REVIEW ARTICLE

Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 63-67

Preparing for a dermatopathology quiz

Biju Vasudevan¹, Manas Chatterjee², Nikhil Moorchung³, Shekar Neema^2
1 Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
² Department of Dermatology, Command Hospital (Eastern Command), Kolkata, West Bengal, India
³ Department of Pathology, Command Hospital (Northern Command), Udhampur, Jammu and Kashmir, India

Correspondence Address:
Biju Vasudevan
Department of Dermatology, INHS Asvini, Mumbai - 400 005, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2349-6029.147285

Dermatopathology is one of the key aspects in dermatological diagnosis and is of immense value to the practicing dermatologist as well as residents pursuing dermatology as a career. It is a visual medium of understanding the subject, and is therefore ideal to be tested similarly. Dermatopathology quiz has become a part and parcel of most scientific deliberations, and is therefore an essential requirement of the postgraduate curriculum. Preparing for a dermatopathology quiz is tougher than preparing for a normal clinical quiz because of the lesser importance given for it in the syllabus of postgraduation and also due to the lack of resources either in getting microscopic sessions arranged or due to lack of flair of the subject compared to cosmetology or dermatosurgery. This review was done with the purpose of educating both the students and quizmasters as to how to prepare for a dermatopathology quiz. It is a unique proposal and, therefore, is gathered from more of personal experience, experience gained from watching quizzes conducted by experienced quizmasters, and also from the advice gained from masters of the subject in relation to the quiz.

Keywords: Histopathology, prepare, quiz, quizmaster

Introduction

Quiz In Dermatopathology

Important Aspects Involved in Preparation for A Dermatopathology Quiz

1. Books and journals
2. Internet resources
   
   
   • Website of ISD: The Dermatopathology Society of India has a quiz section and a separate mindbender section which is uploaded every month, and is a good way to challenge oneself and helps in preparation
   • Dermnetz: The website of New Zealand Society of Dermatology is a good resource for photomicrographs
   • DermOID: Online Interactive Dermatopathology is an excellent clinical resource by University of California, Los Angeles (UCLA). It has a quiz section where new photomicrographs are uploaded along with clinical scenario. On registration, it notifies the user when a new image is available for viewing
   • ETAS Dermatology in Review: It has a Kodachrome section where one can quiz oneself on dermatopathology. It is an excellent resource material which is regularly updated
   • MDLinx Smartest Dermatologist Quizzes on Dermatopathology: This monthly quiz is interesting and goes in a step-wise fashion with different images toward the diagnosis
   • Derm101: This quiz and educational resource started by Dr. Bernard Ackermann also has a step-wise approach with several histopathology images in sequence to help with the diagnosis. Resources "e" and "f" enable clinicopathological correlation
   • Online discussion groups: There are many online discussion groups including acad_iadvl where one can be a member and learn about interesting as well as complicated cases with their clinicopathological correlations. The Dermatopathology Society of India in association with IADVL Special Interest Group on Dermatopathology has been active in posting mindbenders and dermatopathology quizzes regularly
   • ocial media: Social media has opened new realms in learning where likeminded people can get together, discuss the subject of dermatopathology, and learn interesting aspects. Facebook pages and Yahoo groups are examples of such learning.
   
   
   
3. Dermatopathology conferences: These conferences are a treasure trove of learning where microscopy sessions are arranged in DERMACONs, the Dermatopathology Society of India national conferences, and the conferences organized by IADVL Special Interest Group on Dermatopathology.

