April 2018 – Lablogatory

History and Characteristics of Generations

History plays a significant part in the development of any person; we are changed and altered by big historical events that take place during our life time. Understanding history is therefore an essential aspect of understanding people, communities, cultures, and generations.

The oldest generation living today is the GI Generation. This generation was born between circa 1901-1926 and have gone through significant changes in life and work environments during their lifetimes. The term GI Generation stems from the fact that a lot of soldiers from both WWI and WWII came from this generation. This generation came of age during the First World War and the Great Depression and most grew up without electricity, refrigerators, and credit cards.

The Traditionalist Generation was born around 1927-1945, so during the Great Depression and at the end of WWII. This is the era of pre-feminism, so women generally stayed at home to raise children. If women had jobs, it was typically until they were married and in professions such as secretary, nurse, and teacher.

This started to change during the next generation, the Baby Boomers, who were born between 1946 and 1964. The timeframe for this generation is so large that there are essentially two main groups: the revolutionaries from the ‘60s and ‘70s and the yuppies of the ‘70s and ‘80s. Women began working outside the home in record numbers, which created double-income households. Divorce also became more accepted and people starting buying things on credit.

The following generation is Generation X, who are born circa 1965-1980. Because most of their parents both worked, this generation is known as the “latch-key kids”, because they would walk home after school themselves as both their parents were working or divorced. This generation experienced the transition to digital knowledge, but remembers a time without computers.

The Millennial Generation, also known as Generation Y, was born around 1981-2000. This generation grew up in a world of technology and they have experiences some significant technological advances, which typically are very natural to them. They also grew up with enormous academic pressure and also the notion that you might not be save at school due to school shootings.

The newest generation is Generation Z who are born after 2001. People born during this time have never known a world without cell phones or computer and they are very technological savvy. Growing up during the great recession of the late 2000s, Z’ers feel unsettled and a level of professional insecurity.

The events mentioned above are all focused on events that took place in the United States of America, with some worldwide events included. To understand generations from other countries, it is important to learn about important historical events that occurred, while there are also some events that overlap. For instance, internet and cell phone are more widely available worldwide and there might be some similarities across nations in terms of the effect on generational understanding.

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.

The GI generation experienced events that impacted their assertive characteristics. If you know someone in this generation, they probably worked until they couldn’t work anymore instead of retiring. This work ethic comes from growing up during the deprivation of the Great Depression and are often referred to as the “Greatest Generation.” This term was coined by the NBC Nightly News anchor, Tom Brokaw in his book by the same name.

The Traditionalist generation are, well, traditional. The value old-time morals, safety, security and may try your patience, especially in the work place. They are still working and act as the historians of the organization and/or the family because they have been there for a long time. You still might see them serve on Board of Directors and are Presidents because of their organizational knowledge and expertise. They are also known as the Silent Generation for an interesting reason. It was this generation that coined the phrase, “Children are to be seen, and not heard!”

Did you know there are two groups of Baby Boomers? The first group was born between 1946 and 1964. They are often called the “Leading-edge Boomers.” Those born between 1955 and 1964 are often called the “Shadow Boomers or Generation Jones.” The Baby Boomers are the largest generation in the US today, but they are slowly overpowered by the Millennial Generation. The have a team-oriented attitude and take their self-worth from their job. They are driven and optimistic and are often willing to learn how to use technology, but it takes a process as it doesn’t come as natural to them as to younger generations.

The Generation X are often referred to as the “middle child.” This generation is street smart because most grew up in homes where both parents worked or were divorced. They started school without computers, but are experienced with them. They change careers often and are independent, flexible, and can easily adapt to new circumstances. They have an entrepreneurial spirit.

The Millennial Generation is our fastest growing generation in the U.S. workforce. They are the most diverse and are also known as the “Echo Boomers, Millenials, or Generation Y. Millenials understand the world of technology and it comes natural to them. They are resilient, optimistic, and creative because they experienced enormous academic pressure. They are very focused on professional development and to learn and improve what they do.

Generation Z is just starting to enter the workforce and they are independent, open-minded, and determined. They also have an entrepreneurial spirit, like Generation X, and they are loyal and compassionate. This emerging generation will be our new teachers because their minds work in so many directions because of their technology skills and aptitude.

It is easy to see how working with multiple generations in one department offers a full range of experiences, work styles, ideas, as well as, challenges. How can you improve the generational diversity of your personal or professional life?

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-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.

Hematopathology Case Study: A 68 Year Old Man with Epidural Mass

Case History

A 68 year old man with no significant past medical history presented with 3 weeks of upper back pain and bilateral leg weakness. He denied numbness, tingling, leg pain or urinary or fecal incontinence. MRI showed severe cord compression at the upper thoracic spine with a T2-T5 epidural mass. Due to the patient’s decline, an urgent decompression was scheduled and the patient underwent T2-T5 thoracic laminectamies with resection of extramedullary epidural tumor.

Imaging

Frozen Section Diagnosis

“Round blue cell tumor. Await permanents for final diagnosis.”

Differential Diagnosis

Small round blue cell tumor is a term generally used for a group of neoplasms characterized by small, round, basophilic, relatively undifferentiated cells on H & E staining. The differential diagnosis is wide, but includes Ewing’s sarcoma/peripheral neuroectodermal tumor, mesenchymal chondrosarcoma, small cell osteosarcoma, desmoplastic small round cell tumor and Non-Hodgkin Lymphoma. ¹

H&E, 2x

IGH/BCL2 double fusion FISH probe. White arrows: IGH/BCL2 fusion

Diagnosis

Sections show fragments of fibrous tissue and focal bone with extensive crush artifact. There is an abnormal lymphoid infiltrate with areas showing a vaguely nodular architecture. The lymphocytes are small to medium in size with irregular cleaved nuclei, inconspicuous nucleoli and small amounts of cytoplasm. Scattered centroblastic cells are seen but are <15 per high power field. Between the nodules, the cells are centrocytic appearing. Rare mitotic figures are identified.

