Course Book 05

7/23/2019 Course Book 05

1/167

Course in

Pathology and Laboratory Medicine

Schedule, Assignments & Slides

Fall Semester2005 - 2006

Department of Pathology and Laboratory MedicineRobert Wood Johnson Medical School &

Robert Wood Johnson University Hospital

in collaboration with pathology faculty from the following medical centers:

Jersey Shore

J.F. Kennedy

Muhlenberg

Raritan Bay

SomersetSt. Peters


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TEACHIN !E"S#NNE$

PATHOO!" #$PARTM$%T &HA'RMA% Dr. Peter Amenta

C#%"SE I"ECT#" C#%"SE C##"INAT#"

Dr. David Weissmann Ms. Nancy Mundie

Teaching Office, 732-23-!"33

C#'!%TE" E%CATI#N Dr. David #$ran, Direct$r 732-23-!%%

P!H!L" #D $S% S%D S!UD' SMLL (R)UPS

Pathtalk Instructors Case Based Study FacilitatorsDr. Arn$&d 'a(s$n)Dr. Nic$&a *arnard Dr. Marvin +essig

Dr. *i&&ie #yfe)Dr. Marina hemareva Dr. inay Prasad

Dr. '$(ert Tre&stad Dr. 'anda& $vin

Dr. Tetsu$ /himamura Dr. 0anice 0$hns$nDr. '$y 'h$des)Dr. *rand$ $(an$v Dr. 1van ad$ff)Dr. Pau&a rreg$

Dr. #rederic /t$ne Dr. 1ugene Martin)Dr. /emra ara(urunDr. Parisa 0avidian)Dr. 1dita *anci&a Dr. Mercy uriyan) Dr. Da4hne Ang

Dr. Ma&i Deen) Dr. David Weissmann Dr. /i&via De4ara&ta

Part Time InstructorsDr. Peter Amenta Dr. Michae& May

Dr. +auri 5$$de&& Dr. inay Prasad

A&& Path$&$gy 'esidents

SUMMR' PR%S%#!!*)#S+(R)SS PR%S%#!!*)#SDr. Peter Amenta Dr. 6$ng e Dr. Tetsu$ /himamura

Dr. Nic$&a *arnard Dr. *rian /tanf$rd Dr. Anth$ny DAgui&&$Dr. 8ae /$$ im Dr. Nagy Mihai& Dr. Parisa 0avidian

Dr. Arn$&d 'a(s$n Dr. 0$hn #ar(er Dr. /usan /hen-/ch9ar:

Dr. Amri /ah$ta Dr. Peter 6urchenc$ Dr. umidini Mehta

Dr. *i&&ie #yfe-irschner

(U%S! L%$!UR%RSU.S. Health Care Landscape

Mr. 0$hn 5antner, hief #inancia& Officer, '$(ert W$$d 0$hns$n niversity 8$s4ita&

Pathology O Oral Ca!ity "nd #elated StructuresDr. Arn$&d '$senhec, Asst. Dean $f 8$s4ita& Affairs, Ne9 0ersey Denta& /ch$$&

C#NS%$TANTS

$ducational Li%rary Dr. N$rma /as 23-!;2< Mrs. =ana 1tter 23-!!>" Dr. '$(ert +e*eau 23-!;2.

Case based study (CBS) sessions This ty4e $f sma&& gr$u4 e@ercise c$nsists $f the study $f c&inica& cases

9ith the f$&&$9ing main $(Cectives

T$ intr$duce (asic &a($rat$ry eva&uati$ns ref&ecting the a(n$rma& state, and

T$ 4r$m$te the understanding $f re&ati$nshi4s (et9een 4ath$4hysi$&$gy and m$r4h$&$gica& changes

in disease states.

Attendance at these sessi$ns is mandatory, and y$u are e@4ected t$ c$me 4re4ared 9ith 9ritten res4$nses

t$ Buesti$ns. #$r additi$na& inf$rmati$n, see 4age 7.

Summaries of topics in systemic pathology These summaries are a va&ua(&e guide t$ 9hat the facu&tyc$nsiders m$st im4$rtant in each unit. This can he&4 t$ $rgani:e y$ur studying (y em4hasi:ing materia& that

is &ie&y t$ (e c$vered (y the e@ams. 6$ur attendance is reBuired see schedu&eE.

Epidemiologybiostatistics consultations These are inf$rma& sessi$ns, given f$r a&m$st a&& C$urna&artic&es, designed t$ assist students 9ith the eva&uati$n $f the statistica& and e4idemi$&$gica& as4ects $f

assigned 0$urna& &u( artic&es. #acu&ty mem(ers $f the De4artment $f 1nvir$nmenta& and $mmunity

Medicine 9i&& c$nduct these sessi$ns. sua&&y $n&y the $ne student in each secti$n assigned t$ 4resent the

artic&e 9i&& attend the c$nsu&tati$n.

Gross specimen presentations This e@ercise 4r$vides direct e@4erience 9ith the 4ath$&$gy $f $rgans and

tissues rem$ved at surgery $r at aut$4sy. A&& s4ecimens 9i&& (e 4resented (y instruct$rs via c&$sed circuit

vide$. These s4ecimens 9i&& (e dis4&ayed in the &a($rat$ry f$&&$9ing the vide$ 4resentati$n, time

4ermitting. The vide$ 9i&& then (e avai&a(&e in the Media +i(rary f$r y$ur use.

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'ntrodu)tion

!athTal+ Sessins

Ob+e)ti,e

T$ revie9 m$r4h$&$gy and 4ath$4hysi$&$gy $f the assigned t$4ic.

Format

This is an interactive sma&& gr$u4 sessi$n. ?t is necessary that y$u c$me 4re4ared, since y$ur 4artici4ati$n

is e@4ected.

6$u 9i&& discuss (asic facts and c$nce4ts $f the assigned t$4ic.

6$u sh$u&d (e ready ($th t$ as and t$ ans9er Buesti$ns re&ated t$ the t$4ic.

6$u sh$u&d (e fami&iar 9ith assigned images $f gr$ss and micr$sc$4ic &esi$ns and (e ready t$

inter4ret them.

6$u 9i&& (e ased t$ inter4ret s$me 4revi$us&y unassigned images Funn$9n s&idesFE.

M$st $f y$u 9i&& 4resent a 0$urna& &u( artic&e see 4age ;%E, and y$u 9i&& &ead the discussi$n $fy$ur 4resentati$n. n&ess $ther9ise n$ted, the se&ected artic&es are fr$m the Ne9 1ng&and 0$urna&

$f Medicine. They are &isted in each 9ee $f the schedu&e.

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'ntrodu)tion

Case (ased Stud Sessins

Ob+e)ti,e

T$ intr$duce (asic &a($rat$ry eva&uati$n ref&ecting the a(n$rma& state and t$ 4r$m$te the understanding $f

re&ati$nshi4 (et9een &a($rat$ry and m$r4h$&$gica& changes in disease states

Format

The f$rmat $f */ is intended t$ faci&itate &earning thr$ugh active student 4artici4ati$n. /tudents are

e@4ected t$ study the materia&, t$ c$nduct a discussi$n $n the vari$us as4ects $f the case, and t$ arrive at a

c$nc&usi$n as t$ 9hat ai&s the 4atient.

Role o( the 'nstru)tor-

The 4rinci4a& r$&e $f the instruct$r sh$u&d (e that $f a m$derat$rG the instruct$r is free t$ intervene in

discussi$ns and t$ su44&ement avai&a(&e inf$rmati$n. These sessi$ns sh$u&d (e, h$9ever, 4red$minant&y

student driven.

The r$&e $f the instruct$r is t$ enc$urage the student &eading the discussi$nt$ e&icit fu&& res4$nses the case,inc&uding a differentia& diagn$sis (ased $n the findings. The instruct$r is n$t e@4ected t$ 4r$vide ans9ers

t$ a&& Buesti$ns raised, n$r is the &ead student. These sh$u&d (e ans9ered thr$ugh 4artici4ati$n $f the 9h$&e

gr$u4. A&& students are e@4ected t$ active&y 4artici4ate in the discussi$n. 1very student sh$u&d (e given an

$44$rtunity t$ e@4ress an $4ini$n and c$ntri(ute t$ the res$&uti$n $f the case.

Printed &ases

1ach 9ee $ne t$ t9$ 4rinted cases 9i&& (e assigned. These are inc&uded in the Assignments secti$ns in the

sec$nd ha&f $f this ($$.

;. 1ach student sh$u&d study the case and 4r$vide either a 9ritten summary $f the diagn$sis and

c$nc&usi$n fr$m the case materia& $r s$me $ther ty4e $f 9ritten res4$nse at the instruct$rs

discreti$n.

2. On the day $f the sessi$n, $ne student 9i&& (e se&ected t$ &ead the discussi$n. This student sh$u&d

a. 'evie9 the c&inica& summary and 4r$m4t discussi$n $f a differentia& diagn$sis (ased $n the

dem$gra4hics $f the 4atient and c&inica& findings.

(. a&& $n $ther students t$ ans9er the Buesti$ns at the end $f each case. ?ndividua& students

sh$u&d (e res4$nsi(&e f$r ans9ering each Buesti$n, and the gr$u4 as a 9h$&e sh$u&d

c$rrect)su44&ement)su44$rt this students vie9. The instruct$r sh$u&d guide the discussi$n

t$ c$ver the $(Cectives that are re&evant t$ the case and $ffer a fina& c$mment $n each $f the

ans9ers

c. ie9 the s&ides $n We(T 4ertaining t$ the case. The &ead student sh$u&d ca&& $n $ther

students f$r s&ide descri4ti$ns and c$mments. The instruct$r sh$u&d c$rrect)su44$rt

students c$mments, discuss the ty4es $f diagn$sis that the s&ide revie9 indicates, and

summari:e a&& findings.

3. The instruct$r 9i&& 4r$vide c&$sing c$mments 9ith a (rief discussi$n $f h$9 the findings and &a(

va&ues su44$rt the fina& diagn$sis.

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'ntrodu)tion!. The 9ritten case summary $r $ther 9ritten res4$nse students h$me9$rE 9i&& (e c$&&ected and

returned at the ne@t sessi$n 9ith instruct$rs c$mments.

1ach instruct$r and c&ass 9i&& have t$ disc$ver the &earning techniBues that 9$r (est f$r him $r her. The

Hstudent $f the 9eeI strategy descri(ed a($ve may (e re4&aced (y $ther strategies as seems a44r$4riate.

Different c&asses have different H4ers$na&itiesI, and the strategy and 4ers$na&ity sh$u&d match.


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'ntrodu)tion

ST%. 'ATE"IA$

We rea&i:e that in this age $f e@4$nentia& increase in (i$medica& n$9&edge 9e can 4r$vide $n&y a &imited

e@4$siti$n $f $ur fie&d. ?t is vita& that future 4hysicians assimi&ate and u4date a &arge am$unt $f

inf$rmati$n, t$ 9hich $ur c$urse can $ffer $n&y an intr$ducti$n. ?t is im4$rtant that y$u inde4endent&y

4ursue every means avai&a(&e t$ gain c$ntinuing mastery $f the su(Cect. At se&ected 4$ints during thec$urse 9e are a&&$9ing f$r unschedu&ed time t$ ena(&e y$u t$ d$ s$.

The $dachr$me s&ide materia& f$r ($th PathTa& and ase-*ased /essi$ns is avai&a(&e at the Pathology

and Laboratory Medicinesecti$n $n y$ur We(T site.

"e/uired Tet1+: Robbins and otran Pathologic !asis of "isease#7th1diti$n the c$m4&ete editi$nE

P&ease mae sure y$u get the 7thediti$n. Many th$ugh n$t a&&E $f y$ur reBuired reading assignments arefr$m this te@t and are &isted in each 9ee in the Assignments secti$n. ThePocket $dition %f Robbinsf$r

the seventh editi$n 9i&& n$t (e avai&a(&e unti& an unn$9n date in the 2""-> sch$$& year. /tudents 9h$ fee&

a need f$r a m$re c$ndensed te@t t$ su44&ement and n$t re4&aceJJE the c$m4&ete editi$n sh$u&d c$nsider thecurrent, 7thediti$n $f!asic Robbins, 9hich is a($ut ha&f the si:e. E!amination "uestions #ill be based on

the complete edition$ ho#e%er$ and there is no guarantee that relying on the Basicedition #ill suffice

for students to do #ell in the course&

#$r the m$st recent deve&$4ments in the fie&d, y$u sh$u&d regu&ar&y c$nsu&t the&ew $ngland 'ournal of

Medicineand $ther C$urna&s.

