigh In on What You Need to Know.

Histopathological approach to cutaneous lymphoid infiltrate

Cutaneous lymphoid infiltration is common histology seen in the day-to-day practice of dermatopathology. The reasons for this infiltration can range from a spontaneously remitting pseudolymphoma such as Jessner's infiltration to a sinister and aggressive cytotoxic T-cell lymphoma. Before analyzing the slide, the clinical perspective needs to be borne in mind as a diagnosis can never be made in isolation, especially in dermatopathology. In this article, we discuss in brief the various common cutaneous lymphoid infiltrative entities encountered in routine practice, discuss the differentiating features, and suggest an algorithmic approach to arrive at the possible diagnosis.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Corporatization and the rise of private equity in dermatology

Within the past 2decades, for-profit financial groups have become increasingly involved in health care. Outlier dermatology practices with high volumes of well-reimbursed procedures are attractive to consolidation backed by private equity. With fewer choices for independent or group private practice, junior dermatologists are increasingly seeking employment without ownership in private equity-backed corporate groups whose primary fiscal responsibility lies with their investors. Medicare's response to corporatization and consolidation has already changed the practice of dermatopathology. Dermatologists should be aware of this history, given the ability of corporations and private equity groups to shape the present and future of our field.

Dermatopathology education in the era of modern technology.

Continuing technological advances are inevitably impacting the study and practice of dermatopathology (DP). We are seeing the transition from glass slide microscopy to virtual microscopy, which is serving both as an accessible educational medium for medical students, residents and fellows in the form of online databases and atlases, as well as a research tool to better inform us regarding the development of visual diagnostic expertise. Expansion in mobile technology is simplifying slide image attainment and providing greater opportunities for phone- and tablet-based microscopy, including teledermatopathology instruction and consultation in resource-poor areas with lack of specialists. Easily accessible mobile and computer-based applications ("apps"), including myDermPath and Clearpath, are providing an interactive medium for DP instruction. The Internet and social networking sites are enabling rapid global communication of DP information and image-sharing, promoting collaborative diagnostic research and scholastic endeavors.

State restrictions on the interstate practice of dermatopathology are unconstitutional: the tissue is the issue.

The regulation of the interstate practice of dermatopathology, teledermatopathology and teledermatology is the subject of discussion in many recent articles. Laws and regulations in many states complicate such interstate practice, requiring the dermatopathologist to be licensed in the state where the biopsy is taken if the dermatopathologist practices in and is licensed in a different state. To date, this discussion has been from the viewpoint of the dermatopathologist or dermatologist. But, when seen from the patient's viewpoint, its apparent that most such state regulation may be void as an unconstitutional infringement of a patient's fundamental right of unrestricted interstate travel under the Constitution of the United States of America.

Best practices in diagnostic immunohistochemistry: workup of cutaneous lymphoid lesions in the diagnosis of primary cutaneous lymphoma.

Primary cutaneous lymphoma is a common extranodal non-Hodgkin lymphoma. These lesions share common features with their nodal counterparts, but also have differences in morphology, unique clinical presentations, and immunohistochemical features. To review the 2008 World Health Organization (WHO) and 2005 consensus WHO-EORTC (European Organisation for Research and Treatment of Cancer) classifications, and address the immunohistochemical findings in the most common primary cutaneous T- and B-cell lymphomas. Since clonality testing is commonly used as an ancillary test in the evaluation of cutaneous lymphoma, a brief section in the use and pitfalls of clonality testing is included. The WHO and EORTC classification publications and the relevant recent literature were used to compile appropriate and practical guidelines in this review. The practice of dermatopathology and hematopathology varies widely. Thus, while this review provides an overview and guideline for the workup of lymphoid lesions of the skin, the practitioner should understand the importance of clinical correlation as well as appropriate utility of available resources (such as clonality testing) in arriving at a diagnosis in cutaneous lymphoid lesions.

Confusion—specimen mix-up in dermatopathology and measures to prevent and detect it

Maintaining patient identity throughout the biopsy pathway is critical for the practice of dermatology and dermatopathology. From the biopsy procedure to the acquisition of the pathology report, a specimen may pass through the hands of more than twenty individuals in several workplaces. The risk of a mix-up is considerable and may account for more serious mistakes than diagnostic errors. To prevent specimen mix-up, work processes should be standardized and automated wherever possible, e.g., by strict order in the operating room and in the laboratory and by adoption of a bar code system to identify specimens and corresponding request forms. Mutual control of clinicians, technicians, histopathologists, and secretaries, both simultaneously and downstream, is essential to detect errors. The most vulnerable steps of the biopsy pathway, namely, labeling of specimens and request forms and accessioning of biopsy specimens in the laboratory, should be carried out by two persons simultaneously. In preceding work steps, clues must be provided that allow a mix-up to be detected later on, such as information about clinical diagnosis, biopsy technique, and biopsy site by the clinician, and a sketch of the specimen by the technician grossing it. Awareness of the danger of specimen mix-up is essential for preventing and detecting it. The awareness can be heightened by documentation of any error in the biopsy pathway. In case of suspicion, a mix-up of specimens from different patients can be confirmed by DNA analysis.