By immunohistochemistry, the neoplastic cells are immunoreactive for CD20 and BCL2. BCL2 is brighter in the vague nodular areas which are also highlighted by CD10 and BCL6. CD23 is variably positive in a large subset of cells. MUM1 is negative. CD21 highlights the enlarged and irregularly shaped follicular dendritic cell meshwork present in the areas with nodules. CD3 and CD5 highlights admixed T-cells. The proliferation index by Ki-67 is low and approximately 10%.

Cytogenetic analysis using fluorescent in-situ hybridization performed on paraffin embedded sections revealed numerous cells with an IGH/BCL double fusion probe signal pattern consistent with IGH/BCL2 gene rearrangement.

Overall, the morphologic and immunophenotyipic findings in conjunction with the cytogenetic results are in keeping with involvement by a B-cell lymphoma most consistent with a follicular lymphoma. The follicles present contain <15 centroblasts per hpf and the low proliferation fraction makes it most compatible with a low grade (WHO morphologic grade 1-2/3) follicular lymphoma.

Discussion

The differential diagnosis for an extramedullary epidural tumor is wide and can include anything from an epidural abscess to a metastasis. Although rare, lymphoma must be considered, especially when initial pathology shows “Round blue cells.”

Making the diagnosis of follicular lymphoma involves assessing the H & E slides for follicular architecture, characteristic immunostains including positivity for BCL2 within follicles and the typical t(14;18) IGH/BCL2 translocation, which occurs in 90% of cases. ²

Primary spinal epidural lymphoma (PSEL) includes extramedullary/extranodal lymphomas of the epidural space for which there are no other sites of disease at the time of diagnosis. As demonstrated in Figure 1 below, the lymphoma is seen entirely within the epidural space. ³

fig1 — Figure 1. Primary spinal epidural lymphomas. Journal of Craniovertebral Junction and Spine (2011).

An epidural location for lymphoma is observed in 0.1-6.5% of cases. Patients tend to present in the fifth to seventh decade of life with a higher proportion of male to female cases. Presenting symptoms include weakness in the upper or lower limbs and back pain corresponding to the site of involvement of tumor. The most common tumor site is the thoracic spine (75%) followed by lumbar and cervical. Most epidural spinal tumors are B-cell lymphomas of intermediate and high grade, but low grade lymphomas have been reported. ³

Although rare, lymphoma is an important consideration in the differential diagnosis for tumors involving the spine. Surgical intervention is often necessary to relieve spinal cord compression and to make a histologic diagnosis. Treatment includes radiation and chemotherapy. Patients with primary spinal epidural lymphoma tend to have a better prognosis than patients with systemic lymphoma involving the epidural space, as well as patients with metastatic carcinoma. ³

References

Hameed, Meera: Small Round Cell Tumors of Bone. Arch Pathol Lab Med (2007) 131: 192-204.
Louis D.N., Ohgaki H., Wiestler O.D., Cavenee W.K. (Eds.): WHO Classification of Tumors of the Central Nervous System. IARC: Lyon 2007.
Cugati G, Singh M, Pande A, et al. Primary spinal epidural lymphomas. Journal of Craniovertebral Junction and Spine (2011) 2(1): 3-11.

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–Chelsea Marcus, MD is a third year resident in anatomic and clinical pathology at Beth Israel Deaconess Medical Center in Boston, MA and will be starting her fellowship in Hematopathology at BIDMC in July. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Lab Week 2018

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Labs: the final frontier. These are the voyages of lab-techs everywhere. Our continuing mission: to explore strange new orders, to seek out new tests and new sero-preparations, to boldly notify floor clinicians about sample hemolysis for redraw…

Or at least that’s close enough to Gene Roddenberry’s vision for futurism in exploration—except instead of starships, we’re talking Star Labs. Happy 2018 Lab Week everybody, and thanks for checking back in!

Okay, so here’s something a little bit different. Different from my usual Zika or medical school posts, this piece is a celebration of several lab “truths” which I know many of us share. It seems like one of the overarching themes I’ve encountered regarding laboratory operation (and appreciation) is communication. Expectations and needs aren’t always communicated effectively across different medical disciplines and scopes. A while back I thought of 40 things every lab professional should know, but I’d like to expand on that a bit.

How many times have you said or encountered any of the following:

Why does the blue top have to be full, if the other ones weren’t as full?
I just put some blood from the lavender top into the tiger top—patient is a hard stick…
I’m checking on results for the patient in room 123…no, I don’t have their MRN…
There’s a trauma patient coming in via helicopter, I need crossmatched units before they’re here.
Can you please add on a serum lactic acid, there was a BMP from yesterday?
This C. Diff sample is solid…
Why are some hospitals’ rapid flu-tests done with just the swab of a swab kit, a little aliquot of saline from an IV push syringe, and a wasted no gel SST?
Are the results ready for the biopsy we did just now?
Do we have a critical value range for ESR?
We haven’t had an in-service on running POCT Glucose controls, so we haven’t done them yet
I didn’t want the tubes to leak in transit, so I used the labels as tape to keep the caps on!
In order to get SUPER GOLD STAR STROKE AND GOUT CENTER accreditation, we have to slash TATs by 40%

star2 — Captain Hematologist Jean Luc Picard (front) pleads with a clinician that only wants the WBC and H/H from a clotted CBC. Second Officer Riker (bottom left) smiles because he knows clots are dangerous for most analyzers. Lt. Operations Officer Worf (top right) agrees firmly for the sake of honor and quality assurance. An ensign trains on urinalysis (top left). [Source: *Star* *Trek* *TNG*]

I’m sure by now you realize I could go on, and on, and on…There are always issues in laboratory medicine that don’t always translate well between floor clinicians and laboratory staff. It’s a tale as old as time. And, until we do develop universal translator technology, it will remain somewhat of a barrier to improving workflow. So how to we fix it? I argue it starts with Lab Week.