"e/uired 'aterial r !athTal+ Sessins:

/&ide c$&&ecti$n arranged (y 9ee&y t$4icsE $n We(T

/&ides secti$n $f the c$urse ($$ - c$ntains s&ide descri4ti$ns and $ther se&ected materia&

"e/uired 'aterial r Case (ased Stud: Printed cases 4r$vided in the Assignments secti$ns

(idmann)s linical *nterpretation %f Laboratory Tests;;th 1diti$nE, (y '$na&d /acher and 'ichard

McPhers$n #.A. DavisE

ase+!ased Pathology and Laboratory Medicine, 2"", (y Mihai&, 'as$va, and /he *&ac9e&&

Pu(&icati$nsE. N$te that this is an u4-dated versi$n $fLaboratory Medicine ase !ook(y 'as$vaand $thers.

"ecmmended "eading Tets: &etter)s *llustrated ,uman Pathology, (y *uCa and rueger. This is the m$st significant

rec$mmended te@t. The HNetterI in the tit&e is the same Netter 9h$ 4r$duced the magnificent

?*A anat$my at&ases. ?t is n$t reBuired reading, and e@ams 9i&& n$t c$ver materia& 4resent s$&e&yin it a&th$ugh the c$ntents $f theRobbins and&etter)sa&m$st c$m4&ete&y $ver&a4. ?t is an e@ce&&ent

means $f visua&&y reinf$rcing the facts and c$nce4ts fr$mRobbinsand might intr$duce s$me

9e&c$me variati$n int$ y$ur studying.

Other rec$mmended ($$s inc&ude

*nterpretation %f "iagnostic Tests$(y Wa&&ach +itt&e *r$9nE. This 9i&& (e he&4fu& m$st&y in

c$nnecti$n 9ith the c&inica& cases discussed in ase-*ased /tudies.

The Merck Manual $r $ne $f the te@t($$s $f interna& medicine eci&s $r 8arris$nsE.

Pathology -ecrets, (y ?van DamCan$v, M.D., Ph.D. 8an&ey and *e&fusE.

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'ntrodu)tion

Sel-e3aluatin 'aterial:We rec$mmend the f$&&$9ing

Robbins and otran Reiew %f Pathology(y 1d9ard . &att, M.D., and inay umar, M.D, 2nd

1diti$n Mu&ti4&e ch$ice Buesti$ns 9ith ans9ersE. This editi$n is (rand ne9, and the Buesti$ns

ref&ect the f$rmat y$u are &ie&y t$ find $n the *$ards. /evera& c$4ies are avai&a(&e in the Media

+i(rary.

Pathologic !asis %f "isease# -elf+/ssessment /nd Reiew(y ar$&yn . $m4t$n Mu&ti4&ech$ice Buesti$ns 9ith ans9ersE. /evera& c$4ies are avai&a(&e in the Media +i(rary. The Buesti$ns

are 9$rth9hi&eG (ut the ($$ is s$me9hat $&d, and the Buesti$ns n$ &$nger ref&ect the sty&e $f the

*$ards e@aminati$ns.

We( *ased Kui::es htt4))4&eiad.umdnC.edu)E

o Path$&$gy and +a($rat$ry Medicine Kui:

o ?mage-(ased Mini-Bui:

#ther *isual and Audi3isual 'aterialide$ Ta4es $f gr$ss s4ecimen 4resentati$ns f$r this semester, as 9e&& as ta4es rec$rded in recent years, are

st$red in the Media +i(rary.

;;


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'ntrodu)tion

E4A'S, "AES, & E*A$%ATI#NS

On the (asis $f e@aminati$n resu&ts, the student 9i&& (e a9arded grades $f 8$n$rs !E, 8igh Pass 3E, Pass

2E, +$9 Pass ;E, $r #ai& "E. ?n additi$n every student must satisfact$ri&y 4erf$rm in PathTa& sessi$ns

and ase *ased /tudy sessi$ns and attend the /ummary /essi$ns. This 4erf$rmance 9i&& (e eva&uated in 29ritten descri4ti$ns c$m4$sed se4arate&y (y each students PathTa& and ased *ased /tudy instruct$rs.

$aminations

There 9i&& (e three e@aminati$ns thr$ugh$ut the $urse. The first t9$ $f these 9i&& c$nsist $f ($th image-

and te@t-(ased mu&ti4&e-ch$ice Buesti$ns 4r$vided (y facu&ty mem(ers and 9i&& c$ver materia& fr$m the4revi$us third $f the year.

The third and fina& e@am c$vering the entire year 9i&& (e a c$4y $f the Path$&$gy secti$n $f /te4 ? $f the

/M+1. This is Cust a c$4y and n$t the actua& /M+1 e@aminati$n itse&f. The resu&ts $f the &ast e@am 9i&&

(e re4$rted t$ y$u as a 4ercentage grade after the Nati$na& *$ard has ana&y:ed the ra9 sc$res and

c$nverted them t$ 4ercentage grades in $rder t$ mae y$ur grades as fair as 4$ssi(&e.

N$te The time a&&$tment assigned f$r an e@aminati$n is n$t necessari&y the actua& &ength $f time f$r the

e@am. ?t inc&udes time ($th (ef$re and after the e@aminati$n f$r administrative tass.

6$ur fina& grade 9i&& (e as f$&&$9s 6$ur average grade $n the three e@ams 9i&& c$unt f$r ! " #ai&E >-7" ; +$9 PassE

7;-%" 2 PassE

%;-%> 3 8igh PassE

%7-;"" ! 8$n$rsE

A student 9h$ receives a grade $f #A?+ can c$rrect this grade t$ +OW PA// (y 4assing a mae-u4

e@aminati$n, 9hich 9i&& (e c$m4$sed and graded (y the De4artment $f Path$&$gy and +a($rat$ry

Medicine. On this e@aminati$n a student must achieve a sc$re $f at &east >L.

'ou may not memorie "uestions or make notes about "uestions in order to record them for your

o#n or others future use&*ecause 4$rti$ns $f the e@am may (e used again in the future, any attem4t t$ d$

s$ is an h$n$r vi$&ati$n. As a reminder, in regard t$ this and t$ y$ur 4erf$rmance $n the e@am itse&f, thef$&&$9ing h$n$r c$de is in effect

=* hereby affirm that * hae neither gien nor receied unauthori>ed assistance during this examination. *acknowledge that the ode of Professional onduct of ?M"&'+Robert (ood 'ohnson Medical -chool

stipulates that students may not cheat# plagiari>e or assist others in the commission of these acts. * also

acknowledge that the ode of Professional onduct proides that students hae a duty to report any breach

of these ethics through appropriate channels.@

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'ntrodu)tionPer(orman)e 'n Pathtal/ Sessions

1ach student must attend and meaningfu&&y c$ntri(ute t$ the PathTa& sessi$ns. 1ach student 9i&& (e

reBuired t$

Partici4ate in gr$u4 discussi$ns

1va&uate m$r4h$&$gica& findings

?n additi$n, m$st students 9i&& have the $44$rtunity t$ 4resent t$ their 4eers a 4u(&ished artic&e 0$urna&

&u(E.

Per(orman)e 'n &ase Based Study Sessions

1ach student must attend the ase *ased /tudy sessi$ns. /tudents 9i&& (e eva&uated (y the individua&

instruct$rs $n their a(i&ity

T$ ana&y:e 4r$(&ems

T$ 4r$vide ($th 9ritten and $ra& ans9ers and inter4retati$ns t$ Buesti$ns re&ated t$ assigned cases

T$ 4artici4ate in gr$u4 discussi$ns.

$,aluationsThe assessment $f these 4erf$rmances in PathTa& and */ sessi$ns 9i&& (e re4$rted in the fina& 9ritten

eva&uati$n $f each student (y the facu&ty that 9i&& (e sent t$ the Deans Office t$ (ec$me 4art $f the (asis

f$r the Deans &etter.

?n m$re detai& at the end $f the c$urse, students 9i&& (e eva&uated $n their 4erf$rmances, f$cusing $n

ase !ased -tudies PathTalk

n$9&edge $f materia& n$9&edge $f materia&

?nteracti$n and 4artici4ati$n in discussi$ns ?nteracti$n and 4artici4ati$n indiscussi$ns

Perf$rmance as a m$derat$r ?nter4retative si&&s in hist$4ath$&$gy

A(i&ity t$ ana&y:e cases)ans9er assigned Buesti$ns 0$urna& &u( 4resentati$n in m$st casesE

/tudents 9i&& a&s$ (e eva&uated (y the instruct$rs $f ($th gr$u4s $n n$n-c$gnitive attri(utes such as

$mmitment and genera& attitude

$nscienti$usness

$&&a($rati$n 9ith 4eers

+eadershi4 Bua&ities

'res4ect f$r $ther $4ini$ns

/e&f-criticism

1thica& (ehavi$r

8$nesty and integrity

1ach eva&uati$n 9i&& (e in the f$rm $f a sh$rt 4aragra4h, t$ (e sent t$ the registrar f$r inc&usi$n in students

transcri4t. /tudents 9i&& have the $44$rtunity t$ revie9 the eva&uati$ns (ef$re they are su(mitted.

Absen)es0Per(orman)e 'n Small !rou1s

An unsatisfact$ry 4erf$rmance as determined (y y$ur sma&& gr$u4 instruct$rs $r m$re than t9$ a(sences

fr$m $ne $f y$ur sma&& gr$u4 sessi$ns 9i&& reBuire remedia& activity $n an individua& (asis.

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16/167

'ntrodu)tion!rade A11eal Me)hanism

The ourse in Pathology and Laboratory Medicinea&&$9s f$r and str$ng&y enc$urages student-facu&ty

interacti$n. We (e&ieve that g$$d c$mmunicati$n (et9een student and teacher is im4$rtant f$r mutua&

understanding and that it is essentia& f$r &earning.

$xamination Arade

;. After each $f the 2 de4artmenta& e@aminati$ns, ($th the Buesti$n ($$&ets and ans9er

sheets 9i&& (e c$&&ected. Over the c$urse $f the ne@t fe9 days, y$u 9i&& have the$44$rtunity t$ revie9 ($th the Buesti$ns and y$ur ans9ers in a su4ervised setting. After

y$ur revie9 y$u may &eave any 9ritten cha&&enges t$ the Buesti$ns 9ith the su4ervis$r, andthe ($$s)ans9er sheets 9i&& again (e c$&&ected. The c$urse direct$r and the facu&ty 9i&&

then revie9 the cha&&enges. The c&ass 9i&& (e n$tified $f any adCustments, 9hich 9i&& a44&y

t$ every students grade. N$ additi$na& changes are made after the fina& grade f$r each

de4artmenta& e@aminati$n is issued.

*s mentioned abo%e$ you may not memorie "uestions or make notes about "uestions

in order to record them for your o#n or others future use&

2. The?-ML$ Pathology section -tep 3 $xaminationis e@em4t fr$m the a($ve 4r$cedure.

6$ur ra9 sc$re is sca&ed and returned (y the Nati$na& *$ard as a 4ercentage, and this gradeis n$t su(Cect t$ further discussi$n.

$aluation %f -mall Aroup Performance 2PathTalk /nd ase+!ased -tudies7 6$u 9i&& (e given a

c$4y $f y$ur c$urse eva&uati$n, 9hich is (ased $n y$ur 4erf$rmance in sma&& gr$u4s. ?f a seri$us

discre4ancy $ccurs (et9een a students 4erce4ti$n $f his)her 4erf$rmance in the c$urse and the

eva&uati$n, the student sh$u&d a44ea& in 9riting t$ the $urse Direct$r, and the case 9i&& (e

ree@amined.

0inal ourse Arade: As descri(ed a($ve, this grade is determined entire&y $n the (asis $f

e@aminati$n resu&ts and "-2 4ercentage 4$ints fr$m the integrated cases series, 4r$vided attendance

is adeBuate. N$ adCustment can (e made after the grade is a9arded un&ess a c&erica& err$r has (een

made.

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17/167

'ntrodu)tion

H t Arach the Tet1+

Norma S. Saks, Ed.D

The te@t($$ that has (een se&ected f$r this c$urse,Robbins and otran Pathologic !asis of "isease# Bth$dition, is a 4rimary res$urce f$r y$ur inde4endent study. *ecause the te@t is c$m4rehensive and detai&ed,

reading effective&y andefficient&y is essentia&. A hand$ut, -trategies for -tudying Pathology, can (e$(tained at the $gnitive /i&&s Pr$gram $ffices, *8, D33%.

