Month: April 2018

Faculty Insights: Teaching Medical Laboratory Science in a Blended Learning Format

Thus far, we’ve talked about the structure of our blended model of curriculum delivery and the learner experience, but what about the instructor experience teaching in this format?

I surveyed a few of our faculty members about their experience teaching in our Medical Laboratory Science (MLS) Program, and their comments about our blended model of curriculum delivery fell into a few themes:

Benefits of the “flipped classroom” model

“Having students complete the lecture content as homework and then meeting with them for the hands-on ‘face-to-face’ learning adds another layer and more reinforcement of key concepts. If learners can’t understand what they’ve read or interacted with in the online component, they’ve got another chance to hear a short review of the material and actually perform a hands-on, real-world lab activity to reinforce again what they have learned. This is what makes blended learning so effective—read, learn, see, do—it hits the learning from every angle.”

“I believe the blended learning style with the online component is very effective, and I would bet that students retain more information and retain the information longer than in traditional formats. It’s all about reinforcement.”

Role of the instructor from “Sage on Stage” to a facilitator of the student’s knowledge acquisition and enhanced student learning

“As an instructor, I am no longer required to be the “Sage on the Stage,” and the questions from our students tend to be more specific, in that they come into the classroom prepared, having some base knowledge of the content.”

“I love teaching with a blended format. Having the online component allows the student to review the learning content prior to coming to lab where we meet face to face. The online blackboard format allows for several different ways to attack the learning, which is nice for the variety of students that we have (age, gender, and background), as well as a variety of learning styles.”

“Teaching with the online component allows for embedded written lessons, recorded lectures, PowerPoint handouts, images, YouTube videos, interactive activities such as a discussion board and wikis, and online worksheets—all at which the student can work through as fast or as slow as needed. Online learning allows for multiple levels of reinforcement to help make the information stick. It also helps learners be in control of their own learning. Access to information is not just a one-time shot in a live lecture. It’s there to use and review as much as needed.”

More time for instructor-led hands-on activities

“Time is another factor. We are only given so much time with the MLS students, and if we had to present all the lecture material in the classroom, we would not have time for all the laboratory activities that we have developed.”

“I like the fact that it puts the onus on the learner to engage with the material ahead of time, which allows for more hands-on learning in the classroom. The blended format makes it extremely conducive for a laboratory-based class.”

“When teaching morphology of cells, I like to use online question ‘banks’ with images of cells, crystals, casts, etc., for the students’ practice. They can review these question banks as much or as little as needed outside of the classroom. They can practice morphology identification at home, outside of class—all without the need of a microscope. Not only do they come into the classroom/lab knowing their cells, but they can work more efficiently and progress more quickly to advanced case studies.”

“I think the flipped model we implement is a great way to enhance our students’ reading skills and comprehension, while holding them accountable for completing the required assignments.”

“The blended approach allows us to address more difficult concepts. While the students may be able to grasp the concepts from their online reading, they also need talking points to confirm that they actually understand and can apply the concepts. We have found that giving the students the task of learning the online concepts can only really be successful if we follow up with them the next day, starting with a discussion about their online homework. We also give quizzes and have designed laboratory activities that apply the online concepts.”

Varied thoughts about course maintenance

“While the time to develop online content can be extensive, once it’s built in this format, it is easier to update and maintain on an annual basis.”

“It is not so easy to maintain the details in the online course. It takes a lot of time and effort to update all of the dates for assignments and other activities for each class section. Once the core components are built, one can easily add to the content. However, if one is building a new module or lesson, it can take a lot of time. It seems that the time to maintain an online course is similar to the time it takes to keep materials up-to-date in a traditional course.”

“At first, it took some getting used to grading assignments online, but I am used to it now and actually prefer it. It’s so easy for a student to do a “copy/paste” when filling out an online worksheet, so I do question typing (copy/paste) vs. writing things out on a worksheet and how well the information is sticking. With the intensity of our program, time is of the essence. I like that as soon as students submit their online assignments, I can grade it. Some students like to work ahead, and some turn things in at the last second. With the online submissions, I can grade as they come in, instead of getting hit with 24 assignments at once, which is a big time-saver for me.”

Repurposing

“One of the greatest positives with [the software] Blackboard Learn is that we can use the system with multiple learners. The learner has easy access to the course once he/she is added to system. One cannot always say that with traditional classroom teaching/learning. Unless the content/didactic is recorded, there is not easy access to the materials.”