Lab Week is supposed to celebrate the clinicians, laboratory professionals, and ancillary staff that work diligently to produce results. Hundreds of thousands of laboratorians work throughout the country and are highly-trained, well educated professionals who use their expertise to diagnose and monitor treatments. Quality medical testing and exceptional care are part of the core values that each of us are celebrated for every year in April! Let me be clear, we are not support services for other clinical professionals—we’re all on the same team. Don’t be angered by the misinformed questions above, or by the stereotypes you might encounter in pathology, try and use them as teaching platforms within our community.

star3 — Capt. Hematologist Jean Luc Picard (right) takes endorsement from Chief Instrument Engineer Geordi LaForge (left) and while examining active Laboratory Data (center) speaks with clinical staff regarding temporary procedural changes for sending and holding PTT mixing studies while maintenance is being completed. [Source: *Star Trek* *TNG*]

The whole point is that we’re in this together. Not just interdisciplinary teamwork that makes this year’s Star Lab theme so poignant, but teamwork across scopes. Those calls and messages we get in our managers’ offices or various bench top phones are part of our team too. It’s about the patients. We already know we contribute over 70% of clinical relevant information in every patient’s chart—some diagnoses like cancer rely completely on pathologist interpretation for screening, diagnosis, staging, and treatment recommendations.

star4 — While EMH Drs. Mark I and Mark II receive their “bad” results, it’s all part of a larger picture. As a note, “panic results” rarely illicit the expected reaction in the nurses and physicians we report them to. These doctors would think our current medical practice standards medieval, anyway… [Source: *Star Trek Voyager*]

Here are a few examples of effective communication you could keep in mind.

For any Laboratory Professionals reading:

Instead of this: “Our policy is to reject clotted CBCs, we need a redraw, sorry.”
Try this: “While policy says to reject clotted CBCs, it’s not just because it could affect your PLT count. Other cell counts may be affected, and micro-clots can jam up the sensitive lines in the analyzers shutting them down for a while and affecting other patients’ results.” Try and realize that clinicians really do rely on those results! First and foremost, many clinical decisions are made on that last pending result for the next step of treatment. Whether it’s a PLT count or an acetone level, every result matters.

Instead of: “Room numbers aren’t adequate for patient and sample identification, sorry.”
Try this: “Because room numbers can change so quickly, we can’t use them to properly identify a specimen or patient. Do you have any of the following information…?” Understand that doctors, nurses, etc. aren’t always calling the laboratory from a private area. Thus, with so many people walking around a medical unit, a name might not be an option for them to use—room numbers are a sort of code for HIPAA compliance.

For any Clinicians reading:

Instead of this: “I really need you to rush that type and cross, quickly.”
Try this: “What can I do to help facilitate quicker turn-around for getting these units available for my patient?” Not only will you have started a conversation with the bench tech working on crossmatches, but you’ll demonstrate awareness of the complex process of safety/reportability blood bank goes through. Understand that Blood Bank is one of the more highly regulated aspects of laboratory medicine; FDA guidelines treat blood products as both a controlled substance and a tissue transplant, effectively.

Instead of this: “You have to run these samples because the patient is a hard stick.”
Try this: “What would be the minimum amount sufficient to run a particular test?” and if you need more information, simply ask! You’d be surprised how much the lab scientist on the phone would know about a particular testing method. Understand that QNS guidelines for specimens are not arbitrary amounts for the sake of covering repeats or mistakes in analysis. They are there to ensure quality results based on research and efficacy for a given instrument or method.

star5 — We all get angry. Especially at work, when our labs might be understaffed, overloaded, and dealing with instrument failures or evil advanced genetically modified arch-nemeses on the floors like Laboratory Manager Capt. Kirk (pictured). [Source: Star Trek the Wrath of Khan]

So, it’s okay to get frustrated. It’s human. But I’ve got to tell you, I have been on both sides of this now—as a laboratorian and a clinician—and what I see time after time are simple gaps in communication. If we want to get better, not just for us, but for our patients, we should play an active part in helping close that gap.

I gave a few examples above, but how do we really change anything? My answer: interdisciplinary collaboration—and that’s not just a buzz word from my finishing LMU! If we want to really change anything, we should start it. If you’re a bench tech, start a discussion with your senior staff, supervisors, and managers about what you feel could be improved. If you’re a manager, seek out those barriers and be an active advocate for your staff—you’re already an advocate for the lab. If you’re a clinical pathologist, coordinate with your colleagues on the floor, develop more relationships, reach out for more than just consults on sign-outs.

star6 — Don’t be afraid to be a voice for change. Staff meetings, in-services, and self-aware improvement can be facilitated with good leadership, organization, and clear goals! Even if things look grim and you’re on downtime with a full ER, or stuck in the middle of a volatile asteroid field, noted barriers to improved communication will always GET RESULTS. [Source: *Star Trek TNG*]

Want to change the knowledge gaps between clinical staff and laboratory staff? Hold an in-service or distribute messages with the missing information. When I was at Northwestern Medicine’s Blood Bank, I was an instructor once a month for nursing staff regarding blood products and transfusion protocols. We walked through the process with new nurses from proper phlebotomy and labeling, to order sets, to transfusion, to dealing with transfusion reactions. It was excellent! It was a great time to answer many questions and also gain insight into the clinical side of transfusion medicine.

Want to make sure no more sideways or crooked labels get sent to your specimen receiving stations? Instead of relying on the shear number of rejections to speak for themselves, discuss policy changes with your management, find the barriers to this change of specimen labeling, even send flyers out with “best dressed” tube images—it’s worked, I’ve seen it!