+o# to approach the pathology te!tbook for effecti%e independent study:

1ngage in an active vs. 4assiveE a44r$ach t$ reading as f$&&$9s

;. Deve&$4 the ha(it $f &$$ing at the 9h$&e cha4ter)secti$n first t$ see h$9 it is $rgani:ed. hec

$ut the $ut&ine that (egins every cha4ter.E ?f y$u n$9 the structure $f the materia& Hthe (ig

4ictureIE, it 9i&& he&4 y$u reca&& it (etterG as it 4r$m$tes a Hc$gnitive frame9$rI t$ 9hich y$u can

4in detai&s.

2. Attend t$ the f$rmat $f the te@t($$ - Main headings, su(headings, c$&$r c$ding, diagrams, charts,4h$t$gra4hs, genera& 4hysica& arrangement. Thin a($ut h$9 the f$rmat can aid y$ur &earning.

3. 'ead f$r a 4ur4$se and adCust y$ur rate t$ that 4ur4$se. ?f y$u c$me acr$ss materia& that y$u

a&ready n$9, then read thr$ugh it Buic&y. ?f y$ur 4ur4$se is t$ &earn)understand, then s&$9 d$9n

y$ur rate. *t is most effectie to deelop adance Cuestions and then go on a =search@ to find

answers to your Cuestions./$me students &ie t$ f$cus study (y reading re&ated Buesti$ns. *e sure

t$ tae a &$$ at the '$((ins c$m4ani$n Buesti$n ($$.E

!. When y$u identify unfami&iar v$ca(u&ary, n$te the 9$rdsE and f$&&$9 u4. ?f the meaning $f a

9$rd is essentia& in $rder t$ mae sense $f 9hat y$u are reading, &$$ it u4 immediate&y. ?t is (est

t$ have a medica& dicti$nary and y$ur We(sters near(y.E ee4 in mind that these same 9$rds may

a44ear $n an e@am &ater $n.

. +$$ f$r re&ati$nshi4s, n$t Cust a c$&&ecti$n $f facts. $m4are and c$ntrast. This meth$d 9i&& aid in

y$ur retenti$n $f the materia&.

>. Deve&$4 a n$te-taing system. 8$9 9i&& y$u remem(er 9ith$ut rereading the te@t Decide $n a

f$rmat and h$9 much detai& y$u 9i&& inc&ude. reating y$ur $9n charts and ann$tatingcharts)figures in the te@t can 9$r 9e&&.

7. Assess y$ur c$m4rehensi$n at freBuent interva&s. /ummari:e after a meaningfu& chun.

Paraphraserestate in y$ur $9n 9$rdsE.

%. Assess y$ur c$ncentrati$n at freBuent interva&s. /tay a&ert. Av$id reading the te@t as if it 9ere an$ve&.


18/167

'ntrodu)tion

Cmuter Educatin !rgram

,a%id -oran$ Ph&,&

We first 9ish t$ e@tend a 9arm 9e&c$me t$ each $f y$u. ?n $rder t$ faci&itate y$ur mastery $f the su(Cectmateria& the facu&ty are deve&$4ing a num(er $f interactive e@ercises f$r 9e(-(ased teaching in 4ath$&$gy.

T9$ 9e(-(ased t$$&s are n$9 accessi(&e thr$ugh the De4artmenta& 9e( server at htt4))4&eiad.umdnC.edu).

Once c$nnected t$ the server y$u sh$u&d c&ic $n H2 nd6ear $urse in Path$&$gy +a( Medicine.I 6$u

9i&& then (e 4resented 9ith $4ti$ns t$ engage in an interactive 'evie9 $f Path$&$gy and +a($rat$ryMedicine $r t$ tae an ?mage-(ased Mini-Kui: in Path$&$gy.

?f y$u ch$$se the first $4ti$n, H'evie9 Path$&$gy +a( MedicineI y$u may ch$$se fr$m a44r$@imate&y

2> (r$ad t$4ics. 6$u 9i&& su(seBuent&y (e 4r$m4ted f$r y$ur fu&& name. 6$u 9i&& (e 4resented 9ith

Buesti$ns that re&ate t$ the t$4ic $f interest. The 4r$gram features immediate feed(ac regarding the

ans9ers that y$u su(mit as 9e&& as a t$ta& sc$re f$r the secti$n. Once the e@ercises f$r any given sessi$n

are c$m4&eted, the t$ta& sc$re and c$rrect ans9ers are dis4&ayed. The 9e(-(ased revie9 a&s$ features a

rand$m m$de, 9ith Buesti$ns se&ected at rand$m acr$ss a&& t$4ics. Whi&e an e@tensive H?mage-(ased Kui:I

is current&y (eing deve&$4ed, y$u might &ie t$ have a &$$ at the H?mage-(asedMini-Kui:,I (ased $n 2!

Buesti$ns.

6$u may a&s$ access this materia& (y c$nnecting direct&y t$ the Path$&$gy and +a($rat$ry Medicine $urse

We(site htt4))4&eiad.umdnC.edu)4ath$&$gyc$urse).

We h$4e that y$u 9i&& enC$y 2ndyear c$urse in Path$&$gy +a($rat$ry Medicine, and 9e 9e&c$me y$ur

c$mments. #$r c$mments 4&ease c$ntact

David 0. #$ran, Ph.D. 732-23- !%%

David Weissmann, M.D. 732-!;%-%"!7

Nancy Mundie 732-23-!"33

+in 6ang 732-23->%"

;>
http://pleiad.umdnj.edu/http://pleiad.umdnj.edu/pathology_course/http://pleiad.umdnj.edu/http://pleiad.umdnj.edu/pathology_course/


19/167

'ntrodu)tion

Strategies r %sing Cmuters in Sel-$earning

'$(ert +. Tre&stad, MD

The c$m4uter res$urces y$u have at y$ur dis4$sa& are e@tensive and match $r e@ceed th$se $f m$st medica&

sch$$&s. +ie any ne9 t$$&, the va&ue $f the c$m4uter in educati$n is underg$ing ra4id change.

$m4uters 9i&& never re4&ace 4rint ($$s. 6$u can dr$4 y$ur ($$, tae it t$ the (each, $r sit $n it. ?t

never runs $ut $f energyG y$u d$.

We have disc$ntinued $ur Hh$9 t$ use the c$m4uterI sessi$ns in that m$st students n$t $n&y n$9 h$9, (ut

$9n them. ?f y$u fee& that y$u arent using the c$m4uter effective&y, 4&ease as f$r he&4. hanne& y$ur

reBuests thr$ugh the Teaching Office. At vari$us times during the c$urse, 9e 9i&& give y$u dem$nstrati$ns

in 9hich 9e 9i&& use the c$m4uter res$urces.

?n additi$n t$ the &$ca& set $f s$ft9are, there is an e@tensive am$unt $f materia& avai&a(&e $n the ?nternet.

The Qnet is m$ving fr$m * radi$ t$ AM. ?t is fi&&ed 9ith Cun and great stuff. /$ 9hats ne9 1ver (een

t$ Wa&Mart ?n additi$n t$ the materia& avai&a(&e $n the Path$&$gy 4$rti$n $f y$ur We(T site, the

f$&&$9ing are 9e( sites 9$rth e@4&$ring

pleiad&umdn.&edu

Our Path$&$gy De4artments 9e( site.

pleiad&umdn.&edupathology/courseA Path$&$gy and +a($rat$ry Medicine $urse 9e( site. The Buesti$n (an Bui::es can (e f$undhere.

###0medlib&med&utah&edu1ebPath#ebpath&htmlThe 4remier 4ath$&$gy educati$n 9e( site. Kui::es, images, inf$rmati$n. A &$ca& versi$n $f this$utstanding c$&&ecti$n $f images is h$sted $n the Path$&$gy secti$n $f1ebC2. +$$ f$r it there.

###&pathma!&commain&html

A 9$nderfu& c$&&ecti$n $f every ind $f internet 4ath$&$gy res$urce.

pleiad&umdn.&eduhemepath

A &ym4h$ma tut$ria&.

;7


20/167

'ntrodu)tion

)urnal Clu1

uidelines7 H T !resent An Article

/te4hen M. /hea, M.D.

Medica& n$9&edge is changing fast. The (est 9ay f$r a 4hysician t$ Hee4 u4I is t$ ee4 searching and

reading the &iterature. One must &earn t$ read effective&y and critica&&y. This is 9here the 0$urna& &u(c$mes in critica& 4resentati$n $f an artic&e t$ a critica& audience.

The idea is t$ 4resent the su(stance $f a C$urna& artic&e t$ y$ur c$&&eagues critica&&y and succinct&y. ?t

sh$u&d n$t tae m$re than fifteen minutes. T$ get y$ur (earings, after reading the artic&es tit&e, read the

a(stract, es4ecia&&y its 4unch&ine, t$ see 9hat the auth$rs c&aim t$ sh$9.

?n C$urna&s &ie the&ew $ngland 'ournal of Medicine, artic&es are $ften mu&ti-auth$red, (ut in genera& fa&&

int$ $ne $f t9$ categ$ries - re4$rts fr$m a sing&e de4artment e.g. MedicineE $n $(servati$ns (ased $n a

&imited 4atient 4$4u&ati$n, $r &arge mu&ti-center studies.

When y$u descri(e meth$ds t$ y$ur fe&&$9s, y$u need n$t g$ int$ great detai&, es4ecia&&y in the case $f

mu&ti-center studies $r revie9 artic&es, 9hich y$u may have t$ 4resent in se&et$n f$rm.

Present the findings usua&&y y$u 9i&& find them nice&y ta(u&ated.

Present the discussi$n here y$u can aff$rd t$ (e critica&. Were the right c$ntr$&s used are the statistica&

arguments c$nvincing 5ive y$ur $4ini$n, and as y$ur c$&&eagues f$r theirs.

?t may seem hard, (ut it is much m$re effective t$ mae d$ 9ith$ut c$nsu&ting n$tes. The eff$rt t$ d$ s$

f$rces $ne t$ digest the materia& and discard the dr$ss. ?f y$u say it in y$ur H$9n 9$rds,I y$u 9i&& find y$u

understand matters in a ne9 9ay, and y$ur audience 9i&& understand (etter, t$$. 6$u can a&s$ mae

effective use $f the (&ac($ard in this 9ayG d$nt fi&& it u4 in advance, (ut 9rite d$9n sa&ient 4$ints H$n the

f&y.I

The audience sh$u&d (e invited t$ as Buesti$ns, and they sh$u&d d$ s$. 1very$ne sh$u&d (ec$me inv$&ved.

When the c&u( functi$ns this 9ay, a&& gain, es4ecia&&y in (ec$ming unse&fc$nsci$us and effective in thining

$n their feet, in c&arifying their th$ughts, and e@4ressing them effective&y.

1hen 2o Seek EpiBio Consultation

Many $f the artic&es 9i&& inv$&ve Buantitative data, $ften 9ith e4idemi$&$gica& features. ?t is im4$rtant that

y$u &earn t$ inter4ret theseG n$t a&& 4u(&ished c$nc&usi$ns are necessari&y c$rrect. We str$ng&y enc$urage

y$u t$ tae advantage $f the 14i)*i$ c$nsu&tati$n 4r$gram, $ffered (y the facu&ty $f the De4artment $f

1nvir$nmenta& and $mmunity Medicine t$ $ur students. /ee the schedu&e f$r time and &$cati$n.

;%


21/167

'ntrodu)tion

Journal &lubs2S)ien)e as &on,ersation

0$e Wright. *.A.

#r$m the&ew $ngland 'ournal of Medicine, 3;G;, 44 ;"-;2E

? had f$rg$tten a($ut it amidst the $ther tass $f medica&-student &ife e@ams, 4atient 9rite-u4s, the shirt

? needed t$ ir$n. *ut an e-mai& fr$m my fe&&$9 student 0$hn reminded me that it 9as my turn t$ &ead theC$urna& c&u( f$r $ur 8?-A?D/ interest gr$u4. ? had n$ idea 9hat artic&e ? 9$u&d (ring. ? (um(&ed thr$ugh

Pu(Med in search $f a 4a4er, 9andering thr$ugh severa& t$4ics (ef$re &anding $n an artic&e a($ut the high

4reva&ence $f ch&amydia in hina,;a&$ng 9ith an edit$ria&2arguing f$r a 4articu&ar strategy f$r 4reventing ane9 e@4&$si$n $f human immun$deficiency virus 8?E infecti$n. ? 9asnRt sure that ? c$u&d &ead a g$$d

discussi$n $n this artic&e, (ut time 9as u4, s$ ? 4iced it and h$4ed it 9$u&d 9$r $ut. At &east in $ne

im4$rtant sense, it did.