Ethical issues in dermatopathology

Some of the most contentious and relevant ethical issues in dermatopathology include client billing, the practice of dermatopathology by physicians without board certification in dermatopathology, and the practice of including recommendations regarding further surgery in dermatopathology reports. Client billing is a system in which clinicians directly compensate laboratories for pathology services and directly bill patients and/or third-party payers. Although proponents argue that this system can reduce health care costs and increase efficiency, others have argued that it creates an environment that fosters unethical, and potentially illegal, behavior. The development of various types of laboratory models, commonly referred to as “contractual joint ventures,” has served to expand client billing. Although the field of dermatopathology is considered a subspecialty of both clinical dermatology and anatomic pathology, dermatopathology is commonly practiced by clinical dermatologists and general anatomic pathologists who are not board certified in dermatopathology. Although these physicians are legally entitled to practice dermatopathology, some have questioned the ethics of this situation, especially when board-certified dermatopathologists are available. Finally, dermatopathology reports, on occasion, include suggestions regarding the need for additional surgery or other clinical courses of action. Although established guidelines do not fully endorse or discourage this practice, various opinions exist regarding its affect on patient care.

Apocrine secretion in lacrimal gland cysts (dacryops): a common but underrecognized phenomenon

We present six cases (five females, one male; aged 26-81 years) of dacryops, also known as lacrimal gland cyst, all of which occurred at the outer canthal area below the upper eyelid. All presented clinically as a painless cystic lesion that was white to blue in color. Microscopically, in addition to typical features of dacryops, which is characterized by a partially cystic proliferation that includes a double layer of columnar to cuboidal epithelial cells associated with lobules of lacrimal gland tissue, we identified evidence of apocrine secretion (i.e. apical snouts projecting into the lumen), either in the cystic component of the proliferation or in contiguous lacrimal duct, in all cases. One example was unusual. It manifested, in addition to typical cyst formation, with areas of ductal and probably acinar hyperplasia. We conclude that apocrine secretion in dacryops is a common and underrecognized phenomenon. Dacryops should be distinguished from apocrine hidrocystoma, a lesion commonly encountered in the periorbital area in the practice of dermatopathology.

Molecular-Microscopical Correlation in Dermatopathology

Molecular-Microscopical Correlation in Dermatopathology

Visual Perception and Consciousness in Dermatopathology: Mechanisms of Figure-Ground Segregation Account for Errors in Diagnosis

Visual perception has been the object of research in psychology for almost a century. Little has been written, however, about the effects of perceptive phenomena on methods in medicine that utilize interpretation of two-dimensional images for diagnosis. Starting from the work by Edgar Rubin in the beginning of the last century, this article gives a summary of observations of psychologists who investigated the mechanisms of so-called "figure-ground segregation." These unconscious mechanisms follow rules that explain why certain structures are perceived consciously as a figure, whereas other structures surrounding such a figure are neglected and not perceived consciously in detail. Perception of a structure as a figure can be due to, for example, a convex shape of its contour, proximity of lines around it, closed contours, a simple shape, and attribution of meaning to a structure. In examples from the practice of dermatopathology, those unconscious mechanisms of figure-ground segregation will be shown to be relevant to diagnosis of sections of tissue. The mechanisms help to explain why, for example, ill-defined and concave-shaped structures, stromal differences of neoplasms, interstitial infiltrates and deposits, and simulators of common diseases are often difficult to recognize at first sight. Teachers of dermatopathology need to be aware of these unconscious mechanisms of visual perception because they explain why novices struggle with certain diagnoses and differential diagnoses. Proper instruction about these phenomena, early in the process of training, will prevent a student from being frustrated with misperceptions.

Melanoma In Situ Involving an Epidermal Inclusion (Infundibular) Cyst

Epidermal inclusion (infundibular) cysts are common tumors encountered in the practice of dermatology and dermatopathology. Although benign, numerous pathological processes, including benign and malignant tumors, inflammatory dermatoses, and certain infectious entities, have been reported to occur within the epithelial lining of infundibular cysts. We report a rare case of malignant melanoma in situ involving the epithelium of an epidermal inclusion cyst in contiguity with an adjacent malignant melanoma.

Changing paradigms in dermatology: confocal microscopy in clinical and surgical dermatology

The current practice of pathology and dermatopathology depends upon the evaluation of tissue in some manner extirpated from the patient and then processed and stained. While high resolution of detail can be accomplished by this method, there are certain risks and disadvantages. Recent imaging techniques now allow for a potential of achieving noninvasive high-resolution analysis of lesions in situ in the patient. Of these, Reflectance mode confocal microscopy offers the highest resolution imaging comparable to routine histology. Being entirely non invasive, skin can be observed in its native, dynamic state. This chapter will review the fundamentals of in vivo confocal imaging and the clinical applications in general and surgical dermatology.