Want to make sure pathology stereotypes aren’t continued into the future? Change them! I plan to! Everyday I think of new ways to facilitate a new model of inclusion for pathologists into clinical healthcare teams. They’re an integral member already, why not reach past that tumor board, or biopsy report?

star7 — It takes a village to run a lab, or a space station. An interdisciplinary team is the only way healthcare can continue to improve. Shapeshifting flexibility, shrewd business deals, passion for quality assurance, creative license, and scientific knowledge are only as good as the teamwork they are a part of—even if you have religious emissaries on your staff. Sharing knowledge and effective communication are critical for labs, clinicians, and our patients. [Source: *Star Trek DS9*]

The bottom line: if laboratorians want to grow and advance into the changing fronts within healthcare, we should take this opportunity during Lab Week 2018 and really embrace our profession as part of an interdisciplinary team. We deliver exceptional care and advocate for patients through our quality work in detecting, reporting, and preventing illnesses. I recommended laboratory professionals become more actively involved with fellow clinicians to directly improve patient outcomes. Let’s teach, let’s change policies, let’s have interdisciplinary rounds, let’s have roundtable discussions, let’s advocate together.

Because, after all, aren’t we advocating for the same thing: our patients.

Thank you! See you next time, and Happy Lab Week!

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–Constantine E. Kanakis MSc, MLS (ASCP)^CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

Microbiology Case Study: A 36 Year Old Man with Symptoms of Bowel Obstruction

Case History

A 36 year old Caucasian male presented to the hospital with symptoms of a bowel obstruction. His past medical history was significant for a gunshot wound to the abdomen followed by the development of colon cancer with metastasis to the liver. Recently, he had an intestinal stent placed in order to relieve an obstruction from tumoral growth. During the current admission, he was taken to the operating room for a diverting colostomy and two days later developed a fever of 101.1°F and increasing abdominal pain. Due to a concern for sepsis, blood cultures were collected and piperacillin-tazobactam was added to his antibiotic therapy regimen which already included vancomycin and ciprofloxacin.

Laboratory Identification

aero1 — Image 1. Gram stain from the blood bottle showing many gram negative rods (100x oil immersion).

aero2 — Image 2. The organism grew as mucoid colonies on blood, chocolate and MacConkey agars after 24 hours of incubation at 35°C in 5% CO₂.

aero3 — Image 3. The organism exhibited beta hemolysis on blood agar when held up to a light source.

The blood culture signaled positive after less than 24 hours on the automated instrument and Gram stain revealed gram negative rods (Image 1). The organism grew as mucoid colonies on blood, chocolate and MacConkey agars after 24 hours of incubation at 35°C in 5% CO₂ (Image 2). When the blood agar plate was examined with a light source, the organism clearly illustrated beta hemolysis (Image 3). Rapid biochemical testing was positive for catalase, oxidase and indole. The Vitek II identified the isolate as Aeromonas veronii bv. sobria.

Discussion

Aeromonas spp. are facultative anaerobic gram negative rods. They are inhabitants of aquatic ecosystems and as such can cause wound infections in people exposed to polluted lakes or brackish water with fresh breaks in their skin. Additionally, gastroenteritis is common with Aeromonas spp. and are often acquired through ingestion of unpurified water or to a lesser extent by consumption of contaminated meats, fresh produce or dairy products. Extraintestinal infections, including sepsis and meningitis, can result by spread from GI sources or wound infections. Interesting, medicinal leeches, used in the post-operative setting to increase blood flow to the surgical site, are colonized with Aeromonas spp. (most commonly Aeromonas veronii bv. sobria) and can result in systemic infections in the patient.

In the laboratory, Aeromonas spp. grow readily from stool, wound and blood sources on commonly used media and exhibits beta hemolysis on blood agar. In addition, Aeromonas spp. will grow on CIN agar (at room temperature as well as incubator temperature) as colonies with a pink center surrounded by a white apron and are indistinguishable from Yersinia spp. Aeromonas spp. is positive for catalase, oxidase and indole by rapid testing. In most cases, identification of Aeromonas spp. to the complex level can be accomplished by biochemical testing (esculin, VP), automated instrumentation or MALDI-TOF mass spectrometry. The three clinically relevant complexes include: A. hydrophila complex, A. caviae complex and A. veronii complex.

With regards to susceptibility testing for Aeromonas spp., the CLSI M45, 3^rd edition provides guidelines for the three complexes discussed above. Third or fourth generation cephalosporins, fluoroquinolones and trimethoprim-sulfamethoxazole are recommended as antibiotics for primary testing for isolates from extraintestinal sites. Aeromonas spp. are uniformly resistant to ampicillin, amoxicillin-clavulanate and cefazolin and many strains may possess various inducible beta lactamases.

In the case of our patient, with the laboratory identification of Aeromonas veronii bv. sobria, his gram negative coverage was switched to ciprofloxacin for a 10 day course. His PICC was removed and on further imaging studies he was found to have a large abdominal abscess which required surgical drainage. Subsequent cultures from the abdominal abscess were negative.

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-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the director of the Microbiology and Serology Laboratories. Her interests include infectious disease histology, process and quality improvement, and resident education.

FISH! Philosophy

In Seattle, Pike Place Fish Market is nearly synonymous with the Pike Place Market. Tourists and locals stand and watch the fish mongers fill orders by throwing fish around the stand. Everyone, including the employees, laughs and enjoys the atmosphere. This is where the FISH! Philosophy was born. FISH! is a leadership training method that focuses on four concepts to increase collaboration and excitement about work:

Choose your attitude
Be present
Play
Make someone else’s day

These concepts are not mind-blowing, and this is exactly why they’re effective. They are easy to remember and easily integrated into daily practice, whether you are a teacher,a an office worker, or a laboratory professional. Becoming an effective and productive employee starts with choosing your own attitude. For example, when you choose the attitude of empowerment, support, and kindness, you start enacting them. In other words, you become kinder and you support and empower others more easily. As an experiment, I recently said to myself “I am energized and excited” when I was feeling the complete opposite. I started it as more of a joke, to be honest, but the interesting thing is that within twenty minutes, I actually became energized and excited. The power of our attitude is immense and we can all use it to our own and others’ benefit.