There 9ere $n&y f$ur $f us at the sessi$n SCust (are&y en$ugh. My fe&&$9 C$urna&-c&u( mem(ers 9ere

4u::&ed (y s$me $f the statistica& meth$ds, and ? c$u&dnRt he&4 much. And ? disc$vered that ?Rd fai&ed t$

e@amine c&$se&y the m$st interesting as4ects $f the data ta(&es. N$nethe&ess, ? had (r$ught s$me Buesti$ns,

and ? 9as (&essed 9ith th$ughtfu&, ta&ative c$&&eagues. We ta&ed a($ut infecti$us disease, s$cia& 4$9er,

and ec$n$mic deve&$4mentG a($ut 9hether different fact$rs might drive $ut(reas in different regi$ns $f

the c$untry thus reBuiring different interventi$n strategiesEG and a($ut h$9 the structure $f se@ua& net9$rsinf&uences the 4attern $f s4read $f se@ua&&y transmitted diseases. We tried t$ get thr$ugh the data $urse&ves

9ith$ut re&ying $n the inter4retati$ns in the a(stract $r the edit$ria&.

A fe9 days &ater, anu, a C$urna&-c&u( regu&ar, e-mai&ed us a &in t$ a ne9s artic&e a($ut the hinese

ec$n$my, saying, FTh$ught y$u guys might (e interested, c$nsidering $ur c$nversati$n the $ther day.F And

it 9as then that ? remem(ered the genius $f C$urna& c&u( ? 9as interested in reading this rather dry artic&e

a($ut hinese ec$n$mics and 4$&itics, (ecause n$9 ? had a c$nte@t and a 4ur4$se f$r the inf$rmati$n.

M$re$ver, in the 4r$cess $f &$$ing f$r an artic&e, ? had &earned sti&& m$re. #$r instance, 9hi&e &$$ing

thr$ugh the &iterature $n se@ua&&y transmitted diseases, ? had ca&&ed my friend Dan 9h$ had (een in charge

$f the first C$urna& c&u( ?Rd attendedE t$ as him a($ut net9$r the$ry in research $n se@ua&&y transmitteddiseases. ? had read an interesting revie9 artic&e a($ut 5* virus 9hich 9$u&d (ec$me the t$4ic $f

an$ther C$urna&-c&u( meeting 9hen a ne9 research artic&e came $ut3E. ? had &earned a (it a($ut the ec$n$mic

and 4hysica& ge$gra4hy $f hina. ? had remem(ered that h&amydia trach$matis is an $(&igate 4arasite.N$ne $f this n$9&edge S e@ce4t the stray fact a($ut . trach$matis S 9i&& he&4 me $n any e@ams.

N$r did $ur gr$u4 c$me u4 9ith any 4articu&ar&y he&4fu& ideas a($ut A?D/ t$ $ffer t$ the hinese 4e$4&e.

We deve&$4ed n$ ;"-4$int 4&an f$r st$44ing 8? e4idemics. ?t might a44ear as if 9e acc$m4&ished n$thing.

*ut (y strugg&ing thr$ugh the artic&e t$gether, 9e (ecame m$re a9ae t$ the 9$r&d ar$und us and m$re

immersed in the scientific 4r$Cect $f e@4&$ring it.

When ? 9as y$unger, ? genera&&y enc$untered science as a set $f facts t$ (e dri&&ed S O if the facts

are interesting, (ut certain&y n$t an a9aening. When ? fina&&y e@4erienced science as a creative endeav$r, it

9as thr$ugh c$nversati$ns in C$urna& c&u(s.

My first c$nversati$ns 9ere a($ut e4idemi$&$gy, 9hen ? 9as 9$ring at a c$mmunity 8&-4reventi$n

agency 9ith a staff C$urna& c&u(. My ne@t c$nversati$ns 9ere a($ut the immune system, in a C$urna& c&u(

run (y A?D/ activists 9ith the he&4 $f a graduate student in immun$&$gy. ?t 9as a 4erfect e@am4&e $f the

9ay in 9hich certain inds $f A?D/ activists and c$mmunity A?D/ 9$rers n$t $n&y inf&uenced science,(ut 9ere inf&uenced (y it.!We came t$ science in an aty4ica& $rder first thr$ugh scientific meetings and

C$urna& artic&es and $n&y &ater, if at a&&, thr$ugh f$rma& training. ?n the face $f the urgency and uncertainty $f

the A?D/ e4idemic, even n$nscientists &ie me c$u&d see science as discussi$n, de(ate, a c$$4erative searchthr$ugh the unn$9n S and as a creative activity.

As a sec$nd-year medica& student, ? find that my energies and th$se $f my c&assmates are m$re $ften

driven (y fee&ings $f inadeBuacy than (y the ins4irati$n $f science as a C$urney. We 9$rry a($ut things 9e

d$nRt yet n$9 (ut that are n$9n (y $thers S es4ecia&&y th$se 9h$ 9i&& test us. /4ending time $n the

unn$9n $ften seems indu&gent.

;


22/167

'ntrodu)tionThis 4rec&inica& 4eri$d $f acBuiring the facts $f medicine is an inevita(&e 4hase $f $ur deve&$4ment as

4hysicians. ertain&y, my greatest suffering in medica& sch$$& c$mes 9hen ? resist that necessity. ? can see

that my 4atients 9i&& need me t$ have a g$$d 4$rti$n $f th$se facts in hand, and 4atients, after a&&, are the

reas$n ? came t$ medica& sch$$&.

/ti&&, s$me $f my s9eetest times here have (een th$se 9hen science st$44ed (eing facts t$ dri&& and

(ecame a c$nversati$n. Our 8?-A?D/ C$urna& c&u( is inf$rma&, sma&&, and &ed (y studentsG it meets $n a

catch-as-catch-can, n$t-during-e@am-9ee schedu&e. N$nethe&ess, it has survived f$r a year n$9. N$

facu&ty mem(ers are ever 4resentG ? d$u(t that many n$9 it e@ists. N$ $ne is handing $ut e@tra-credit4$ints f$r attendance. *ut 9e care a($ut A?D/, and s$ 9e va&ue A?D/ research.

$&untary C$urna& c&u(s reBuire intense sincerityG &itt&e e&se can m$tivate 4e$4&e t$ read scientific

artic&es and rea&&y engage 9ith their c$ntents. During my time in an immun$&$gy &a($rat$ry, ? used t$

receive ann$uncements a($ut an$ther C$urna& c&u(, 9hich started 9ith sa&utati$ns &ie F5reetings, *-ce&&

fansF $r F8e&&$, *e&ieversJF N$t (eing a *-ce&& fan in 4articu&ar ? &ie them fine, (ut ?Rm m$re $f a T-ce&&

&$ya&istE, ? never attended. *ut ? &$ved the greetings (ecause they c$nCured u4 visi$ns $f a gr$u4 $f

enthusiasts. A g$$d C$urna& c&u( must inc&ude n$t $n&y FC$urna&,F (ut a&s$ Fc&u(.F#$r this reas$n, ? distinguish C$urna& c&u(s that are reBuired as in 9$r settingsE $r $ffer tangi(&e

re9ards f$r instance, n$tice fr$m 4$9erfu& 4e$4&eE fr$m v$&untary ass$ciati$ns. The f$rmer are a s$rt $f

mandat$ry fun, m$re FC$urna& meetingF than FC$urna& c&u(.F ?n a C$urna& c&u(, mem(ers are having a

c$nversati$n f$r its $9n sae. Pe$4&e sh$9 u4 at a g$$d C$urna& c&u( even 9hen the ($ss is $ut $f t$9n $r

the materia& 9$nRt (e $n the test. At these m$ments, science is n$ &$nger a means t$ an end (ut a 4&easura(&e

end in itse&f.

?tRs n$t that ? $44$se C$urna& meetings. 1ven a C$urna& meeting f$sters an a44reciati$n f$r the 4rimary

&iterature $f science, a hea&thy se4ticism a($ut its findings, and the si&&s t$ read critica&&y. 0$urna&

meetings and C$urna& c&u(s a&ie he&4 readers t$ f$rm c$nc&usi$ns, raise d$u(ts, and as Buesti$ns that

e@tend m$re dee4&y and 9ide&y than th$se $f the a(stracts and acc$m4anying edit$ria&s. *$th 4revent us

fr$m treating C$urna&s as e@tensi$ns $f te@t($$s S and remind us t$ Buesti$n $ur te@t($$s.

*ut $n&y 9e $urse&ves can give each $ther science as c$nversati$n. T$ d$ s$, 9e have t$ ann$unce $ur

enthusiasm and active&y see $ut $thers 9h$ share it. This is n$t as easy as it s$unds sincerity is a f$rm $f

vu&nera(i&ity. /im4&y 4ut, $ne riss &$$ing &ie a gee. *ut there are 9$rse things, inc&uding never &$ving

science yet s4ending $neRs career immersed in it.

0$urna& c&u(s d$nRt a&9ays 9$r, $f c$urse, (ut theyRve ev$&ved s$me 4ractices that mae success m$re

&ie&y. #$r e@am4&e, each meeting sh$u&d f$cus $n at &east $ne artic&e c$ntaining 4rimary data, a&th$ugh

revie9 artic&es can (e an i&&uminating additi$n. The res4$nsi(i&ity f$r 4resenting artic&es sh$u&d r$tateam$ng mem(ers, a&& $f 9h$m sh$u&d (e m$re $r &ess eBua&&y c$mf$rta(&e S $r ready t$ dive in fear&ess&y

S in the c&u(Rs research area. /eni$r mem(ers sh$u&d n$t d$minate, and every$ne sh$u&d 4artici4ate.

Presentati$ns sh$u&d (e (rief, aiming t$ start and faci&itate c$nversati$n, give s$me (acgr$und, and c&arify

research meth$ds. ?dea&&y, the res4$nsi(i&ity f$r schedu&ing sessi$ns, reserving meeting s4ace, and sending

$ut reminders sh$u&d a&s$ r$tate. These cust$ms su44$rt an under&ying 4r$4$siti$n the C$urna& c&u( is a

c$nversati$n am$ng eBua&s a($ut the 9$r and fruits $f science.

/cience maes its s4&ashes 9ith ne9 resu&ts. /cience &ives, h$9ever, n$t (y resu&ts, (ut (y the

e@changes $f ideas that f$&&$9 them. And s$ C$urna& c&u(s are a 9ay $f ee4ing science a&ive S even in

medica& sch$$&, and (ey$nd.

;. Parish W+, +aumann 1O, $hen M/, et a&. P$4u&ati$n-(ased study $f ch&amydia& infecti$n in hina a hidden

e4idemic. 0AMA 2""3G2%-73.

2. *eyrer . 8idden e4idemic $f se@ua&&y transmitted diseases in hina crisis and $44$rtunity. 0AMA 2""3G2%


23/167

'ntrodu)tion

2;


24/167

S)hedule*Assignments* 3

Slides

22


25/167

4ee/ 5- August 56758$ell and !iss-e Response to *n.-ry + %nvironmental Pathology

Sched-le

3onday$ *ugust 45

;" AM - N$$n

Orientati$n +ecture 8a&&

2uesday$ *ugust 46

;-2 PM +ecture A4$4t$sis and Necr$sis West +ecture 8a&&

2-! PM ase-*ased /tudy e&& ?nCury +a($rat$ry 1nvir$nmenta& Path$&$gy

2hursday$ *ugust 47

;-! PM PathTa& e&& ?nCury +a($rat$ry

1nvir$nmenta& Path$&$gy

-riday$ *ugust 48

;"-;;AM /ummary ?nf&ammati$n)Tissue West +ecture 8a&& 'e4air

;; AM- N$$n 0$urna& c&u()14i-*i$ $nsu&t +a($rat$ry '$$m 2"7 ?nf&ammati$n)Tissue 'e4air

23


26/167


ssignments

!opic 6? $ell and !iss-e Reaction to *n.-ry

Re@-ired Reading?Robbins and otran Pathologic !asis of "isease# Bth $dition,

e&&u&ar Ada4tati$ns, e&& ?nCury, and e&& Death, ha4ter ;, 44. 3-!>

Recommended Reading&etterDs *llustrated ,uman Pathology

ha4ter ; 5enera& 'eacti$n Patterns

!opic :? %nvironmental Pathology

Re@-ired Reading?Robbins and otran Pathologic !asis of "isease# Bth $dition,

1nvir$nmenta& Path$&$gy, ha4ter

Re@-ired St-dy for Small (ro-ps

PathTal/ssignments?

