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The John Hopkins Atlas of Surgical Pathology.
  1. Tim Stephenson

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    Epstein JL, ed. (£139.00 + VAT.) Churchill Livingstone, 1999. ISBN: 0 4430 7933 1

    I am a lover of well written textbooks and, I suspect, like most histopathologists a relatively late adopter of new technologies such as the use of the digital image. I therefore faced the review of this CD-ROM atlas of surgical pathology with some trepidation—the reader should take this into account. This CD-ROM installs, or uses, Quick Time, Adobe Acrobat, and Folio Bound Views to present and navigate between what is stated to be over 4000 images taken from 1500 different lesion types. The images are almost all haematoxylin and eosin stained sections. The quality of photomicrography is good—illumination is even, the staining is not obviously faded, and there are no colour casts. The colour intensity is rather strong and occasionally slightly muddy. The resolution of the images is not obviously stated, but is such that a full screen image looks good, without obvious pixellation, but when the zoom in facility is used, the pixellation becomes obvious when the magnification has been increased by 50% or more. In practice, this meant that the images were best viewed at full screen and not zoomed at all.

    An animated tutorial takes the viewer through the possible ways of using the atlas. I found watching the mouse arrow move around the screen by itself and press buttons slightly tedious, and aborted this programme in favour of getting started and pressing all the buttons myself.

    There appear to be two main ways of using this atlas. The first is entitled “pattern recognition”. In this, one selects the desired topographic site from a reasonably comprehensive list, presented around an image of a ghostly blue coloured human body, and then screens are presented primarily by histological pattern, with possible diagnoses as the subheadings. It immediately becomes apparent that to navigate this, one has to know the name of the histological picture being looked up—if you do not know what it is called, you do not know where to start looking. Thus—for example, if you were a trainee presented with a case of crescentic glomerulonephritis but did not know what it was called, you would have to leaf through all of the pictures of glomerular disease to find out what it was called. However, once there, information about the conditions is succinct and well edited. The juxtaposition of competing differential diagnoses makes navigating this section rewarding and attractive. The second main mode of using the atlas is the “self assessment quiz mode”. In this, one again selects the desired topographical site and then brief histories are presented, together with a collection of thumbnail sketch histological images. These can then be interrogated further by enlargement before arriving at a mental diagnosis. There does not appear to be anywhere to record one's diagnosis to the computer, and to have it marked. Instead, the diagnosis is revealed after clicking on a button. This at least avoids the frustration of computer marking of free text answers, where permissible near misses get (infuriatingly) marked wrong. I found it interesting that it was reasonably easy to predict which cases were benign and which were malignant from the number of images presented. Malignant conditions can be justified within a few images. Benign ones usually take a lot of images at different magnifications to provide evidence of lack of malignancy. There is obviously “a learning curve” with the manipulation of digital images, and I found the exercise very difficult compared with direct microscopy of slides. The main problem appeared to be the slight over emphasis on high power images, the inability to select one's own field, and the lack of resolution compared with real microscopy. On the positive side, however, was the requirement to make a commitment to a diagnosis on the basis of a given field. This is obviously something that could be used in the future for testing professional interpretation in a very standardised way.

    All of this raises the question “who would derive most value from the program?”. I don't think there is a lot of new information here for existing consultants. However, I can imagine the images being useful in teaching (I should note that I attempted to cut and copy some of the images out of the program, without knowing whether I am allowed to or not, but in any event, the program would not allow me to do this). Trainees might prefer this to a paper atlas because a large number of reasonably high quality images are contained here, and the indexing is fine for someone used to navigating electronic indexes. However, they would need to be at a level where they know the names of basic histological patterns. I would therefore envisage that this would be invaluable to SpRs as an adjunct to viewing slide collections and participating in bench work.

    I would recommend that departments setting up an electronic learning resource for their trainees add this to the collection of available CD-ROM programs and think that practical use would be seen at least by those trainees who enjoy operating this type of technology.