To be present is not an easy task. We are often pulled in many different directions, whether professionally or personally. Sometimes we can only think about work when we are at home, or we want to be at home when we are at work. The power of being present comes from acceptance; accepting that we are at work frees us from the resistance that is sapping our energy if we are mentally at home. We have all had conversations where someone wasn’t quite present and we can all remember how frustrating that was. On the other hand, having a conversation with someone who is present makes us feel important, appreciated, and empowered.

Work can be a serious place, especially when lives are at stake. However, there are always moments of play possible, even if it is during breaks or at lunch. If we focus on making someone else’s day, not only do we create a happier work force, we become happier ourselves. We all know how good it feels to make someone laugh, to make someone feel cared for. Perhaps it is something small, like asking if you can bring someone a coffee when you are running out to get one. Or perhaps you leave them a nice note or do a small task for them to make their day easier. I have a notepad with “Awesome Citations.” It is a simple note that I fill out and I hand to someone each week. Making someone’s day does not have to be big or extravagant. It is often the small gestures that people remember.

So go out and be present, while choosing your attitude. Play a little at work to make someone’s day. The simple acts we take every day can transform an entire department and organization. So why not throw some fish and have some fun?

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My story begins many decades ago when I was working in the laboratory at Bronson Methodist Hospital in Kalamazoo, Michigan. While my favorite departments were Blood Bank and Hematology, I had the honor of working with Joie Vine and Dr. Hubbard, the supervisor and chief pathologist, respectively, of the microbiology department. Microbiology was my least favorite department, but luckily for me, Dr. Hubbard discovered early on that I loved to learn. Dr. Hubbard was small in stature, yet large in leadership skills. He knew when to be serious and when to be light-hearted. That attitude permeated the lab. Dr. Hubbard made it possible for me to go to the AABB conferences and U-Hospital (University of Michigan) for specialized training. As a lab professional, I was living the dream!

It was spring when Joie told me she was going on vacation and was short-staffed. She asked me to fill in for her during the lunch hour for one week, which would allow her staff to go to lunch. I said yes. Everyday Dr. Hubbard would check in with me on his way to and from lunch. By Thursday, I was really missing Blood Band so I decided to have some fun. When Dr. Hubbard stopped by microbiology, I opened a feces container. I look at him and said, “hmmm, looks like feces,” held it to my nose, “smells like feces,” and with my finger, I scooped a little and placed it in my mouth. I proclaimed, “it tastes like feces!” He was in total shock. After a brief moment I burst into laughter and so did he! I had placed peanut butter in the feces container!

So if you’re thinking you can’t apply the Fish Philosophy to the clinical laboratory environment, remember, we “Choose our Attitude every day.” It feels good to “Be There” when a friend needs us. I’ll always remember when Dr. Hubbard said that “I Made His Day!” because we took a break from our serious work and played!

Catch the Energy — Lab Professionals are Fun People!

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Tissue is the Issue: Splitting Specimens, Part 1

When we think about infectious disease (ID) and specific syndromes (culture-negative endocarditis, for example), it can be difficult to know the etiology.¹ This is because different microorganisms can cause similar symptoms and depending on the specimen submitted to the laboratory for testing, you may need to split your specimen. It may be that the infection is localized to a small area (valve vegetation) and all you get for processing is a small volume of tissue. Another scenario is that you get a sufficient amount of specimen, but you must split the specimen for culture, multiple send out studies, pathology, etc. Or even worse–a small volume specimen that you need to split for multiple diagnostic tests.

We recently had a case of endocarditis. The patient’s blood cultures were negative, and she was going to have her mitral valve replaced. The ID team requested that we send the tissue for broad-range bacterial and fungal sequencing. We can do that- not a problem.

The Issue

As requested, the specimen (mitral valve vegetation) was split once it was received in the laboratory. Half went into the freezer for sequencing requests which we send to a reference laboratory and the other half was processed for bacterial (including mycobacteria) and fungal cultures.

In our experience, if no organisms are observed, then no DNA is detected. Therefore, it is not beneficial to send tissue for sequencing if we do not observe an organism (or something that looks suspicious for an organism) to begin with. In parts 2 and 3 of this series we will go into greater detail of the workflow for examining tissue for infection, but for now we will focus on the processing piece.

No organisms were observed in the direct smears (Gram, fungal, and acid-fast) and all cultures were negative. Because no organisms were observed, we did not send the tissue for sequencing. However, the patient was not improving and ID insisted that we send the tissue for sequencing anyway. As a last ditch effort we decided to homogenize the frozen tissue to see if by chance organism was present.

Long story short: the Gram stain did not reveal organism, but acridine orange² did. We cultured the tissue and recovered an organism. Moral of the story: specimen processing can be tricky. It is an inherent issue that we must be aware of. How were we to know in which part of the tissue the organisms were? By definition, this is sampling error at its finest.

The Solution

Moving forward, rather than split the specimen prior to processing we have changed our protocol to homogenize the tissue first, then split the specimen. We believe this will eliminate similar scenarios from happening again in the future.

The Conclusion

All specimens are different in their composition. Unlike body fluids, which are easy to vortex and make homogeneous; tissue is more complex. Whatever the specimen, make sure your protocol(s) reduces sampling error.

References

Subedi S, Jennings Z, Chen SC. 2017. Laboratory Approach to the Diagnosis of Culture-Negative Infective Endocarditis. Heart Lung Circ. 26(8):763-771.
Lauer BA, Reller LB, Mirrett S. 1981. Comparison of acridine orange and Gram stains for detection of microorganisms in cerebrospinal fluid and other clinical specimens. J Clin Microbiol.14(2):201-5.

Martinez Headshot-small 2017

-Raquel Martinez, PhD, D(ABMM), was named an ASCP 40 Under Forty TOP FIVE honoree for 2017. She is one of two System Directors of Clinical and Molecular Microbiology at Geisinger Health System in Danville, Pennsylvania. Her research interests focus on infectious disease diagnostics, specifically rapid molecular technologies for the detection of bloodstream and respiratory virus infections, and antimicrobial resistance, with the overall goal to improve patient outcomes.