$dachr$mes $n We(T

/&ide descri4ti$ns 0$urna& c&u( artic&es

o 'ournal lubsE-cience as onersation/ee intr$duct$ry materia&s $f this

($$&etE

o Mutations in T$RT# The Aene for Telomerase Reerse Transcriptase# in /plastic

/nemia, 8ir$i 6amaguchi, M.D., et a&. $&ume 32;!;3-;!2! A4ri& 7, 2""Num(er ;!

o Telomerase Mutations in /plastic /nemia, Wi&&iam 1. #i((e, M.D., Ph.D.

$&ume 32;!%;-;!%3 A4ri& 7, 2"" Num(er ;!

&ase7Based Studyssignments?

Printed ase ; H32 year-$&d man f$und unc$nsci$us at the scene $f a fireUI

Printed ase 2 HA 73-year-$&d ?ta&ian manUI

&ase7Based StudyRe@-ired reading? (idmann)s linical *nterpretation of Laboratory Tests

Princi4&es $f inter4retati$n $f &a($rat$ry tests

2!


27/167


44. 3-;"

$m4&ete (&$$d c$unt

44. >;->7 'ed (&$$d ce&& and hem$g&$(in c$ncentrati$n

44. %2-% Peri4hera& (&$$d and granu&$cytes

44. %7->-7" *i&iru(in

44. 73-7! O(structive &iver en:ymes

44. 7>-7


28/167


Printed $ases

Printed &ase 95- :; year7old man (ound un)ons)ious at the s)ene o( a (ire

This 32-year-$&d 9hite ma&e 9as (r$ught t$ the emergency r$$m after having (een f$und in a sma&& st$rage

(ui&ding in an industria& 4ar. A44arent&y, he had (een drining and sm$ing 9hen a fire started in the(ui&ding. sing avai&a(&e fire e@tinguishers c$ntaining car($n tetrach&$ride he succeeded in 4utting $ut the

fire (ut 9as $verc$me (y sm$e and 4assed $ut. 8e 9as f$und unc$nsci$us severa& h$urs &ater (y his

c$9$rers. A ha&f-em4ty ($tt&e $f 9hisey and a trash (aset c$ntaining 4artia&&y (urnt 4a4er and rags 9ere

n$ted. One $f his c$9$rers 9h$ acc$m4anied the rescue sBuad t$ the h$s4ita& stated that he ne9 $f n$

maC$r i&&nesses in the 4atient (ut the 4atient 9as n$9n t$ have a drining 4r$(&em.

Physical e!amination$n admissi$n revea&ed a semic$nsci$us, 9e&&-deve&$4ed, mi&d&y $(ese 9hite ma&e.

Ora& tem4erature -V# Pu&se - 3 ;"" 2>

*N mg)d+E 7-2! 2> 27 !7 7< ;2>

reat. mg)d+E ".7 - ;.! ;.3 ;.3 2.% !.< %."

T$t. *i&. mg)d+E "."-;. ;. .2

Dir. *i&. mg)d+E "."2-".;% ".; 2.7 !.; 3.> 2.%

A/T )+E "- 2%% ;!7" 2;" ;


29/167


characteri:ed (y 4ersistent Caundice and increasing res4irat$ry difficu&ty eventua&&y deve&$4ing

4u&m$nary edema and e@4iring $n the %thday after admissi$n. An aut$4sy 9as 4erf$rmed.


30/167


Printed &ase 9;- A


31/167


2


32/167

?e%ie# images:avai&a(&e $n ase-*ased

/tudies secti$n $f Path$&$gy We(T site.

Clinical Course: Whi&e underg$ing testing ,he had a 4r$gressive&y d$9nhi&& c$urse,deve&$4ing menta& $(tundati$n. *r$nchia&(rushings 9ere $(tained. An aut$4sy 9as4erf$rmed 9hen he e@4ired 7 9ees 4$stadmissi$n.

>uestions for home#ork 0 to be #ritten and brought to class (at instructors discretion);. #r$m the inf$rmati$n given derive the red (&$$d ce&& indices. What d$ they te&& y$ua($ut the 4atientRs erythr$cytes2. What &a($rat$ry tests are c$mm$n&y used t$ eva&uate hem$stasis 8$9 d$ y$uinter4ret their resu&ts in terms $f the c$agu&ati$n 4r$cess3. What is the 4r$4er meth$d f$r c$&&ecti$n $f a r$utine urina&ysis in an adu&t man and

9$man!. ?n #igure ! $n We(T, 9hat is the r$d-&ie $r dum((e&&-&ieE (r$9n $(Cect a tiny (ita($ve and t$ the right $f center What different diseases is it ass$ciated 9ith

>uestions -or ,iscussion 0 9ot 1ritten

;. What is the m$st &ie&y diagn$sis in this case and h$9 d$ y$u su44$rt it

$4yright 2""; #rederic . /vara, MD A&& 'ights 'eserved.

$le)trolytes

Na ;3% m1B)+ ;3>-;!>E

3.> m1B)+ 3."-."E

& ;" m1B)+ mgL %.-;".E

Ph$s4h$rus 3. mgL 2.-!.E

A& Ph$s ;>; )+ 3"-;2"E

*i&iru(in ".> mgL "-;.E

/OT A/TE ;;; )+ ;2-!E

/5PT A+TE )+ 3-!"E

55TP 22; )+ ;-7"E


33/167

"odachrome Slides

&ell and Tissue Res1onse to 'n+ury 0 $n,ironmental 'nsults

Cell Inury

&ell 'n+ury 95 &ellular S>elling

@idney$ +emato!ylin A eosin stain&


34/167

&ell 'n+ury 9? Myo)ardial 'n(ar)t

This cr$ss-secti$n $f the a4e@ $f the heart sh$9s a recent, 4a&e ye&&$9-gray infarct 9ith acentra& dar red-(r$9n tract $f ru4ture. AdCacent t$ this is a 9hite, $&d my$cardia& scar.

8$9 9$u&d y$u acc$unt f$r a&& the vari$us c$&$rs y$u see in these &esi$ns

&ell 'n+ury 96 &oagulati,e %e)rosis- S1leni) 'n(ar)t

T9$ &arge infarcts areas $f c$agu&ative necr$sisE are seen in this secti$ned s4&een. /ince

the eti$&$gy $f c$agu&ative necr$sis is $ften ischemia, the infarct $ccurs in a vascu&ardistri(uti$n that is 9edge-sha4ed 9ith a (ase at the $rgan ca4su&e.

&ell 'n+ury 9@ iue(a)ti,e %e)rosis- i,er Abs)ess

+emato!ylin and eosin. +$9 4$9er. The &iver sh$9s a sma&& a(scess here fi&&ed 9ithmany neutr$4hi&s, 4r$(a(&y the resu&t $f (acteria& $r funga& infecti$n. The infecti$n e&icits

a mared acute inf&ammat$ry res4$nse, and 4r$te$&ytic en:ymes fr$m the inf&ammat$ryce&&s digest the tissue. This a(scess is an e@am4&e $f &$ca&i:ed &iBuefactive necr$sis.

&ell 'n+ury 9< iue(a)ti,e %e)rosis- Brain* !ross

+iBuefactive necr$sis is usua&&y the resu&t $f a (acteria& $r funga& infecti$n, (ecause these

4r$cesses ev$e a massive inf&u@ $f inf&ammat$ry ce&&s, 9hich re&ease vari$us

degradative en:ymes. #$r unc&ear reas$ns, a hy4$@ic insu&t t$ the (rain as $44$sed t$

m$st $ther $rgansE resu&ts in &iBuefactive necr$sis. As this infarct in the (rain (ec$mes$rgani:ed and res$&ved, the &iBuefactive necr$sis &eads t$ res$&uti$n 9ith cystic s4aces.

&ell 'n+ury 9 iue(a)ti,e %e)rosis- Brain

This is &iBuefactive necr$sis in the (rain in a 4atient 9h$ suffered a Fstr$eF 9ith f$ca&

&$ss $f (&$$d su44&y t$ a 4$rti$n $f cere(rum. This ty4e $f infarcti$n is mared (y &$ss $f

neur$ns and neur$g&ia& ce&&s and the f$rmati$n $f a c&ear s4ace at the center &eft. The4r$te$&ytic en:ymes res4$nsi(&e f$r the necr$sis c$me fr$m &ys$s$mes, either fr$m the

dead ce&&s $r fr$m the invading &eu$cytes, $r fr$m ($th.

&ell 'n+ury 98 &aseous %e)rosis- ung* !ross

This is the gr$ss a44earance $f case$us necr$sis in a hi&ar &ym4h n$de infected 9ith

tu(ercu&$sis. The n$de has a cheesy tan t$ 9hite a44earance. ase$us necr$sis is rea&&y

Cust a c$m(inati$n $f c$agu&ative and &iBuefactive necr$sis that is m$st characteristic $fgranu&$mat$us inf&ammati$n.


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&ell 'n+ury 95C &aseous %e)rosis- ung

+emato!ylin and eosin stain& Lo# po#er&Often the resu&t $f myc$(acteria& $r funga&infecti$n, case$us necr$sis is characteri:ed (y ace&&u&ar 4in areas $f necr$sis, as seen

here at the u44er right. T$ the &eft and d$9n it is surr$unded (y a granu&$mat$us

inf&ammat$ry reacti$n c$m4$sed $f 4a&isading Fe4ithe&i$idF histi$cytes, &ym4h$cytes,and $ther ce&&s. A&th$ugh n$t seen here, mu&tinuc&eated giant ce&&s are a&s$ characteristic.

&ell 'n+ury 955 Fat %e)rosis- Pan)reas* !ross

This is fat necr$sis $f the 4ancreas. e&&u&ar inCury t$ the 4ancreatic acini &eads t$ re&ease

$f 4$9erfu& en:ymes that damage fat (y the 4r$ducti$n $f s$a4s, and these a44ear

gr$ss&y as the s$ft, cha&y 9hite areas seen here $n the cut surfaces. Necr$sis $f the

acinar ce&&s $f the 4ancreas re&eases &i4ase and 4r$teases that in turn &ead t$ inCury and

death $f adi4$se ce&&s. Trig&ycerides are hydr$&y:ed t$ g&ycer$& and fatty acids, and thefatty acids are then sa4$nified c$nverted t$ s$a4sE (y reacting 9ith ca&cium, magnesium

and s$dium. ?f fat necr$sis is e@tensive, sufficient ca&cium may (e de4$sited t$ resu&t inhy4$ca&cemia and in s$me cases even tetany. Adi4$se tissue in $ther areas (reast $r

thigh, etc.E may a&s$ underg$ necr$sis f$&&$9ing trauma.

&ell 'n+ury 95; Fat %e)rosis Pan)reas

+emato!ylin and eosin stain& Lo# magnification&Micr$sc$4ica&&y, fat necr$sis

adCacent t$ 4ancreas is seen here. There are s$me remaining steat$cytes at the &eft 9hich

are n$t necr$tic. The necr$tic fat ce&&s at the right have vague ce&&u&ar $ut&ines, have &$sttheir 4eri4hera& nuc&ei, and their cyt$4&asm has (ec$me a 4in am$r4h$us mass $f

necr$tic materia&.

&ell 'n+ury 95: !angrene- D#ryE

This is gangrene, $r necr$sis $f many tissues in a ($dy 4art. Th$ugh n$t a distinct

4ath9ay $f ce&& death, the term is in c$mm$n surgica& usage. /$-ca&&ed FdryF gangrene isthe resu&t $f &$ss $f (&$$d su44&y 9ith c$agu&ative necr$sis due t$ an$@ia. ?n this case, the

t$es 9ere inv$&ved in a fr$st(ite inCury.

&ell 'n+ury 95? !angrene- D4etE

This is gangrene $f the &$9er e@tremity. ?n this case the term F9etF gangrene is m$re

a44&ica(&e (ecause $f the &iBuefactive c$m4$nent fr$m su4erim4$sed infecti$n in

additi$n t$ the c$agu&ative necr$sis fr$m &$ss $f (&$$d su44&y. This 4atient had dia(etesme&&itus. #$r a &iterary treatment $f gangrene, read The -nows of FilimanGaro(y 1rnest

8eming9ay.