In summary, I would stress the following key points as benefits of adopting a blended approach to curriculum delivery:

  • Increased classroom time for hands-on activities that are more closely aligned with what the students will actually be doing once they graduate, get jobs, and go to work.
  • Increased instructor satisfaction.
  • Students are more prepared for the classroom activities.
  • Increased ability to engage students with higher-learning concepts.
  • Course maintenance is more efficient, and learning tools are enhanced.
  • Time and cost savings are realized, related to repurposing of curriculum across different learners.

 

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-Susan M. Lehman, MA, MT(ASCP)SM graduated from the University of Wisconsin-Madison in 1983 with a BS in medical technology. She is program director for the Medical Laboratory Science Program and course director for Clinical Microbiology I and II; her areas of interest include distance education and education methodology.

Transparency in Injury Reporting

Susan was getting ready to work in the microbiology lab. She sat down after donning her lab coat, but before she put on gloves, she picked up some reports that were on the counter. As she picked them up, she noticed she got a small paper cut on her finger. Thinking nothing of it, she put her gloves on and went to work.

Chuck opened the door to walk into the back of the main lab. A cardboard box was in the walkway, and Chuck hit it with his toe and fell to his knee. He figured he wasn’t hurt, so he didn’t say anything since filling out paperwork was such a nuisance- and no one saw it happen.

Jean was walking into the hospital during the ice storm to get to work. Shortly after she closed the car door, she slipped and landed on her wrist. It hurt a little, but she figured it would be fine, so she didn’t say anything.

Accidents happen often in the laboratory setting, and many of them go unreported. The first thing that should occur after an injury is first aid. Then the incident needs to be reported. That may mean telling someone in charge in the department- a lead technologist or a manager. That can vary depending on the department and the time of day. Next, the incident should be reported to an institutional Occupational Health department or to a designated authority (such as the emergency Department) if the Occupational Health office is closed. This step is vitally important.

Make sure the details of the incident are recorded accurately, and that any witnesses are identified. Some facilities use an electronic reporting system, and others require a nurse to fill out the forms. Good communication is important here so that a thorough follow-up by the lab safety professional can occur later. The fewer details left out, the better.

We are human, and accidents happen, but the route to a better safety culture in the department is transparency. All injuries at work need to be reported. There is no shame in an injury, and there should be no reprisals, and reporting leads to prevention of injuries. The communication about the event is crucial- the reporting may prevent someone else from being injured in the same way. In some labs there have been serious injuries that occurred because no one reported a previous similar event. That can and should always be avoided. There are other reasons to report injuries as we – those stories at the beginning of the article did not have a happy end – because they were not reported.

After a week, Susan noticed that her little paper cut had become red and swollen. She made an appointment with her physician who prescribed an antibiotic. The antibiotic didn’t work, and after a serious bout of septicemia, Susan had to have part of her hand amputated to prevent the spread of the rare bacterial infection.

A day after Chuck tripped, Elaine walked into the lab and tripped on the same cardboard box. Elaine fell hard and broke her hip. She needed immediate surgery. She would have retired in another month.

 

Two weeks after her fall in the parking lot, Jean decided to go to the urgent care since her wrist was still hurting. An x-ray revealed a fracture that would need a surgical repair. Jean went to the Occupational Health office to report the event. Because there was such a delay in reporting, the compensation department decided they could honor the claim, and Jean’s medical follow-up was not covered.

There are many reasons to report an injury at work. The first one is about you- protect your own health and your future- that’s worth a few minutes of paperwork and a short visit to the Occupational Health office. The second reason to report is about everyone else. If something is unsafe in your environment and it has caused an injury, let someone know. That sort of communication and transparency is important to the entire team. Accidents happen, but even when they do, we can respond quickly and communicate so that safety improves after the event. As a lab safety professional, make sure you talk about accident transparency, and make sure it is something practiced by the entire team.

 

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–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Microbiology Case Study: A Middle-Aged Man with Malaise, Shaking, and Chills

Case history

A middle-aged male presented to the hospital emergency room with the complaints of malaise, shaking and chills for the last two days. He denied any runny nose, cough, abdominal pain, nausea, vomiting, headache or known sick contacts. His past medical history was significant for alcohol use disorder. Imaging of the abdomen revealed an ill-defined region of decreased attenuation in the right lobe of the liver measuring 4.8 x 4.7 x 2.2 cm. The Gram stain of the abscess showed 4+ WBCs (PMNs) and 4+ gram negative rods with a very large capsule surrounding them (Image 1).  The organisms grew very mucoid colonies on 5% sheep blood, chocolate, and MacConkey agars (Image 2).  A string test performed on the mucoid bacterial colonies was >5 mm (Image 3).