Chemistry Case Study: Conjugated Bilirubin in Neonatal Jaundice

Case History

Patient was a 1-week-old infant in the level 2 NICU born at 37 weeks. This infant was initially born with indirect hyperbilirubinemia but now also has increasingly elevated level of direct bilirubin (see measurements in table below). Neonatologist requested conjugated and unconjugated bilirubin test due to increasing elevated level of direct bilirubin. Conjugated bilirubin test is not routinely performed in our hospital laboratory and needs to be send out.

Question: What’s the difference between conjugated bilirubin and direct bilirubin? When does conjugated bilirubin need to be assessed?

	Ref Range	3/6/18	3/7/18	3/9/18	3/10/18	3/12/18
Bilirubin total, neonatal	1.0-10.5 mg/dL	9.2	8.7	10.8	10.2	8.6
Bilirubin direct, neonatal	0.0 – 0.6 mg/dL	0.5	0.7	1.8	1.8	2.1

Discussion

Neonatal jaundice is commonly seen in newborns in the first few days of life, mainly due to increased bilirubin formation from break down of red blood cells and limited conjugation of bilirubin. Total bilirubin normally peaks at day 2-3 and should decline by day 4-5. Sample is collected via heelstick in green top tube and protected from light. Measurement of total bilirubin is interpreted based on the Bhutani Nomogram to assess risk of hyperbilirubinemia. Most often, unconjugated bilirubin is elevated in neonatal jaundice owing to hemolytic causes. In cases with prolonged jaundice, conjugated bilirubin needs to be determined to rule out cholestasis.

Conjugated bilirubin refers to bilirubin conjugated with one or two glucuronic acid, and this term “conjugated bilirubin” is often used interchangeably with direct bilirubin. Direct bilirubin refers to bilirubin fractions that can directly react with diazo reagent without the addition of accelerator, such as methanol or ethanol. This fraction usually includes conjugated bilirubin and delta bilirubin. Delta bilirubin is formed by covalent bonding between conjugated bilirubin and albumin, and has a similar half-life as albumin, 21 days. Therefore, direct bilirubin measurement overestimate conjugated bilirubin and in cases with persist or atypical jaundice, clear differentiation between conjugated and direct bilirubin is important. Clinician should know what the laboratory is measuring when interpreting the bilirubin fraction results.

In laboratories, conjugated bilirubin can be assessed by the VITROS BuBc dry slide, which simultaneously measures unconjugated (Bu) and conjugated (Bc) bilirubin by use of a mordant. In the presence of the mordant, the visible spectra of conjugated and unconjugated bilirubin are different, allowing measurement of both species from a single slide. Fractions of bilirubin can also be separated by HPLC, but this is not practical to use in a routine clinical laboratory. In this case, conjugated bilirubin was measured by VITROS BuBc slide test, and result came back elevated at 1.0 mg/dL (ref range: < 0.3 mg/dL).

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-Megan Ketcham, MD is a 4^th year anatomic and clinical pathology resident at Houston Methodist Hospital. She will be completing both hematopathology and dermatopathology fellowships. Her interests include pathology resident and medical student education and skin lymphomas.

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-Xin Yi, PhD, DABCC, FACB, is a board-certified clinical chemist, currently serving as the Co-director of Clinical Chemistry at Houston Methodist Hospital in Houston, TX and an Assistant Professor of Clinical Pathology and Laboratory Medicine at Weill Cornell Medical College.

Blood Bank Case Study: Transfusion Transmitted Malaria

Case Study

A 26 year old African American female with sickle cell anemia presented to a New York emergency room with cough, chest pain, fever and shortness of breath. Laboratory results showed an increased white blood cell count, slightly decreased platelet count and a hemoglobin of 6.2 g/dl. Her reticulocyte count was 7%, considerably below her baseline of 13%. Consulting the patient’s medical records revealed history of stroke as a child and subsequent treatment with chronic blood transfusions. She was admitted to the hospital for acute chest syndrome and aplastic crisis and care was transferred to her hematologist. Two units of RBCs were ordered for transfusion.

The blood bank technologists checked the patient’s blood bank history and noted her blood type was A, Rh(D) positive, with a history of a warm autoantibody and anti-E. The current blood bank sample confirmed the patient was blood type A, RH(D) positive with a negative DAT but the antibody screen was positive. Anti-E was identified. Per request of the hematologist, phenotypically similar units were found and the patient was transfused with 2 units of A RH(negative), C/E/K negative, HgS negative, irradiated blood. The patient’s hemoglobin rose to 8g/dl and she was discharged from the hospital 3 days after transfusion.

Ten days after discharge the patient returned to the emergency room with symptoms including aching muscles, fever and chills. A delayed transfusion reaction was suspected. A type and screen was immediately sent to the blood bank. The post transfusion type and screen remained positive for anti-E, DAT was negative. No additional antibodies were identified. However, a CBC sent to the lab at the same time revealed malarial parasites on the peripheral smear. The patient was consulted for a more complete medical history and reported that she had never traveled outside of the country. A pathology review was ordered and the patient was started on treatment for Plasmodium falciparum.

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Discussion

Red Blood cell transfusions can be life saving for patients with sickle cells anemia. These patients are frequently transfused by either simple transfusion of red cell units or by exchange transfusion. Because of this, alloimmunization is reported to occur in 20% to 40% of sickle cell patients.¹Blood bank technologists are very diligent in adhering to strict procedures and follow a standard of practice aimed to prevent transfusion reactions. While preventing immune transfusion reactions may be the most forefront in our minds when transfusing the alloimmunized patient, it is important to consider transfusion transmitted diseases as a potential complication of blood transfusions.

Malaria is caused by a red blood cell parasite of any of the Plasmodium species. Mosquito transmitted infection is transmitted to humans through the bite of an infected mosquito. Transfusion-transmitted malaria is an accidental Plasmodium infection caused by a blood transfusion from a malaria infected donor to a recipient.