36/167

&ell 'n+ury 956 A1o1tosis- iral He1atitis

+emato!ylin and eosin stain&


37/167

Prostate gland& +emato!ylin A eosin stain& right imageD& *enign 4r$static

hy4er4&asia *P8E $r n$du&ar hy4er4&asia is an e@treme&y c$mm$n c$nditi$n seen in men

$ver the age $f " years. The hist$&$gic ha&&mar $f *P8 is the e@4ansi&e n$du&e,4$rti$ns $f t9$ $f 9hich are seen in this 4h$t$micr$gra4h. 1ither the g&ands, the str$ma,

$r ($th may underg$ hy4er4&asia. The cause is m$st &ie&y re&ated t$ e@cess stimu&ati$n

$f the 4r$state g&and (y test$ster$ne $r its meta($&ite dehydr$test$ster$ne.

&ell 'n+ury 9;C Heart- Hy1ertro1hy

This is cardiac hy4ertr$4hy inv$&ving the &eft ventric&e the cham(er $n seen here $n the&eftE. The num(er $f my$cardia& fi(ers d$es n$t increase, (ut their si:e can increase in

res4$nse t$ an increased 9$r&$ad, &eading t$ the mared thicening $f the &eft ventric&e

in this 4atient 9ith systemic hy4ertensi$n.

&ell 'n+ury 9;5 Atro1hy- Mus)le Fibers

2richrome stain& +igh magnification&There are s$me musc&e fi(ers here that sh$9

atr$4hy. The num(er $f ce&&s is the same as (ef$re the atr$4hy $ccurred, (ut the si:e $fs$me fi(ers is reduced. This is a res4$nse t$ inCury (y Fd$9nsi:ingF t$ c$nserve the ce&&.

?n this case, innervati$n $f the sma&& fi(ers in the center 9as &$st.

&ell 'n+ury 9;; 'ntra)ellular A))umulation o( !ly)ogen

Li%er& +emato!ylin A eosin stain& F7& *y &ight micr$sc$4y ce&&s c$ntaining e@cess

de4$siti$n $f g&yc$gen a44ear t$ have c&ear $r vacu$&ated cyt$4&asm. /ince this

a44earance c$u&d a&s$ (e due t$ the accumu&ati$n $f 9ater hydr$4ic s9e&&ingE $r fat,s4ecia& stains are usua&&y em4&$yed t$ aid in differentiati$n. ?f the g&yc$gen 9as

4reserved during hist$&$gic 4r$cessing, it can (e dem$nstrated as a reddish c$&$r (y the

4eri$d acid-/chiff PA/E stain. 'eacting the tissue 9ith diastase t$ digest g&yc$gen servesas a negative c$ntr$&. This is the &iver fr$m a 4atient 9ith $n 5ieres disease, $ne $f the

g&yc$gen st$rage diseases. These entities 9i&& (e discussed m$re fu&&y in the secti$n $n

genetic disease. 5&yc$gen can a&s$ accumu&ate in the idney, &iver, 4ancreas, andmy$cardium $f 4atients 9ith dia(etes me&&itus.

&ell 'n+ury 9;: 'ntra)ellular A))umulation o( i1ids

Li%er& +emato!ylin A eosin stain& 4 le!t imageD&This is an e@am4&e $f theaccumu&ati$n $f trig&ycerides steat$sis $r fatty changeE in he4at$cytes and can (e resu&t

$f any $f the f$&&$9ing c$nditi$ns

;. ?ncreased entry $f fatty acids int$ the ce&&s.2. 'educed $@idati$n $f fatty acids

3. 1@cess 4r$ducti$n $f fatty acids fr$m acetate.

!. ?nadeBuate &i4$4r$tein re&ease fr$m he4at$cytes.. 'educed &i4$4r$tein re&ease fr$m he4at$cytes.


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Steatsis 8Fatt Change9

TeHistlg Eamles

Micr$vesicu&ar e&& en&argedG numer$us sma&&

fat dr$4&etsG n$ a&terati$n innuc&ear m$r4h$&$gy $r &$cati$n

sua&&y due t$ acute t$@ic

he4at$ce&&u&ar inCuryG a&c$h$&,tetracyc&ine, as4irin, etc.

Macr$vesicu&ar&arge dr$4&et E

e&& en&argedG usua&&y a &argesing&e fatty vacu$&eG cyt$4&asm

and nuc&eus 4ushed t$ 4eri4hery

sua&&y due t$ chr$nic inCuryGma&nutriti$nG chr$nic a&c$h$&

a(useG c$rtic$ster$idsG

meth$tre@ateG $rganic s$&vents,etc.

Subcutaneous tissue& 3asson trichrome stain& 7& right imageD& Numer$us f$amce&&s in the su(cutane$us tissue $f a ;-year-$&d ma&e 9ith a t$ta& serum ch$&ester$& &eve&

$f 2 mg)d+. This is an @anth$ma and the intrace&&u&ar &i4id is 4red$minant&y

ch$&ester$& and ch$&ester$& esters.

&ell 'n+ury 9;? 'ntra)ellular A))umulation o( 'ron

A Prussian (&ue reacti$n is seen in this ir$n stain $f the &iver t$ dem$nstrate &arge

am$unts $f hem$siderin that are 4resent in he4at$cytes and u4ffer ce&&s. When ferric

ir$n reacts 9ith an acid s$&uti$n $f 4$tassium ferr$cyanide, it f$rms a dee4 (&ue

c$m4$und, ferric ferr$cyanide as seen here. This is the Prussian (&ue reacti$n.

&ell 'n+ury 9;6 'ntra)yto1lasmi) A))umulation o( Melanin

+emato!ylin and eosin stain& +igh magnification. This is the micr$sc$4ic a44earance$f a ma&ignant me&an$ma. +arge 4$&yg$na& ce&&s $r s4ind&e ce&&s in s$me casesE have

very 4&e$m$r4hic nuc&ei 9hich c$ntain 4r$minent nuc&e$&i. The ne$4&asm is maing

(r$9n me&anin 4igment. A #$ntana-Mass$n stain f$r me&anin may he&4 t$ detect sma&&am$unts $f cyt$4&asmic me&anin.

&ell 'n+ury 9;@ 'ntra)ellular A))umulation o( Bilirubin

Li%er& +emato!lin A eosin stain & 45. This is an e@am4&e $f drug-inducedch$&estasis. M$st $f the he4at$cytes c$ntain numer$us greenish $r greenish(r$9n

dr$4&ets $f c$nCugated (i&iru(in. ?ntracani&icu&ar ch$&estasis is a&s$ 4resent. #ree (i&iru(inis derived fr$m the 4$r4hyrin ring $f hem$g&$(in during red (&$$d ce&& destructi$n andcan resu&t in ce&& inCury (y unc$u4&ing $@idative 4h$s4h$ry&ati$n in mit$ch$ndria $r (y

causing 4r$tein &$ss thr$ugh an effect $n the 4&asma mem(rane.


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&ell 'n+ury 9;< Anthra)osis- ung

The (&ac streas seen (et9een &$(u&es $f &ung (eneath the 4&eura& surface are due t$anthrac$tic 4igment. This anthrac$sis $f the &ung is n$t harmfu& and c$mes fr$m the

car($nace$us materia& (reathed in fr$m dirty air ty4ica& $f industria&i:ed regi$ns $f the

4&anet.

&ell 'n+ury 9; Metastati) &al)i(i)ation- ung

8ere is s$-ca&&ed Fmetastatic ca&cificati$nF in the &ung $f a 4atient 9ith a very high serum

ca&cium &eve& hy4erca&cemiaE. runchy a&ve$&i.

&ell 'n+ury 9;8 #ystro1hi) &al)i(i)ation- Stoma)h

This is dystr$4hic ca&cificati$n in the 9a&& $f the st$mach. At the ($tt$m $f the image is

an artery 9ith ca&cificati$n in its 9a&&. There are a&s$ irregu&ar (&uish-4ur4&e de4$sits $fca&cium in the su(muc$sa. a&cium is m$re &ie&y t$ (e de4$sited in tissues that are

damaged.

En"ironmental Pathology

&ell 'n+ury 9:C Radiation 'n+ury

?ectum& +emato!ylin A eosin stain& =4& le!t imageD& This 4h$t$micr$gra4hi&&ustrates the chr$nic effects $f radiati$n inCury t$ the rectum $f a 9$man 9h$ has had

4e&vic irradiati$n ;7 years 4revi$us&y f$r cervica& carcin$ma. The recta& 9a&& is thicened

(y fi(r$sis, the muc$sa is u&cerated, and the vesse&s are ectatic. A chr$nic inf&ammat$ryinfi&trate and scattered a(n$rma& fi(r$(&asts are 4resent.

?ectum& +emato!ylin A eosin stain& =4 right imageD& /imi&ar findings can (e seendee4er in the 9a&&, and here $ne $f the vesse&s a&s$ a44ears hya&ini:ed.

&ell 'n+ury 9:5 Heroin- ung

Lung& +emato!ylin A Eosin Stain& 55. The a&ve$&ar s4aces $f the &ung fr$m this2!-year-$&d her$in addict are fi&&ed 9ith the 4in, h$m$gene$us f&uid $f 4u&m$nary

edema. M$st &ie&y this 9as a hy4ersensitivity reacti$n t$ the drug $r $ne $f its

adu&terants.

An$ther c$mm$n finding in the &ungs fr$m intraven$us drug users is the 4resence $f

granu&$mas sec$ndary t$ s$me $f the di&uents used t$ HcutI the drug such as ta&c. Ta&c isa si&icate c$m4$und that is mi&d&y fi(r$genic and 9ide&y used in industry. *esides its use

as a di&uent f$r Hstreet drugsI, e@4$sure t$ ta&c $ccurs in miners and mi&&ers, am$ng

9$rers in the 4harmaceutica& and c$smetics industries, and $f c$urse am$ng c$smetic

users.


40/167

&ell 'n+ury 9:; Heroin %e1hro1athy

+emato!ylin and eosin stain&


41/167

4ee/ ;- August ;;7;@'n(lammation0Tissue Re1air

Sched-le

2uesday$ *ugust =

;-2 PM +ecture 5enera& +a($rat$ry

Medicine

West +ecture 8a&&

2-! PM ase-*ased /tudy

?nf&ammati$n

+a($rat$ry

2hursday$ *ugust 52- PM Path Ta& ?nf&ammati$n +a($rat$ry

-riday$ *ugust 6

;"-;;AM /ummary ?mmunity West +ecture 8a&&

;;AM-N$$n 0$urna& &u()14i-*i$ $nsu&t +a($rat$ry '$$m 2"7

?mmunity


42/167


ssignments

!opic? Reaction to !iss-e *n.-ry? %dema9 !hrombosis9 and *nflammation

Re@-ired Reading?

Robbins and otran Pathologic !asis of "isease# Bth $dition, Acute and hr$nic ?nf&ammati$n, ha4ter 2, 44. !7-%>

Tissue 'ene9a& and 'e4air, ha4ter 3, 44. %7-;;%

8em$dynamic Dis$rders, Thr$m(em($&ic Disease, and /h$c, ha4ter !, 44. ;;, 2""!

&ase7Based Studyssignments?

Printed ase ; - HThe case $f the e@cessive n$se(&eedsUI

Printed ase 2 - HA >7 year $&d 9hite fema&e 9as readmittedUI

ase+!ased Pathology and Laboratory Medicine, ase ;7 HA 7" year-$&d gardenerUI

&ase7Based StudyRe@-ired reading? (idmann)s linical *nterpretation of Laboratory Tests

Princi4&es $f inter4retati$n $f &a($rat$ry tests

44. ;"-;7

Anemia and c$agu&ati$n

44. ;!-; 1@trinsic hem$&ytic anemias

44. 3"-3;" Thr$m($cyt$4enia due t$ immune destructi$n $f 4&ate&ets

44. 22-2> $agu&ati$n cascade

44. 2>!-2> $agu&ati$n tests

44.