1. Based on topic
   • Questions based on H and E stained slides only: Self-explanatory
   • Questions based on clinicopathological correlation
   • Questions based on clinical syndromes
   • Questions based on special stains
   • Questions based on special investigations
   • Others.
   1. Questions based on clinicopathological correlation- Here, the sequence of events would include an initial brief clinical history followed by a photomicrograph/series of photomicrographs of the lesion at different magnifications. Then, the quizmaster may ask for a diagnosis; alternatively, he may provide a few differential diagnoses and ask the participants for a firm diagnosis based upon the differentials
   2. Questions based on clinical syndromes- The quizmaster may throw a question like, "What is the other name for the clinical syndrome which presents with a triage of recurrent oral aphthous ulcers, genital ulcers, and uveitis and shows this characteristic histopathological picture?" The histopathological picture flashed would be of vasculitis. The diagnosis in this case is Behηet disease. The quizmaster may also choose to ask the participants about a relatively obscure clinical syndrome. An example of an uncommon syndrome is Wells syndrome or eosinophilic cellulitis which is an uncommon condition of unknown etiology. ^[1] The presentation usually involves a mildly pruritic or tender cellulitis-like eruption with typical histologic features characterized by edema, flame figures, and a marked infiltrate of eosinophils in the dermis. ^[2] The clinical picture may be shown along with the typical histopathology; a question like this could be a real trap for the unwary
   3. Questions based on special stains- There are innumerable special stains which may be used in pathology. Stains which are used in dermatopathology may be classified as histochemical stains, immunohistochemical stains, and immunofluorescent stains. Histochemical stains include stains like the periodic acid-Schiff (PAS) stain for neutral mucin, the Alcian blue stain for acid mucin, and the Masson's Fontana stain for melanin. There are a large number of other special stains which may be used in dermatopathology. The quizmaster may flash a slide of a slit skin smear stained using a modified Ziehl-Neelsen (ZN) stain and the question may be something like "identify the stain and the organism." Alternatively, the quizmaster may flash a slide of melanin stained using a stain like Masson's Fontana and ask the participants to identify the stain and what it has stained
   4. Immunohistochemical stains are more difficult to interpret. They are used to stain a specific protein. The quizmaster may flash the slide of a lesion like a melanoma stained with the specific antibody HMB45. The question asked by the quizmaster to the participants could be to name the other lesions HMB45 may be positive in. The diagnosis of cutaneous lymphomas may be corroborated by immunohistochemical stains and the same may be shown/asked for diagnosis Direct immunofluorescence staining is used to detect the presence of immunoglobulins and complement in the skin. Fluorescein isothiocyanate-labeled antibodies against IgG, IgM, IgA, fibrin, and C3 are applied to frozen sections of fresh tissue and examined by fluorescence microscopy. Characteristic staining patterns are seen in the immunobullous diseases, lupus erythematosus, and vasculitis. There are other conditions where these immunofluorescence stains are positive and which may sometimes corroborate the diagnosis, such as in lichen planus. The quizmaster could flash a photomicrograph of a case of pemphigus and show the characteristic IgG linear staining of the epidermal intercellular spaces.
   5. Questions based on special investigations- Electron microscopy (EM) is rarely required for routine diagnosis and management of skin diseases. However, it may be used for the specific diagnosis of mechanobullous disorders such as epidermolysis bullosa and for the diagnosis of poxviruses in the skin. The quizmaster could flash a slide of a poxvirus in the skin and ask the participants to identify the organism. Scanning EM can be used to identify certain mineral deposits, photographs of which can be flashed on the screen for identification. Photographs of fluorescent in situ hybridization (FISH) in cases of melanoma may also be shown and the use of FISH in dermatopathology may be asked. FISH can be used to discriminate nevus from melanoma so that ambiguous melanocytic lesions could be more accurately classified or prognostication could be improved in melanoma patients. ^[3]
   6. Others- Special histopathological features, characteristic appearances like "Splendore-Hoeppli," named bodies like "copper penny bodies," and history of disorders are some of the other favorites
2. Type of question format
   • Direct- Direct theoretical questions with short answers or explanations required
   • Visual clues- Histopathology alone, clinical and histopathology combined
   • Connects- Could be clinical or histopathological or combined short or long visual/theoretical connects
   • Problem solving- A clinico-histopathological question is posed and the teams are asked as to how best it can be tackled
   • Abstract linking questions- An abstract picture may be shown and the teams are asked to correlate with a histopathological finding
   • Rapid fire questions- Here, few easy questions are to be answered in a short specified duration of time. They will have very short answers and have to be answered rapidly. It tests the reflex mental action of the teams.

