Chapter three
Methodology and research
3.1 LOCATION OF STUDY: NIGERIA
Nigeria is a most populous country in Africa with the population of 177 million as at year 2014. Recently, Nigeria is made up of 36 states and Federal Capital Territory. The nation comprises of six geographical zones as shown in Figure 1 stated North Central, North East, North West, South East, South-South and South West.
Figure 1: Geo Political zones in Nigeria.
The need on the pathologists in Nigeria is getting higher due to the low quality of healthcare delivery and shortage of healthcare professionals. Also the population of Nigeria is increasing with high cost of healthcare, making the health ministry planning everyday to raise the educational resources and equipped the institution with facilities and professionals. Recent study has shown by the World Health Organization (WHO) about Nigeria that there is inadequate hands and professional in the Health system in delivering quality care to the population who needs attention promptly and concurrently.
The innovation of Telemedicine has introduced various offers for countries like Nigeria without enough human resources in implementing the techniques from the developed societies.
The implementation of National Health Policy and the current reforms in the health sector are therefore expected to address the problems inflicting public health care development in Diagnostic system in Nigeria.
3.2 TELEPATHOLOGY IN NIGERIA
As indicated by Professor Mandong Mafila a Pathologyist at University of Jos Nigeria claimed that there is shortage of Pathologist in Nigeria about 150 expert pathologists.
Instead of relying on report from clinical laboratories of evidence based medicine only, the rapid development of technology application in pathology makes the medical information available today. The traditional delivery of pathology education through workshops centred didactic lectures, group tutorials and practical exhibitions using microscope glass slides, specimen and autopsy which is a way for propelling in electronic learner methods. It can be used to deliver healthcare to the patient using telepathology model.
Health facilities in Nigeria have demonstrated some practices on the invent of telepathology to healthcare and research work, including Public and Private Hospitals.
Successful adoption and implementation of rapidly advancing educational technologies in the resource-constrained environment obtainable in most of sub Sahara Africa requires a comprehensive analysis of the learners’ reflections on their use and effectiveness. This work aimed to evaluate the perspectives of new technology enhanced ways of teaching and learning currently employed for pathology education in Nigeria.
3.3 FINDINGS ON THE TELEPATHOLOGY APPLICATION IN NIGERIA
This demonstration was shown by finding from Fifty five(52) students from two universities in Nigeria namely, Benue State University, Markurdi and the private Bingham University, Jos made enquiry on the parameters and experience associated with application of technology in connection with pathology education and evaluation which was graded on the respondents on a scale similar to the likert scale.
3.4 RESULT
The final result show clinicopathology conferences are the most effective methods of teaching pathology. While 34.5% out of 55 strongly agreed that practical demonstration of digital pathology is effective. 49.1% preferred computer based digital microscope images and 15(27.3%) strongly agreed that microscope digital images are easier to understand when placed side by side with gross specimen and clinical appearance images.
The use of digital images in multiple choice questions to test the interpretative skills and diagnostic reasoning was strongly agreed to by five (9.1%), agreed by 15(27.3%), disagreed by 11(20%) and 13 (23.6%) students strongly disagreed. Majority (20, 36.4%) agreed to the use of digital images instead of glass slides mounted on a microscope during the practical component of the objective structured practical examination (OSPE). The same proportion of students supported the use of digital images in the oral component of OSPE. Forty-seven (85.5%) of the students reported that classes were sometimes interrupted due to technical problems with equipment. Each student has at least an electronic device useful for studying pathology microscope images with the majority (39, 70.9%) owning a laptop computer; 23(41.8%) students owned an electronic tablet and the same proportion have mobile phones adequate for viewing digitized images. Four (7.3%) of the student never had internet connectivity on their devices, 21(38.2%) always had connectivity while 29(52.7%) sometimes had connectivity. Thirteen (23.6%) could access the internet through the institution provided internet services through their devices and personally paid subscriptions while the majority was only by personal subscription only. Sum of Forty-nine (90.7%) out of 54 respondents did not participate in any web based peer study group and only five (9.3%) had joined such a group. Forty-one (78.8%) of 52 respondents opined that digital images have helped their understanding of gross pathology while 11(21.2%) said it made no effect. Ten (18.9%) of 53 students preferred learning with only gross specimens in pots but more of them, 43(81.1%) disagreed. The cost of access to the internet was rated by the students to be the most important factor adversely affecting the use of online – based resources for learning pathology.