43/167


Printed &ase 95- The &ase o( the $)essi,e %osebleeds'e4r$duced, 9ith 4ermissi$n, fr$m a C$urna& c$4yrighted (y the American /$ciety f$r &inica& Path$&$gyc$ntact Dr. Weissmann f$r c$4yright detai&sE

Patient: !%-year-$&d fema&e.Chief Complaint:Patient had (een in her usua& state $f g$$d hea&th unti& recent&y 9hen she n$ted signs and sym4t$ms $f

an u44er res4irat$ry infecti$n. /he n$ted rhin$rrhea, c$ngesti$n, c$ugh, and &ater deve&$4ed e4ista@is n$se (&eedingE. The

e4ista@is 4r$gressive&y 9$rsened and the 4atient su(seBuent&y deve&$4ed hematuria and 4etechia $n the right thigh.

Patient c$m4&ained $f severe heachaches and a fever, (ut denied chi&&s, night s9eats, visua& changes, sh$rtness $f (reath,

$r hemat$che:ia.

3edical +istory nremara(&e.

Surgical +istory h$&ecystect$my and tu(a& &igati$n.

Social +istory Patient has sm$ed 2 4acs $f cigarettes 4er day f$r the &ast 3" yearsG denied any a&c$h$& $r drug a(use.

-amily +istory M$ther died at age ! fr$m em($&ic cere(ra& vascu&ar accident. #ather died at age ! fr$m my$cardia&

infarcti$n. Patient has 2 (r$thers 9ith hy4ertensi$n and a sister 9ith &ung cancer.

Physical and 9eurological E!amination The 4atients tem4erature 9as e&evated at ;"". #, and she a44eared mi&d&y

c$nfused. Petechiae 9ere 4resent $ver the &$9er e@tremities.

Prin)i1al aboratory Findings

Test PatientGs Result %ormal

W* $unt s+D % "-;ed ratioH PTT# partial thromboplastin timeH L"# lactate

dehydrogenaseH !? blood urea nitrogen.


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#igure ; On ase-*ased /tudy secti$n $f We(T Patients 4eri4hera& (&$$d smear i&&ustrating schist$cytes

;"""@ magnificati$nE.

>uestions

;. What is areE this 4atientRs m$st striing &a($rat$ry resu&ts

2. 8$9 d$ y$u e@4&ain this 4atientRs m$st striing findings)&a($rat$ry resu&tssE

3. What c$nditi$nsE d$es this 4atientRs &a($rat$ry and $ther findings suggest!. Which additi$na& &a($rat$ry testsE are a44r$4riate t$ $rder $n this 4atient and 9hy

. What is the m$st a44r$4riate treatment f$r this 4atient


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Printed &ase 9;- A @< year old >hite (emale >as readmitted

CL3L !"-7E T$ta& 4&asma 4r$tein .!gm)d& >-%E

(ands 3"L "-7E A&(umin 3." gm)d& 3.-E

&ym4hs 7L ;3-!E Arteria& (&$$d gases

85* ;"." gmL ;2-;%E 48 7.;" 7.3-7.!E

8T 3".% L 37-!7E 4O2 3> mm85 32-!>E

M

M8 3".> 4g 27-3;E 4O2 >" mm8g 7!-;"%E

Pits 2"< th$u ;3"-!""E O2 saturati$n %< L


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Kuesti$ns #$r 8$me9$r - T$ *e Written And *r$ught T$ &ass at the instruct$rs discreti$nE;. What 4recauti$ns are necessary in cu&turing (&$$d and determining the significance $f any $rganisms $(tained2. 8$9 is e@aminati$n $f the urine sediment 4erf$rmed and 9hat can it revea&

Kuesti$ns #$r &ass Discussi$n - N$t Written

;. What is the m$st &ie&y diagn$sis in this case and h$9 d$ y$u su44$rt that diagn$sis


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"odachrome Slides

Rea)tions to Tissue 'n+ury 95 $udation

+emato!ylin A eosin stain& 3edium po#er& Lung./een here is vas$di&ati$n 9ith e@udati$n that has &ed t$ an$ut4$uring $f f&uid 9ith fi(rin int$ the a&ve$&ar s4aces, a&$ng 9ith PMNRs. The series $f events in the 4r$cess $f

inf&ammati$n are

;. as$di&ati$n &eads t$ greater (&$$d f&$9 t$ the area $f inf&ammati$n, resu&ting in redness and heat.

2. ascu&ar 4ermea(i&ity end$the&ia& ce&&s (ec$me F&eayF fr$m either direct end$the&ia& ce&& inCury $r viachemica& mediat$rs.

3. 1@udati$n f&uid, 4r$teins, red (&$$d ce&&s, and 9hite (&$$d ce&&s esca4e fr$m the intravascu&ar s4ace as a

resu&t $f increased $sm$tic 4ressure e@travascu&ar&y and increased hydr$static 4ressure intravascu&ar&y

4. ascu&ar stasis s&$9ing $f the (&$$d in the (&$$dstream 9ith vas$di&ati$n and f&uid e@udati$n t$ a&&$9chemica& mediat$rs and inf&ammat$ry ce&&s t$ c$&&ect and res4$nd t$ the stimu&us.

Rea)tions to Tissue 'n+ury 9; %eutro1hil in A)tion

This animati$n dem$nstrates the acti$ns $f neutr$4hi&s in the acute inf&ammat$ry 4r$cess. These series $f events

in the 4r$cess $f inf&ammati$n are mediated (y

/e&ectins m$&ecu&es $n &eu$cytes +-se&ectinE and end$the&ium 1-se&ectin, P-se&ectinE act as rece4t$rs

t$ 4r$vide &$$se (inding f$r r$&&ing.

?AM-; interce&&u&ar adhesi$n m$&ecu&e ; 4r$vides m$re firm adhesi$n $f the neutr$4hi&, via integrins

$n neutr$4hi& surfaces, t$ the end$the&ium.

D3; this ce&& t$ ce&& adhesi$n m$&ecu&e aids in dia4edesis.

a and +T*! chem$ta@is is aided (y the a c$m4$nent fr$m c$m4&ement activati$n, a&$ng 9ith

&eu$triene *!, a 4r$duct $f the &i4$-$@ygenase 4ath9ay $f arachid$nic acid meta($&ism.

3( and ?g5 $4s$nins such as the 3( c$m4$nent fr$m c$m4&ement activati$n, as 9e&& as

immun$g&$(u&in 5, c$at f$reign $(Cects such as (acteria t$ aid in 4hag$cyt$sis (y (inding t$ &eu$cyte

rece4t$rs.

Mye&$4er$@idase, &ys$:yme after engu&fment, i&&ing $f (acteria $ccurs via generati$n $f t$@ic $@ygens4ecies su4er$@ideE c$nverted t$ hydr$gen 4er$@ide and further c$nverted t$ a hy4$ch&$r$us radica& (y

mye&$4er$@idase fr$m neutr$4hi& granu&es. ?n the a(sence $f $@idati$n, &ys$:yme fr$m neutr$4hi&

granu&es can f$rm h$&es in micr$(ia& mem(ranes.

Rea)tions to Tissue 'n+ury 9: #ia1edesis


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+emato!ylin A eosin stain& 3edium po#er&Neutr$4hi&s that are marginated a&$ng the di&ated venu&e 9a&&

arr$9E are sBuee:ing thr$ugh the (asement mem(rane the 4r$cess $f dia4edesisE and s4i&&ing $ut int$

e@travascu&ar s4ace.


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Rea)tions to Tissue 'n+ury 9? A)ute 'n(lammation

*ppendi!& +emato!ylin A eosin stain& 7& This is a 4$rti$n $f the 9a&& $f the a44endi@ fr$m a y$ung9$man 9h$ had a feca&ith at the a44endicea& $4ening. N$te the se4arati$n $f the fi(ers in the muscu&aris (y

edema f&uid and masses $f 4$&ym$r4h$nuc&ear &eu$cytes. This neutr$4hi&ic infi&trati$n $f the muscu&aris

c$nfirms the diagn$sis $f acute a44endicitis. The increased vascu&ar 4ermea(i&ity $f the vesse&s in this arearesu&ts in the &eaage $f a 4r$tein-rich e@udate, the edema f&uid, int$ the interstitium. Thr$ugh a 4r$cess n$9n

as e@travasati$n, the &eu$cytes &eave the circu&ati$n and migrate, under the inf&uence $f chem$tactic fact$rs, t$

the site $f inCury. The maC$r c$m4&icati$n $f acute a44endicitis is 4erf$rati$n 9ith the f$rmati$n $f4eria44endicea& a(scesses and 4erit$nitis.

Rea)tions to Tissue 'n+ury 96 A)ute 'n(lammation ;

Lung& +emato!ylin A eosin stain& 5& An$ther e@am4&e $f acute inf&ammati$n is seen in this

4h$t$micr$gra4h fr$m a 4atient 9ith (r$nch$4neum$nia. The a&ve$&i are fi&&ed 9ith neutr$4hi&s that have

emigrated fr$m the se4ta& vesse&s, 9hich are mared&y di&ated.

Rea)tions to Tissue 'n+ury 9@ &hroni) 'n(lammation- #iagram

e&&u&ar interacti$ns 9ith chr$nic inf&ammati$n are diagrammed.

Rea)tions to Tissue 'n+ury 9< &hroni) 'n(lammation- ung

hr$nic inf&ammati$n can (e seen in c$nCuncti$n 9ith s$me degree $f scarring. 8ere, chr$nic inf&ammati$n $f

the (r$nchi has &ed t$ di&ati$n and scarring 9ith increased tan t$ 9hite c$&&agen$us tissue.

Rea)tions to Tissue 'n+ury 9 &hroni) 'n(lammation

Lung& +emato!ylin A eosin stain& A /$metimes acute inf&ammati$n may ev$&ve int$ chr$nicinf&ammati$n. A&& the ha&&mars $f chr$nic inf&ammati$n can (e seen in this 4h$t$micr$gra4h a m$n$nuc&ear

ce&& infi&trate, tissue destructi$n, and fi(r$sis. The n$rma& architecture $f the &ung has (een destr$yed (y masses

$f inf&ammat$ry ce&&s main&y &ym4h$cytesE and fi(r$sis. /evera& cystic s4aces &ined (y cu($ida& e4ithe&ium and4artia&&y fi&&ed (y inf&ammat$ry ce&&s neutr$4hi&s, macr$4hages, and &ym4h$cytesE are a&& that remain $f the

4ree@isting a&ve$&i.

Rea)tions to Tissue 'n+ury 98 &hroni) 'n(lammation- Al,eolar 4alls

+emato!ylin A eosin stain& 3edium po#er.This is an e@am4&e $f &ess massive chr$nic inf&ammati$n.ertain eti$&$gic agents such as viruses are m$re &ie&y t$ &ead t$ chr$nic rather than acute inf&ammati$n, as

seen here in the &ung $f a 4atient 9ith inf&uen:a A. N$te a&s$ that the inf&ammat$ry infi&trates $f chr$nicinf&ammati$n are m$re &ie&y t$ (e interstitia& 9ithin tissuesE rather than e@udative a($ve surfaces $r in

s4acesE as in acute inf&ammati$n.


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Rea)tions to Tissue 'n+ury 95C !ranulomas- o> Po>er

+emato!ylin A eosin& Lo# po#er.The f$ca& nature $f granu&$mat$us inf&ammati$n is dem$nstrated in thismicr$sc$4ic secti$n $f &ung in 9hich there are scattered granu&$mas in the 4arenchyma. This is 9hy the chest

radi$gra4h 9ith tu(ercu&$sis $r $ther granu&$mat$us diseases is $ften descri(ed as Freticu&$n$du&arF. A (i$4sy

c$u&d miss such &esi$ns fr$m sam4&ing err$r, t$$.

Rea)tions to Tissue 'n+ury 955 !ranulomas- Medium Po>er

+emato!ylin A eosin& 3edium po#er&8ere are t9$ 4u&m$nary granu&$mas. 5ranu&$mat$us inf&ammati$nty4ica&&y c$nsists $f e4ithe&i$id macr$4hages, giant ce&&s, &ym4h$cytes, 4&asma ce&&s, and fi(r$(&asts. There may

(e s$me neutr$4hi&s.

+iterary n$te ?f y$u 9ant t$ (e fancy, f$r m$re than $ne granu&$ma y$u can use the 5ree 4&ura& $f granu&$ma

and ca&& them Fgranu&$mataF.