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Image 1. Gram stain of abscess showing 4+ WBCs and 4+ GNR with large capsule.
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Image 2. Cultures showed mucoid colonies on the chocolate and MacConkey agars.
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Image 3. A string test was performed on the mucoid colonies and was positive (mucoid capsule “string” > 5mm).

Discussion

The organism was identified as Klebsiella pneumoniae by MALDI-TOF MS.  Based on the mucoid capsule and positive string test, this organism was further identified as hypermucoviscous K. pneumoniae.

Hypermucoviscous K. pneumoniae is a relatively newly recognized hypervirulent variant of K. pneumoniae. It was first described in the Asian Pacific rim and is now increasingly recognized in Western countries. Defining clinical features include serious, life-threatening community-acquired infection in younger healthy hosts, an unusual feature for enteric gram negative bacilli in the non-immunocompromised population. It can cause a variety of diseases including, but not limited to liver abscess, pneumonia, meningitis, osteomyelitis, necrotizing fasciitis and endophthalmitis.

Intestinal colonization, appears to be a critical step leading to infection. It is seen mostly in Asians, raising the issue of a genetic predisposition vs. geospecific strain acquisition.  The increased virulence might be due to the ability to more efficiently acquire iron and perhaps an increase in capsule production, which confers the hypermucoviscous phenotype to the organism. The vehicles for acquisition and subsequent colonization appear to be food and water, person-to-person transmission (e.g., close contacts such as family members or sexual partners) or animal-to-person transmission (e.g., between pets and their owners).

To date, most strains of hypermucoviscous K. pneumoniae have been very susceptible to antimicrobials except ampicillin.  However, in recent literature, propensity for hypermucoviscous Klebsiella pneumoniae to become multi-, extreme or pandrug-resistant, including the acquisition of extended-spectrum β-lactamases (ESBL) and carbapenemases has been reported. Since hypermucoviscous K. pneumoniae strains often cause abscesses, source control is a major aspect of the overall management plan and a need to drain abscesses and closed space infections is essential for optimal outcome.

References

  1. Alyssa S. Shon, Rajinder P.S. Bajwa and Thomas A. Russo; Hypervirulent (hypermucoviscous) Klebsiella pneumonia: A new and dangerous breed; Virulence 4:2, 107–118; February 15, 2013; 2013 Landes Bioscience
  2. Bonnie C Prokesch, Michael TeKippe, Jiwoong Kim, Prithvi Raj, Erin McElvania TeKippe, David E Greenberg; Primary osteomyelitis caused by hypervirulent Klebsiella pneumonia; The Lancet Infectious Diseases , Volume 16 , Issue 9 , e190 – e195

 

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-Muhammad Ahmad, MD is a 2nd year anatomic and clinical pathology resident at University of Chicago (NorthShore) program based at Evanston Hospital, Evanston, IL. His academic interests include breast pathology and cytopathology.

-Erin McElvania, PhD, D(ABMM), is the Director of Clinical Microbiology NorthShore University Health System in Evanston, Illinois.

CMS’s National Coverage Determination for Next Generation Sequencing (NGS) – What Does This Mean for the Future of NGS Testing for Molecular Oncology?

I thought I’d take a break from the next generation sequencing (NGS) wet bench description this month to review news occurring in the world of reimbursement of testing of cancer specimens with next generation sequencing.  As a tech, I don’t deal with the nitty gritty of insurance reimbursement of our tests on a day to day basis, but this one caught my eye as it would have had a real impact on the NGS testing in our lab.  On November 30th, 2017, a proposal was released by the Centers for Medicare & Medicaid Services (CMS) to review the national coverage analysis tracking sheet for NGS for Medicare beneficiaries with advanced cancer.  In the original wording of the proposal, one thing it stated was that CMS should only reimburse NGS testing for advanced cancers when the testing was done with an FDA approved assay.  This caught me, as well as many others in the molecular community, by surprise.  The reason?  Currently, there are only a few FDA approved assays on the market; much of the testing occurring right now for oncology assays by NGS are lab-developed tests (LDTs), including the ones that we run in our lab.  Under the proposal’s language, these types of assays would not be reimbursed for Medicare patients (and where CMS reimburses, the major insurance companies follow), making it very difficult for us to continue the testing that we perform.