Table 1: Respondents perception about pathology images
Choice of the most effective method of learning with microscope images Strong Disagree Disagree Undecided/Neutral Agree Strong Agree
Glass slides mounted on the microscope 0 2(3.6%) 5(9.1%) 33(60%) 15(27.3%)
Power point projected microscope images 0 2(3.6%) 10(18.2%) 27(49.1%) 16(29.1%)
Microscope image from glass slide mounted on a microscope with camera projected on large screen 0 0 0 24(43.6%) 31(56.4%)
Directly looking at internet based microscope images projected on large screen 8(14.5%) 20(36.4%) 14(25.5%) 8(14.5%) 4(7.3%)
Distributing the digital images of cases to students’ mobile devices days before classes. 0 8(14.5%) 12(21.8% 19(34.5%) 15(27.3%)
Use of digital images illustrated with arrows pointing to morphological features. 0 1(1.8%) 3(5.5%) 25(45.5%) 25(45.5%)
Microscope digital images are easier to understand when placed side by side with gross specimen and clinical appearance images 1(1.8%) 7(12.7%) 9(16.4%) 23(41.8%) 15(27.3%)
Differences exist between digital images and what is seen directly under the microscope 1(1.8%) 4(7.3%) 18(32.7%) 19(34.5%)
13(23.6%)
Use downloadable online histopathology webinars for self study 8(14.5%) 18(32.7%) 9(16.4%) 12(21.8%) 7(12.7%)
3.5 IMMUNOHISTOCHEMICAL TESTS OF BREAST CANCER BETWEEN NIGERIA AND UNITED STATED OF AMERICA
A web based quality immunohistochemical tests of breast cancer biomarker between a well standardized laboratory at University of Chicago, United States of America and a field laboratory in Ibadan, Nigeria. Web-based conferences using Web conferencing tools as Skype and WebEx were used to hold periodic discussion on the Immunohistochemistry(IHC) stains.
In Nigeria, IHC determination of breast tumor markers was introduced where the analysis of breast tissue to guide treatment decisions. The aim is to study and examine the reproducibility of test result obtained from a field laboratory in Nigeria in comparison with data obtained from a well established laboratory at the University of Chicago, Illinois using tissue microarray (TMA) technology. It was also assessed that the feasibility of Web-based conferences and digital microscopy in ensuring quality assurance (Huo D et al. 2009).
Breast tumor markers such as estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) have become very useful in predicting prognosis and determining therapy options for patients with breast cancer. This has been particularly helpful in identifying those patients who would benefit from antiestrogen therapy and also those who would likely respond to HER2-based therapy. The effective use of these markers, therefore, would naturally depend on the accurate, reliable, and reproducible determination of their presence and levels in individual breast tumors.
Immunohistochemistry (IHC) has so far been used for ER, PR, and HER2 determination. However, despite long-term use worldwide, there still exists significant intralaboratory and interlaboratory variability of IHC results. Some identified reasons for interlaboratory discrepancies include the following: type of antibody clone used, differences in antigen retrieval techniques, formalin fixation time, and different scoring/reporting systems. As a result, an ad hoc consensus conference, consisting of directors from a broad range of IHC laboratories, was convened in 2006, which put together recommendations aimed at standardizing IHC laboratory practices. The factors considered at the conference included preanalytic factors, which focus on fixation techniques; analytic factors, which talk about antigen retrieval procedure; and postanalytic factors, which discuss the scoring and reporting systems (Klock C and Gomes R. 2008) and (Mckenna J. and Florell S. 2007).