Rea)tions to Tissue 'n+ury 95; !ranulomas- High Po>er

+emato!ylin A eosin stains& +igh po#er&

-ig 4&5iant ce&&s are a Fc$mmitteeF $f e4ithe&i$id macr$4hages. /een here are t9$ +anghans ty4e giant ce&&s in9hich the nuc&ei are &ined u4 ar$und the 4eri4hery $f the ce&&. Additi$na& 4in e4ithe&i$id macr$4hages c$m4$se

m$st $f the rest $f the granu&$ma.

-ig & These are e4ithe&i$id ce&&s ar$und the center $f a granu&$ma. They get their name fr$m the fact that they

have &$ts $f 4in cyt$4&asm simi&ar t$ sBuam$us e4ithe&ia& ce&&s. Their nuc&ei tend t$ (e &$ng and stringy.

Rea)tions to Tissue 'n+ury 95: Fibrinous Peri)arditis- !ross

/ee4age $f a 4r$tein-rich f&uid int$ a cavity &eads t$ an e@udate. The fi(rin in this f&uid can f$rm a fi(rin$us

e@udate $n the surfaces. 8ere, the 4ericardia& cavity has (een $4ened t$ revea& a fi(rin$us 4ericarditis 9ith

strands $f stringy 4a&e fi(rin (et9een viscera& and 4arieta& 4ericardium.

Rea)tions to Tissue 'n+ury 95? Fibrinous Peri)arditis

+emato!ylin A eosin& 3edium po#er&Micr$sc$4ica&&y the fi(rin$us e@udate is seen t$ c$nsist $f 4in strands

$f fi(rin Cutting fr$m the 4ericardia& surface at the u44er &eft. *e&$9 this, there are a fe9 scattered inf&ammat$ryce&&s.


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Rea)tions to Tissue 'n+ury 956 Ab)ess- Bron)ho1neumonia* !ross

This a(scessing (r$nch$4neum$nia has numer$us areas $f raised, &ighter tan a44earance 9hich are the areasc$ntaining the e@tensive neutr$4hi&ic infi&trates.

Rea)tions to Tissue 'n+ury 95@ Pulmonary Ab)ess- o> Po>er

Lung& +emato!ylin A eosin stain& 5& This is a 4h$t$micr$gra4h $f an a(scess fr$m an$ther 4atient, actua&&y

a y$ung ($y 9ith chr$nic granu&$mat$us disease, an inherited dis$rder in 9hich $@ygen-de4endent mechanisms

f$r (acteria& i&&ing are deficient. The a&ve$&ar tissue in the center $f the a(scess has (een destr$yed andre4&aced (y a &arge mass $f necr$tic de(ris and neutr$4hi&s. The edge $f the a(scess c$ntains fi(r$(&asts and a

4r$minent vascu&ature. /$me $f the a&ve$&i surr$unding the a(scess c$ntain an inf&ammat$ry e@udate.

Rea)tions to Tissue 'n+ury 95< Pulmonary Ab)ess- Medium Po>er

+emato!yling A eosin stain& 3edium po#er&8ere is a f$ca& a(scess in the &ung. The a&ve$&i in this area have(een destr$yed.

Rea)tions to Tissue 'n+ury 95 !ranulation Tissue

Stomach& +emato!ylin A eosin stain& =4& The re4air $f damaged tissue inc&udes severa& 4r$cesses ;E ne9(&$$d vesse& f$rmati$n, 2E fi(r$(&ast 4r$&iferati$n, 3E de4$siti$n $f e@trace&&u&ar matri@, and !E $rgani:ati$n.

This 4h$t$micr$gra4h i&&ustrates granu&ati$n tissue f$rmati$n in a gastric u&cer. The surface $f the u&cer is

c$m4$sed $f inf&ammat$ry ce&&s and fi(rin. *eneath this is a rich c$m4&e@ $f ne9 (&$$d vesse&s, fi(r$(&asts and

inf&ammat$ry ce&&s.

Rea)tions to Tissue 'n+ury 9 58 !ranulation Tissue- High Po>er

+emato!ylin A eosin stain& +igh Po#er&At high magnificati$n, granu&ati$n tissue has ca4i&&aries, fi(r$(&asts,and a varia(&e am$unt $f inf&ammat$ry ce&&s m$st&y m$n$nuc&earE.

Rea)tions to Tissue 'n+ury 9;C Keloid

This is an e@am4&e $f an e@u(erant scar in a 4atient 9h$ has had a(d$mina& surgery. The e@cess f$rmati$n $f

scar tissue is ca&&ed Fe&$idF.

Rea)tions to Tissue 'n+ury 9;5 S/in- "oung S)ar

Skin& +emato!ylin A eosin stain& Lo# po#erOne $f the $utc$mes $f acute inf&ammati$n and the re4air4r$cess is fi(r$sis and scarring. This is a sin (i$4sy fr$m a 4atient 9h$ deve&$4ed s$me tenderness at the site

$f a 4revi$us (i$4sy f$r a sin tum$r. $m4are the e4idermis and dermis in the center $f the s4ecimen 9ith

th$se same areas t$9ard the edges $f the (i$4sy.


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Rea)tions to Tissue 'n+ury 9;; $dema- !ross

-ig 4&This e@am4&e $f a f&uid c$&&ecti$n, a fricti$n (&ister $f the sin, is an a&m$st trivia& e@am4&e $f edema.

-ig &This e@am4&e $f edema 9ith inf&ammati$n is n$t trivia& at a&& there is mared &aryngea& edema such that

the air9ay is narr$9ed. This is &ife-threatening. Thus, f&uid c$&&ecti$ns can (e seri$us de4ending u4$n their&$cati$n.

Rea)tions to Tissue 'n+ury 9;: $dema

+emato!ylin A eosin stain& Lo# po#er&The a&ve$&i are distended 9ith edema f&uid 9hich a44ears 4in and

h$m$gene$us in hemat$@y&in and e$sin stains. N$te the di&ated se4ta& vesse&s fr$m 9hich the f&uid $riginates.This is an e@am4&e $f 4u&m$nary edema fr$m a 4atient 9ith &$ngstanding c$ngestive heart fai&ure. The

accumu&ati$n $f the f&uid in the &ungs is due in 4art t$ an increase in the intravascu&ar hydr$static 4ressuresec$ndary t$ decreased cardiac $ut4ut.

Rea)tions to Tissue 'n+ury 9;? i,er- Passi,e &ongestion

8ere is an e@am4&e $f a FnutmegF &iver seen 9ith chr$nic 4assive c$ngesti$n $f the &iver. N$te the dar redc$ngested regi$ns that re4resent accumu&ati$n $f '*Rs in centri&$(u&ar regi$ns.

Rea)tions to Tissue 'n+ury 9;6 &ongestion- ung

Lung& +emato!ylin A eosin stain& 5& This 4h$t$micr$gra4h i&&ustrates a case $f acute 4assive c$ngesti$n

$f the &ung in a 4atient 9ith &eft ventricu&ar fai&ure f$&&$9ing a my$cardia& infarcti$n. The se4ta& ca4i&&aries aremared&y distended 9ith (&$$d. The intra-a&ve$&ar c$&&ecti$ns $f red (&$$d ce&&s and fi(rin 4resent are a resu&t $fca4i&&ary ru4ture. Acute 4u&m$nary c$ngesti$n can &ead either t$ fu&&-(&$9n 4u&m$nary edema as seen a($ve $r

t$ the accumu&ati$n $f hem$siderin-&aden macr$4hages and se4ta& fi(r$sis.

Rea)tions to Tissue 'n+ury 9;@ &oronary Artery Thrombosis- !ross

8ere is c$r$nary thr$m($sis. A c$r$nary artery (uried in the e4icardia& fat has (een &$ngitudina&&y secti$ned t$revea& a 4a&e, 4in-(r$9n thr$m(us.The thr$m(us $cc&udes the &umen and 4r$duces ischemia and)$r infarcti$n

$f the my$cardium.

Rea)tions to Tissue 'n+ury 9;< &oronary Artery Thrombosis 5

+emato!ylin and eosin stain& 3edium po#er&8ere is $cc&usive c$r$nary ather$sc&er$sis. The c$r$nary at the

&eft is narr$9ed (y >" t$ 7"L. The c$r$nary at the right is even 9$rse, 9ith evidence f$r 4revi$us thr$m($sis,$rgani:ati$n $f the thr$m(us, and recana&i:ati$n such that there are three sma&& &umens remaining.

The f$rmati$n $f the thr$m(us in this c$r$nary artery 9as main&y due t$ t9$ fact$rs ;E the e@4$sure $f

su(end$the&ia& tissue su(stances resu&ting fr$m u&cerati$n $f the ather$mat$us 4&aBue, and 2E distur(ances in

&$ca& (&$$d f&$9 caused (y disru4ti$n $f the end$the&ia& surfaces.


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Rea)tions to Tissue 'n+ury 9; &oronary Artery Thrombosis ;

+emato!ylin and eosin stain& 3edium po#er&This is an ather$mat$us 4&aBue in a c$r$nary artery that sh$9s

end$the&ia& denudati$n 9ith disru4ti$n and $ver&ying thr$m(us f$rmati$n at the right. N$te the a44earance $fthe vesse& 9a&& at the &eft margin $f the image.

Rea)tions to Tissue 'n+ury 9;8 Mural Thrombus

A &arge mura& thr$m(us has f$rmed $ver a my$cardia& infarcti$n in the &eft ventric&e $f the heart.

Rea)tions to Tissue 'n+ury 9:C #isseminated 'ntra,as)ular &oagulation- ung

+emato!ylin A eosin stain& +igh po#er&Disseminated intravascu&ar c$agu&ati$n D?E is a c$nseBuence $f

9ides4read activati$n $f the c$agu&ati$n system thr$ugh end$the&ia& inCury and)$r re&ease $f thr$m($4&astic

su(stances int$ the circu&ati$n. D? can (e seen 9ith severe infecti$ns, trauma, ne$4&asia, and $(stetricc$m4&icati$ns, am$ng $thers. /ma&& fi(rin thr$m(i can f$rm in sma&& arteries $f (rain, heart, &ungs, idneys, and

$ther $rgans t$ 4r$duce ischemic tissue damage.

Rea)tions to Tissue 'n+ury 9:5 #isseminated 'ntra,as)ular &oagulation- Kidney

+emato!ylin A eosin stain& 3edium po#er&/ma&& fi(rin thr$m(i fr$m 9ides4read activati$n $f the

c$agu&ati$n system 9ith disseminated intravascu&ar c$agu&$4athy D?E can (e seen in ca4i&&ary &$$4s in thisg&$meru&us, high&ighted (y a fi(rin stain. +a($rat$ry findings 9ith D? inc&ude decreased 4&ate&ets, diminished

fi(rin$gen, 4r$&$nged 4r$thr$m(in time, e&evated 4artia& thr$m($4&astin time, and e&evated D-dimer.

$nsum4ti$n $f c$agu&ati$n fact$rs 9ith generati$n $f fi(rin s4&it 4r$ducts, a&$ng 9ith 4&ate&et c$nsum4ti$n,

&eads t$ these findings.

Rea)tions to Tissue 'n+ury 9:; Pulmonary Thromboembolus- !ross

The main 4u&m$nary trun magenta arr$9E and 4u&m$nary arteries t$ right and &eft &ungs green arr$9sE are

seen here $4ened t$ revea& a &arge Fsadd&eF 4u&m$nary thr$m($em($&us.This is $ne $f the fe9 causes $f near&y

instant death.

Rea)tions to Tissue 'n+ury 9:: Pulmonary Hemorrhagi) 'n(ar)t- !ross

+arge thr$m($em($&i can cause death. Medium si:ed thr$m($m($&i (&$cing a 4u&m$nary artery t$ a &$(u&e $r

set $f &$(u&esE can 4r$duce the &esi$n seen here--a hem$rrhagic 4u&m$nary infarcti$n. *ecause the 4atient hassurvived, there is time f$r the tissue t$ f$rm a distinct reacti$n.The infarct is 9edge-sha4ed and (ased $n the4&eura. These infarcts are hem$rrhagic (ecause, th$ugh the 4u&m$nary artery carrying m$st $f the (&$$d and

$@ygen is cut $ff, the (r$nchia& arteries fr$m the systemic circu&ati$n su44&ying a($ut ;L $f the (&$$d t$ the

&ungsE is n$t cut $ff.

$m4ared t$ the sadd&e em($&us in the 4u&m$nary arteries in the &ast s&ide, 9hat ind $f vesse& d$ y$u thin 9as$cc&uded t$ 4r$duce this &esi$n 8$9 d$ y$u thin this 4atient 9as affected


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Rea)tions to Tissue '

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