Strategies For Winning A Quiz

1. It is important to know the level of questions asked in a particular quiz for knowing what to study for a particular quiz
2. Quizzing is like a team sport where contribution from both partners is important for success. It is important to have good communication with your partner and one should decide beforehand as to who is going to answer as it can result in confusion and one can lose precious marks
3. uiz is generally multistep which includes a preliminary round and a final round. Different strategies are required for both the rounds. The preliminary round generally has multiple choice questions and favors those who are better at remembering difficult facts, while the mains is more likely to be helpful to those who have good visual recall and presence of mind. A successful team is prepared for both and the partners should complement each other in different rounds
4. To qualify in the preliminary round is the first step and one should resist the temptation of attempting more questions by guessing, as most of the quiz formats have negative marking and one can lose a large number of marks because of wrongly attempted questions
5. The main quiz is conducted on stage in the presence of a learned audience and it is very important to maintain composure and presence of mind. In contrast to the preliminary round, there are no negative marks for attempting wrongly and unanswered questions are passed to the next team. It is important to make intelligent guesses as one can get precious marks by doing so. However, there is a tendency of some students to attempt more questions in the preliminary round and end up accumulating negative marks, and not answering in the main quiz for fear of being ridiculed if a wrong answer is given. This tendency is to be curbed to enjoy success.

How Should a Quizmaster Prepare a Dermatopathology Quiz?

1. The number of people in the team must be specified. As a general rule, it is best to keep the teams down to two to a maximum of three participants
2. The decision of the quizmaster will be final and will not be subjected to any change
3. Numbers of rounds have to be specified. They could range from 4 to 8. The questions will be asked in the form of definite sequences like
   1. Simple forward and reverse sequence- The first round starts from team A, second from team B, and so on. After the half-way stage, the sequence is reversed
   2. Infinite rebound- This means that if team A is asked a question and is unable to answer the question, the question passes to team B. If team B answers the question correctly, the next question is directed at team C and not team B. This way, the questions are evenly distributed and there is no chance of any sequence-induced bias.
4. The participants shall not be allowed to use mobile or other electronic instruments
5. Audience shall not give any hints or clues to the competitors
6. Replacement of any participant of a team is not allowed after registration
7. It is important to remember that if a large number of teams are registering, a preliminary round can be held before the teams are selected for the finals. The preliminary round can be in the form of multiple choice questions which can be corrected easily. The top four or six teams can be selected for the final round. It is advisable not to have more than six teams on the stage
8. It is a good practice to call all the teams few minutes prior to the quiz and give them a short briefing regarding the quiz and its rules, especially on the time available to answer the questions, before it is actually announced on stage. This will help in calming down the participants, make the quiz more user-friendly, and thus helps in better performances.

1. Include questions that the audience can understand, but which may be difficult to answer. The audience must be able to comprehend the question, but only the participants and few expert audiences may be able to answer
2. Include visually compelling content. Photomicrographs keep the crowd interested without compromising on the quality of questions
3. Reserve few questions for the audience. Also, the unanswered questions by the teams can be passed to the audience.

1. Prelims
   1. Adequate answer sheets and question papers
   2. Projector if required
   
   
   
2. Finals
   1. Projector
   2. Appropriate stage arrangement- For seating of teams, so that all teams can have good visual access to the screens and they are visible to the audience also. It is best to keep a separate monitor for each team so that they do not need to look back at the screen and can look toward the audience and vice versa
   3. Scorer
   4. Timekeeper.

Conclusion

References

1.	Wells GC. Recurrent granulomatous dermatitis with eosinophilia. Trans St Johns Hosp Dermatol Soc 1971;57:46-56.
2.	Brehmer-Andersson E, Kaaman T, Skog E, Frithz A. The histopathogenesis of the flame figure in Wells' syndrome based on five cases. Acta Derm Venereol 1986;66:213-9.
3.	Bangash HK, Romegialli A, Dadras SS. What's new in prognostication of melanoma in the dermatopathology laboratory? Clin Dermatol 2013;31:317-23.