Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 23 RE: Resident Responsibilities Revised June 21, 2010 NAME OF ROTATION: Neuropathology YEAR(S) OF RESIDENCY ROTATIONS ARE TAKEN AND DURATIONS: First, second, third and fourth years, integrated with surgical pathology and autopsy pathology. Additional experience will be gained through periodic brain cuttings and monthly formal conferences offering a systematic review of neuropathology topics. A one-month rotation in neuropathology is offered for additional training at Covenant Medical Center, if so desired, arrangements could be made for a one-month neuropathology rotation at an offsite institution not affiliated with Texas Tech Medical Center; this requires special arrangements through the LCGME office. SITE: Primary: Covenant Medical Center GOALS: Residents will be exposed to Neuropathology on an ongoing basis through rotations in autopsy and pathology and surgical pathology. The mandatory one-month rotation will be supervised by a faculty member with specialty training in neuropathology. The resident will have access to an extensive teaching file in neuropathology and to Greenfield’s and Davis’s neuropathology textbooks. The resident will become familiar with classification, morphology and clinical sequelae of major brain tumors. The resident will become familiar with nonneoplastics CNS disease primarily through brain cutting and teaching resources. The resident will be expected to assist in, and become competent in brain removal at autopsy. During the one month rotation neuropathology, the upper level resident will gain practical experience in neuropathology that should prove useful in private practice, and for board review. An extensive teaching file of glass slides, Kodachrome and texts/atlases are available for study. OBJECTIVES – General. (See Neuropathology Knowledge and Skill Appendix for details) Demonstrate knowledge of basic anatomy and major disease processes of the brain and spinal cord Demonstrate knowledge of basic gross description of the normal brain Demonstrate knowledge of the routine sections to be taken for gross & microscopic examination of the brain and spinal cord Demonstrate diagnostic knowledge of the common brain tumors Demonstrate knowledge of the common special stains used in neuropathology Demonstrate knowledge of basic muscle pathology and common enzyme histochemical stains used in muscle biopsy interpretation. Demonstrate understanding of the common neurodegenerative diseases. Demonstrate awareness of all safety procedures related to brain evaluation, including procedures related to CJD and related prion diseases Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 24 RE: Resident Responsibilities Neuropathology Revised June 21, 2010 Duties and Responsibilities in Neuropathology: The resident is responsible for collecting all relevant clinical information, including pertinent laboratory results, clinical history and radiographic imaging studies (BRAIN LESIONS SHOULD NEVER BE DIAGNOSED WITHOUT CORRELATION WITH THE RADIOGRAPHIC FINDINGS). The resident will examine and assist with workup on all CNS related surgical specimens, including cutting frozen sections and making touch/squash preps. The resident will study neuropathology texts, atlases, and other study material and perform relevant literature searches as needed in order to meet all of the above goals and objectives especially when studying entities for which there are not available specimens. Supervision and Evaluations: The attending pathologist will closely monitor, supervise and direct the residents activities at all times on all cases, and all surgical pathology and autopsy cases will be verified and reviewed by the supervising pathologist. Residents are evaluated on a monthly basis by each of the attendings involved in their training that month, and by the program director on a quarterly basis; and finally on a yearly basis prior to signing of new contracts. Both the resident and pathologist sign each one of these evaluation forms at the time of evaluation. The monthly evaluation will serve to identify areas of improvement early, as well as the resident’s achievement of the goals and objectives. The month Neuropathology rotation will be evaluated in this way, with Neuropathology training in Autopsy and Surgical Pathology incorporated into those evaluations. Subjective (Residency Competency Assessment) and Objective Evaluations The standard form (Residency Competency Assessment will be completed by each attending pathologist on rotation with the resident each month (not just at the end of a multimonth rotation), including the elements as noted previously for competency based evaluation. The results of additional objective evaluation tools used must be noted on the form, with additional documentation as appropriate. This may be in the form of checklists. Such checklists should promptly be completed by each supervising faculty member. The evaluation should be discussed with the resident at the time of completion, with both the attending physician and resident signing the form after discussion. Pertinent constructive written comments are REQUIRED for evaluations of borderline (4) or unsatisfactory (1-3) ratings. Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 25 RE: Resident Responsibilities Neuropathology Revised June 21, 2010 Plans for remediation of borderline or unsatisfactory ratings must be documented in writing. LIST of specific evaluation tools other than case by case review [to include written or practical quizzes, etc., with specific competency element to be evaluated; 360 evaluations (by technical and transcription staff), etc.] (List here): RESIDENT DOCUMENTATION of activities: Keep log of neuropathology cases as part of Autopsy and Surgical Pathology logs TEACHING STAFF RESPONSIBLE FOR SUPERVISION: Surender Bodhireddy, M.D., Staff Pathologist, Covenant Health System Surgical pathology faculty, Texas Tech Medical Center Department of Pathology Autopsy pathology faculty, Forensic Pathology Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 26 RE: Resident Responsibilities Neuropathology Revised June 21, 2010 Neuropathology Knowledge and Skill Appendix: 1. Demonstrate proficiency at removing a brain and spinal cord at autopsy. 2. Review and know the basic neuroanatomy of the cerebral hemispheres, brainstem, cerebellum and spinal cord. 3. Be familiar with basic anatomical sites in the coronal, horizontal and sagittal planes. 4. Select appropriate regions for histology after brain cutting. 5. Know the major vessels and those most often involved in thrombotic and embolic episodes. 6. Know the various causes of in-situ thrombosis in the CNS vessels. Know the causes for embolic stroke and how this stroke might differ pathologically from a thrombotic stroke. 7. Be able to discuss anoxia including the concept of selective vulnerability, location, histologic appearance and evolution of lesions. 8. Be familiar with the types of vasculitis that may affect the CNS and their histological appearance. 9. Know the different types of vascular malformations, frequency, presenting signs and symptoms, and treatment. 10. Discuss the types of aneurysms that occur in the cranial vault. 11. Name the causes, frequency and locations of parenchymal hematomas 12. Know the most common consequences of CNS trauma, including subarachnoid hemorrhage, subdural and epidural hematomas, contusions, and diffuse axonal injury. Be familiar with the histologic appearance of diffuse axonal injury. 13. Discuss the difference in gross appearance of contusions and infarctions. 14. Know the consequences and location of lesions due to hypotension. 15. Discuss the causes and consequences of venous thrombosis. 16. Be able to distinguish reactive gliosis from neoplastic glioma. 17. Know the common location, age at presentation, gross and microscopic appearance, treatment and prognosis of the following tumors: a. Meningioma b. Glioblastoma multiforme c. Astrocytoma (anaplastic, pilocytic, brainstem glioma, cerebellar astrocytoma) d. Medulloblastoma e. Pineal tumors f. Pituitary tumors g. Oligodendrogliomas h. Ependymomas i. Choroid plexus tumors j. Cerebral neuroblastoma (PNET’s) k. Ganglioglioma l. Suprasellar tumors m. Hemangioblastoma Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 27 RE: Resident Responsibilities Neuropathology Revised June 21, 2010 n. o. p. q. Primary lymphoma Colloid cyst Neurofibroma Schwannoma 18. Know the common metastatic tumors and where they tend to localize in the brain. 19. Be able to discuss the pathogenesis of bacterial meningitis and abscesses. Know the pathological changes, complications and common organisms that affect different age groups. 20. Be familiar with the pathological changes, clinical settings, and geographical distribution (when applicable) of the following fungal organisms: a. Aspergillosis b. Candida c. Mucormycosis d. Cryptococcosis e. Histoplasmosis f. Coccidioidomycosis 21. Know the pathological changes, location of lesions, clinical presentations, and treatment for tuberculosis, sarcoidosis and neurosyphilis. 22. Discuss the pathological changes and clinical presentations of the following parasitic infections: a. Toxoplasmosis (know in utero effects) b. Hartmanella and Naegleria c. Cysticercosis d. Echinococcus e. Schistosomiasis f. Malaria g. Do these organisms infect select areas of the brain or are they diffuse? 23. Know the clinical presentations, pathological changes sites affected and causative organisms of the following viral processes: a. HSV b. HVZ c. PML d. SSPE e. CMV (know in utero effects) f. Poliomyelitis g. Rabies h. Arboviruses 24. Discuss the pathological changes and clinical presentation of Creutzfeldt-Jacob disease. What is a prion and how does CJD relate to Kuru and scrapie? Texas Tech University Health Sciences Center Department of Pathology Resident Guidelines VIII Page 28 RE: Resident Responsibilities Neuropathology Revised June 21, 2010 25. Know what post infectious and acute hemorrhagic encephalomyelitis is, and the pathological changes in the CNS. What is the common clinical setting for the onset of these diseases? 26. Be familiar with the brain findings in Reyes syndrome. 27. Be familiar with the pathology of the following degenerative diseases and have some general knowledge as to how the patients present clinically. What are the inheritance patterns if any and what chromosomes are involved? a. Alzheimer’s disease b. Pick’s disease c. Huntington’s disease d. Parkinson’s disease e. Amyotrophic lateral sclerosis f. Progressive supranuclear palsy g. Friedreich’s ataxia h. Striatonigral degeneration i. Olivopontocerebellar atrophy 28. For multiple sclerosis, know the variable presentation, age, epidemiology, CSF findings, MRI changes and pathological changes in chronic and acute to subacute forms. 29. Know what areas of the CNS are involved in Devic’s type demyelination. 30. Be able to give characteristics of major developmental anomalies of the CNS. 31. Be able to distinguish neurogenic from myopathic processes in muscle.