The process for a proposal such as this one includes posting the proposal, then allowing a period for public comments about the proposal.  Six weeks were given for people to post their comments online, during which, 315 comments were left.  These comments included praise to CMS for recognizing that NGS testing is increasingly useful for precision medicine, but also stressed the limitations of only allowing FDS approved assays to be used.  Some comments pointed out how clinicians and pathologists work together in the institutions performing the NGS assays in a way that would be impossible if forced to use an assay from an outside institution.  They also indicated how difficult it would be for all NGS testing to be performed by the very small number of FDA approved assays and how it is almost impossible for small academic institution labs to get FDA approval for assays due to the amount of money and time the approval process takes.

On March 16, 2018, the final decision memo was released with altered wording compared to the original and can be found here https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=290 and is also shown below:

“A.  Coverage

The Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:

  1. Patient has:
    1. either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and
    2. either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and
    3. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
  2. The diagnostic laboratory test using NGS must have:
    1. FDA approval or clearance as a companion in vitro diagnostic; and
    2. an FDA approved or cleared indication for use in that patient’s cancer; and
    3. results provided to the treating physician for management of the patient using a report template to specify treatment options.
  3. The diagnostic laboratory test using NGS must have:
    1. FDA approval or clearance as a companion in vitro diagnostic; and
    2. an FDA approved or cleared indication for use in that patient’s cancer; and
    3. results provided to the treating physician for management of the patient using a report template to specify treatment options.
    4. Other

Medicare Administrative Contractors (MACs) may determine coverage of other Next Generation Sequencing (NGS) as a diagnostic laboratory test for patients with cancer only when the test is performed in a CLIA-certified laboratory, ordered by a treating physician and the patient has:

  1. either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and
  2. either not been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and
  3. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

See Appendix D for the NCD manual language.”

 

In part B, it addresses those assays that are not FDA approved, but are run in a CLIA-certified laboratory.  This part was added in the final decision and makes it possible for non-FDA approved assays run in CLIA-certified laboratories to be reimbursed, dependent upon the local MACs.  While this is a huge improvement over the previous, there are still questions regarding some of the wording and we will have to see how this affects testing for our patients.  For example, in 1b, where it mentions repeat testing – some patients have multiple mutations that are followed over time for hematological malignancies – will this be considered repeat testing? It will remain to be seen.  Needless to say, I am happy to be able to continue doing my job.

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-Sharleen Rapp, BS, MB (ASCP)CM is a Molecular Diagnostics Coordinator in the Molecular Diagnostics Laboratory at Nebraska Medicine. 

Microbiology Case Study: A 28 Year Old Female with Cough.

Case History

A 28 y/o female with a past medical history of chronic eosinophilic pneumonia, chronic persistent asthma, and elevated IgE status post Xolair therapy presented with a cough. She is a former smoker and a former IV drug user. She has been having a productive cough since March and has not improved despite multiple courses of antibiotic therapy. She coughs mostly in the morning and describes her sputum as thick and greenish. She does not have any associated fevers and does not feel that her rescue inhalers help much. She was given a course of doxycycline for 10 days, and sputum was sent for culture.

Laboratory Identification

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Image 1: Gram stain showed many polys, moderate mixed gram positive and gram negative organisms. Sputum culture was reported out as mixed gram negatives.
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Image 2: Chocolate and blood agar plates of the mixed gram positive and gram negative organisms.

One of the gram negative rods was identified by the MALDI-ToF as Pasteurella multocida.

Discussion

The genus Pasteurella consists of multiple identified species with the one most commonly seen in the clinical setting as Pasteurella multocida. As a genus, they are typically gram-negative straight bacilli that are nonmotile, oxidase-positive, catalase-positive, nitrate reducing, and ferment glucose. They will grow on blood and on chocolate agars, but importantly will not grow on MacConkey. Their colony morphology on blood agar is generally convex, smooth, and nonhemolytic.

Infections with Pasteurella are classically associated with animal bites, such as from a dog or cat. However, prior cases in the literature have shown that pulmonary infection with Pasteurella can be associated with other chronic pulmonary diseases such as COPD (1). The choice for using doxycycline is supported in the literature and was specifically discussed in a prior case with improvement (2).

References:

  1. Klein NC. et al. Pasteurella multocida pneumonia. Semin Respir Infect 1997; 12 (1): 54-56.
  2. Bhat S. et al. A case of lower respiratory tract infection with canine-associated Pasteurella canis in a patient with chronic obstructive pulmonary disease. J Clin Diagn Res 2015; 9 (8): DD03-DD04.

 

-Jeff Covington, MD, PhD, is a 1st 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.