Donors, especially those from malarial endemic countries who may have partial immunity, may have very low subclinical levels of Plasmodium in their blood for years. Even these very low levels of parasites are sufficient to transmit malaria to a recipient of a blood donation. Though very rare, transfusion-transmitted malaria remains a serious concern for transfusion recipients. These transfusion-transmitted malaria cases can cause high percent parisitemia because the transfused blood releases malarial parasites directly into the recipient’s blood stream.

Blood is considered a medication in the United States, and, as such, is closely regulated by the FDA. Blood banks test a sample of blood from each donation to identify any potential infectious agents. Blood donations in the US are carefully screened for 8 infectious diseases, but malaria remains one infectious disease for which there is no FDA-approved screening test available. For this reason, screening is accomplished solely by donor questioning.² A donor is deferred from donating if they have had possible exposure to malaria or have had a malarial infection. Deferral is 12 months after travel to an endemic region, and 3 years after living in an endemic region. In addition, a donor is deferred from donating for 3 years after recovering from malaria. It is important, therefore, for careful screening to take place by questionnaire and in person, to make sure that the potential donor understands and responds appropriately to questions concerning travel and past infection.

Malaria was eliminated from the United States in the early 1950’s. Currently, about 1700 cases of malaria are reported in the US each year, almost all of them in recent travelers to endemic areas. From 1963-2015, there have been 97 cases of accidental transfusion-transmitted malaria reported in the United States. The estimated incidence of transfusion-transmitted malaria is less than 1 case in 1 million units.⁴ Approximately two thirds of these cases could have been prevented if the implicated donors had been deferred according to the above established guidelines.³ While the risk of catching a virus or any other blood-borne infection from a blood transfusion is very low, a blood supply with zero risk of transmitting infectious disease may be unattainable. With that being said, the blood supply in the United Sates today is the safest it has ever been and continues to become safer as screening tests are added and improved. Careful screening of donors according to the recommended exclusion guidelines remains the best way to prevent transfusion-transmitted malaria.

References

LabQ, Clinical laboratory 2014 No.8, Transfusion Medicine. Jeanne E. Hendrickson, MD, Christopher Tormey, MD, Department of Laboratory Medicine, Yale University School of Medicine
Technical Manual, editor Mark K. Fung-18^th edition, AABB. 2014. P 201-202
https://www.cdc.gov/malaria/about/facts.html. Accessed April 2018
The New England Journal of Medicine. Transfusion-Transmitted Malaria in the United States from 1963 through 1999. Mary Mungai, MD, Gary Tegtmeier, Ph.D., Mary Chamberland, M.D., M.P.H., June 28, 2001. Accessed April 2018
Malaria Journal. A systematic review of transfusion-transmitted malaria in non-endemic areas. 2018; 17: 36. Published online 2018 Jan 16. doi: 1186/s12936-018-2181-0. Accessed April 2018
http://www.aabb.org/advocacy/regulatorygovernment/donoreligibility/malaria/Pages/default.aspx

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-Becky Socha, MS, MLS(ASCP)^CMBB^CMgraduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

To Be (MDS) or Not To Be? The Conundrum of Cytoplasmic Vacuolation in Hematopoietic Precursors

Every hematopathologist and pathology trainee knows to be wary of the myriad of causes that could mimic the dysplastic changes seen in marrows involved by MDS. Many times morphology alone, without genetic or cytogenetic evidence of clonality can be tricky. The list of things that can recapitulate changes seen in MDS seems to grow longer every day – and with it the length of our ‘canned comments’ on ruling out reactive causes of dysplasia. Within the recent past, two bone marrow biopsies crossed my microscope, both sent to ‘rule out’ MDS. Both had almost identical morphologic findings, but very different diagnoses. Here are some representative images from the marrow aspirates and iron stains:

mds — Figure 1. Representative Wright-Giemsa stained cells from Case 1 (A and B) with accompanying iron stain (C) showing numerous ring sideroblasts. Representative Wright-Giemsa stained cells from Case 2 (D) with accompanying iron stain (E) showing some ring sideroblasts.

Discussion

Images A through C come from case 1, a 67-year-old woman with a past medical history of non-alcoholic steatohepatitis (NASH) complicated by hepatic encephalopathy and recurrent ascites who underwent bone marrow biopsy for new onset pancytopenia with transfusion-dependent anemia. The marrow was slightly hypercellular for age and showed progressive trilineage maturation. Granulocytic and erythroid progenitors did not reveal quantitatively significant dysplasia. The one dysplastic megakaryocyte identified is pictured here (panel A). Interestingly many erythroid and granulocytic precursors showed cytoplasmic vacuolation (panel B showing granulocytic vacuolation). An iron stain (panel C) revealed 44% ring sideroblasts. Case 2 is represented in images D and E and was from a 64-year-old man with no significant past medical history who presented with lethargy and anemia. This marrow was also slightly hypercellular for his age and showed borderline-significant dysplasia in megakaryocytic maturation. Granulopoiesis and erythropoiesis were unremarkable except for cytoplasmic vacuolations in many cells (panel D). An iron stain showed 8% ring sideroblasts (panel E).

Both cases were signed out descriptively, urging the clinician that we needed to rule out reactive causes of dysplasia before a definitive diagnosis of MDS could be rendered. In both cases we suggested waiting for the cytogenetics results for a more comprehensive analysis. Additionally, we recommended testing for serum copper since copper deficiency can be the cause of dysplastic morphology, cytoplasmic vacuolation, and ring sideroblasts.

Case 1 revealed markedly diminished copper and normal cytogenetics. Copper replenishment was curative. Case 2 revealed normal copper levels and a complex karyotype that contained numerous MDS-associated abnormalities confirming the clonal, and therefore malignant nature of these changes. Despite being almost identical morphologically, these case were diagnostically and prognostically poles apart.