3.6 PROCESS AND REVIEW OF THE DIAGNOSIS BETWEEN NIGERIA INSTITUTION AND UNIVERSITY OF CHICAGO
An initial concordance analysis was performed comparing IHC results from the Nigerian laboratory, which used whole sections, with corresponding IHC results from the Chicago laboratory derived from TMAs. The IHC test results for ER and PR from Nigeria were initially scored into 5 categories based on percentage and intensity of IHC reaction (Dako ER/PR pharmDx Interpretation Manual), whereas in Chicago, the results were scored using the 4-point scale (Reiner et al). For the purpose of comparison, the conversion table proposed by Shousha was used. Assessment of HER2 status was performed according to recommendations of the American Society of Clinical Oncology and College of American Pathologists. For this concordance analysis, they had 155 comparable ER results, 164 comparable PR results, and 154 comparable HER2 results.
Twenty three digital microscopic images of randomly selected cases were taken by the histotechnologist in Ibadan from the study histologic slides with appropriate positive and negative controls for ER, PR, and HER2 markers using a digital camera, which was mounted on a microscope. The images were then transmitted in JPEG format over the Internet as e-mail attachments to the pathologist in Chicago. The images were reviewed by the pathologists in Chicago for scoring, image quality, and staining characteristics using free graphic software Picasa from Google and ImageScope, Aperio Technologies (Vista, CA). The images were then jointly reviewed by both pathologists during the Web conferences using figure 2. The purpose of this stage was to assess the quality of digital images and staining techniques in Nigeria and further train the attending pathologist at the Ibadan field IHC laboratory on techniques of assessment of staining quality and scoring.
Tissue microarray slides created at the University of Chicago were also scanned using Automated Cellular Imaging System. Digital images of discordant cases were then jointly reviewed online by pathologists using freely downloadable viewing software Image Scope Viewer (Aperio Technologies) and WebEx, a virtual meeting manager that enabled us to share desktops, presentations, and images in real time. Web-based conferences were held biweekly, during which we discussed IHC staining protocols, standardized scoring systems, and resolved discrepant cases.
Figure 2: Exhibition of the automated cellular Imaging System that shows breast cancer TMA cores immunostained with HERS2
This digital image above, along with the Web-based conferences proved to be useful and cost-effective tools for long-distance training and pathology consultations, especially in developing countries with limited access to information, skilled specialists, and resources. This was demonstrated by the ability of the pathologist to jointly review images and thus resolve discrepant cases and was further confirmed by an overall improvement in the concordance results during the second evaluation, which compared results from TMAs in Chicago with results of TMA slides restained and scored in Nigeria.
Similar benefits have been reported in other studies using Web-based tools for pathology consultation. A pilot project between the Italian hospital in Cairo, Egypt, and Civico hospital in Palermo reported benefits in costs reduction and ability to exchange knowledge of high scientific value, ultimately leading to better medical services through the use of static and dynamic techniques of telepathology (Ayad E. 2008). This study demonstrated the usefulness of simple Web-based conferencing tools such as Skype and MSN for analyzing digital images in off-site pathology consultations (Klock C and Gomes R. 2008). Another study conducted in the Mohs surgical laboratory compared the pathologic diagnosis between video images and conventional light microscopy. This study used off-the-shelf consumer products like a digital video camera mounted on a microscope to transmit images from the Mohs surgery suite to a consultant viewing station off-site where the images were reviewed via iChat AV on a computer by a dermatopathologist. The Mohs laboratory group reported complete agreement between the iChat AV dynamic telepathology diagnosis and conventional light microscopy diagnosis for frozen section slides and 95% agreement for FFPE slides. These results further confirmed the potentials we found in the use of virtual images for pathologic consultation. However, in addition, it was demonstrated that the use of these online tools in training local pathologists with demonstrable improvement in antigen retrieval, staining, and scoring techniques (Mckenna J. and Florell S. 2007). In more advanced centers, high-speed, automated whole-slide imaging systems are being used to generate digital images of sufficient quality for pathologists to make reliable diagnostic decisions.