Copper is an element that serves as a micronutrient required for hematopoiesis. It’s presence in many readily available foods including meat, fish, nuts, and seeds renders diet-related copper deficiency a rare phenomenon. Zinc-supplementation is one of the causes of copper deficiency in published reports. Copper deficiency has been well documented to mimic dysplastic changes seen in MDS; but these morphologic findings and cytopenia are reversible. Characteristically, cytoplasmic vacuolation is an important morphologic clue that there could be an underlying paucity of serum copper. Another aspect of copper deficiency is the presence of ring sideroblasts which also can mean MDS. It is very important to consider this differential diagnosis when dealing with marrow specimens sent to rule out MDS. This Lablogatory post highlights the significant overlap between presentation and morphologic findings between MDS and copper deficiency supporting the notion that a high index of suspicion, good communication, stat copper levels, and cytogenetics or MDS FISH studies are very helpful in delineating benign from malignant.

References

Dalal N. et al. Copper deficiency mimicking myelodysplastic syndrome. Clin Case Rep. 2015 May; 3(5): 325–327.
Willis M.S. Zinc-Induced Copper Deficiency: A Report of Three Cases Initially Recognized on Bone Marrow Examination. AJCP. 2005 Jan; 123(1): 125–131
D’Angelo G. Copper deficiency mimicking myelodysplastic syndrome. Blood Res. 2016 Dec; 51(4): 217–219.
Karris S and Doshi V. Hematological Abnormalities in Copper Deficiency. Blood 2007 110:2677

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-Kamran M. Mirza, MD PhD is an Assistant Professor of Pathology and Medical Director of Molecular Pathology at Loyola University Medical Center. He was a top 5 honoree in ASCP’s Forty Under 40 2017. Follow Dr. Mirza on twitter @kmirza.

Microbiology Case Study: A 79 Year Old Male with Rheumatic Heart Disease

Case History

The patient is a 79 y/o male with past medical history of rheumatic heart disease, permanent atrial fibrillation, mechanical aortic and mitral valves (2004), status post single chamber pace maker for bradycardia (2010), and prostate adenocarcinoma treated in 2000. He had new MRI compatible pace maker placed on Oct 19, 2017. During follow-up he was noted to have a hematoma over the incision site. He had a revision done on Nov 3, 2017. At that time, the blood from the incision site was sent for culture.

Laboratory Identification

Gram stain showed moderate amount of polys with no bacteria seen. The isolate was a gram-negative rod that was identified on the MALDI-ToF as Burkholderia multivorans.

burkmult1 — Image 1: Semi-mucoid, yellow-grey colonies on Chocolate agar and on Blood agar plates.

Discussion

The Burkholderia genus appears as gram-negative medium-sized straight rods, with the exception being B. mallei which is a coccobacillus. The will grow on blood, chocolate, and MacConkey agar. Oxidative-fermentative-base-polymyxin B-bacitracin-lactose (OFPBL) agar can be used to isolate B. cepacia and Ashdown medium can be used to isolate B. pseudomallei. They are non-lactose fermenters on MacConkey, but B. cepacia can turn into a dark pink to red due to oxidation of lactose after 4-7 days.

B. multivorans is a species within the Burkholderia genus, which are normal to plant, soil, and water, but not normally considered common human flora. Formerly of the Pseudomonas genus, B. cepacia, B. mallei, and B. pseudomallei are the most commonly seen as infections in humans. Further, B. cepacia and B. mallei are not typically human pathogens in a healthy human host. Because of the rarity of this genus to infect humans, their pathogenicity is not well known; but, importantly, they are intrinsically resistant to many antibiotics and can thus be associated with hospital acquired infections.

Of this genus, very little literature is present on B. multivorans specifically, and of the literature that does exist, most of it is in relation to cystic fibrosis patients. Taxonomic advances has shown that B. cepacia complex is a cluster of nine closesly related genomic species or genomorvars (1). B. multivorans represents genomorvar II. Hospital acquired clinical infections from this complex (but perhaps not specifically from this particular genomorvar) has been seen following catheterization, cystoscopy, heart surgery, and with contaminated ventriculoatrial shunt (2). B. multivorans biochemically is oxidase positive, catalase positive, lipase positive, nitrate-reducing, urease positive, resistant to colistin, and can grow at 42C (3, 4).

A recent comparative genomic study showed that B. multivorans is a highly evolutionarily preserved genome with genomic characteristics from the environment and isolated from cystic fibrosis patients to be similar, and that isolates from different continents are also similar (5). Further, a murine model for pulmonary infections showed that B. multivorans could persist in the host by establishing an intracellular presence within macrophages, which could explain the persistence of this pathogen in cystic fibrosis patients (6). Importantly though, due to the conserved and common genomic structure, there rests a possibility for potential vaccination for cystic fibrosis patients against B. multivorans.

The patient was prescribed a single dose of oral Bactrim and then advised to come into the hospital for admission for IV antibiotics. IV ceftazidime was started with pending blood cultures, which are negative at the time of this documentation.

References:

Coenye T. et al. Taxonomy and identification of the Burkholderia cepacia complex. J Clin Microbiol 2001;39:3427-3436.
Pallent LJ. et al. Pseudomonas cepacia as contaminant and infective age. J Hosp Infect 1983;4:9-13.
Henry DA. et al. Phenotypic methods for determining genomovar status of Burkholderia cepacia complex. J Clin Microbiol 2001;39:1073-1078.
Vandamme P. et al. Occurrence of multiple genomovars of Burkholderia cepacia in patients with cystic fibrosis and proposal of Burkholderia multivorans sp. nov. Int J Syst Bacteriol 1997;47:1188-1200.
Peeters C. et al. Comparative genomics of Burkholderia multivorans, a ubiquitous pathogen with a highly conserved genomic structure. PLoS One. 2017, 21; 12 (4): e0176191.
Chu KK. et al. Persistence of Burkholderia multivorans with the Pulmonary Macrophage in the Murine Lung. Infect Immun 2004; 72 (10): 6142-6147.

-Jeff Covington, MD, PhD, is a 1^st year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.