Lablogatory

Are Antibacterial Soaps Effective?

The FDA is asking manufacturers to prove the effectiveness of their antibacterial products that use triclosan or triclocarban as the active ingredient. (See the press release here.) This comes on the heels of last week’s announcement of their plan to help phase out the use of medically important antibiotics in food animals.

When I became a microbiologist I stopped using products with triclosan in an effort to curb antibiotic resistance. While I like to see the FDA’s efforts, I wonder if they’re doing too little, too late, and I’m not the only one.

Some additional reading on the topic:

1. Mechanism of triclosan resistance study, published 1999.

2. Another triclosan resistance study, published 2006.

Edited to add: Maryn McKenna’s excellent write-up on the topic.

-Kelly Swails is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Resolutions

Have you thought about your New Year’s resolution yet? Hopefully you haven’t thought about when you’re going to break it. In addition to personal goals, we should all think about resolutions that we can make professionally. Whether it is stick to productivity numbers or finally finish that last credit to get another certification, this is the time of year to think about how you can grow in 2014. Our personal lives can affect our professional life and it is the balance between these two that keeps us sane and able to go back to work day after day. When one takes a little too much of your time you must step back and figure out where that fulcrum needs to be placed.

Growth in any career can be small steps or can be a leap such as another degree or promotion. Every person’s career is on a different trajectory and it really is up to the individual on how far they want to go. It is the decisions we make that shape our careers. Some people will tell you to be aggressive and take what you think you deserve, and others will say be patient, put in the work, and good things will come your way. (I wrestled in high school so you can take a guess at which philosophy I follow!) Whichever one you follow the big decisions and hard work you put in will only take you as far as you want it to. I have met many people my age that are happy working on the bench and have no aspirations of being a supervisor. Whatever you choose to do you should be happy and feel engaged that the work you’re doing is helping people. We are in healthcare and even though a lot of us don’t directly see patients the work we do helps nurses and physicians help the patient.

With only a couple weeks left in 2013 this is a great time to reflect on personal and professional accomplishments while also getting ready to start a new year that is full of new challenges and also new opportunities. As I usually say, no challenge is too large to take on and no opportunity is too small to overlook. For example I wrote an article for Lab Medicine and gave a 5 year progress report on my career and it turned into an opportunity to blog for one of the most important organizations for the laboratory profession. I always wanted to take the ideas I had in my own lab and throw them out there and see what other people thought of them and how they do certain things. When we write these blogs we love to hear comments and discussions of how you the reader interact and “live” in your own laboratory. Reflecting on 2013 I’m thankful for Lab Medicine for this great opportunity and my resolution for 2014; I’m going to be moving up that ladder, one rung at a time.

–Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.

On the Lab Medicine Website

We’ve got some great new content exlusive to the Lab Medicine website to share with you.

Aleksandr Ivanov discusses Barriers to the Introduction of New Medical Diagnostic Tests.

Attipoe et. al. present the unexpected finding of Diphyllobothrium nihonkaiense. This is the second documented finding of this particular parasite in the United States.

Beavers et al report a case of an albumin transfusion reaction.

‘Tis the Season

The holiday season is rife with celebrations. Tree Trimmings! Presents! Gatherings! And let’s not forget the food. Turkey! Dressing (with or without oysters)! Cookies and its glorious dough! An unfortunate side effect of holiday celebrations is food poisoning, specifically those caused by, Salmonella, Campylobacter, and Vibrio.

According to the CDC, Salmonella and Campylobacter are in the top five pathogens with Salmonella being the biggest culprit in hospitalization. If you want to prevent Salmonella poisoning—or think you might already have it—here’s a handy guide to causes, symptoms, and treatment.

Raw eggs and mishandled poultry aren’t the only causes of food poisoning, though. Shellfish can be a concern, as is undercooked beef and unpasteurized dairy products. The Mayo Clinic has a wonderful chart describing the major food poisoning pathogens. A noticeable omission is Bacillus cereus, which breeds quite nicely in leftover rice.

For laboratory professionals, foodborne illnesses are a common cause of laboratory-acquired hospital infections. Be vigilant when handling enteric specimens and enteric cultures. Observe basic lab safety—use personal protective equipment, don’t use personal electronics in the lab, and be obsessive about washing your hands. Don’t let Salmonella or one of his buddies ruin your holiday season.

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Are Pathologists and Primary Care Physicians Ready for the Genomic Era and Personalized Medicine?

I was reading about the FDA’s recent crackdown on 23andme to stop marketing their saliva based whole genome testing and interpretation service. Rather than resist, 23andme decided to comply and is currently in “talks” with the FDA so that they can complete the process for FDA validation and again begin to market their kits and testing. For now, they can continue to provide their genealogy testing and whole genome sequencing without interpretations.

Currently, in some academic research centers, whole genome or exome sequencing via next generation sequencing (NGS) methods is utilized on a limited basis by researchers and clinicians to identify pathogenic mutations. NGS and bioinformatic analysis methods continue to steadily improve and costs have been decreasing. However, there are limitations and barriers to widespread use at this point. These include but are not limited to: 1) widely used databases such as the Human Gene Mutation Database (HGMD) and the Online Mendelian Inheritance in Man (OMIM) still only contain information that only covers a fraction of the human genome, 2) more research is still needed to identify more variants mutation-disease associations, and 3) most mutations identified fall under the category of “unknown clinical significance”.

Tools such as NGS, despite its improvement over previous technology, still cannot identify large deletions or copy number variations (CNV) and is a technology not accessible, cost-wise and support-wise, to most health care institutions. Despite all of this, primary care physicians, even now, still may be confronted with patients who bring them their genomic screening results, whether obtained from commercial services provided by companies like 23andme or through molecular testing through a health care institution. But today’s physicians, including primary care physicians and pathologists, were not trained in medical school to understand how this testing is performed or the significance of these results. But the time is coming, and maybe sooner than we realize, when we will have to deal with such testing on a daily basis.

So, it is imperative that we train our doctors and doctors-in-training now to be ready for when that time comes. But, my question this week is “How should we go about it?” Additionally, who should compose the health care team to provide guidance and counseling to patients once results are available? And who should regulate how testing should be done and what information should be included in results reporting? Leave me a comment if you have an opinion or any ideas.

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Global Health Engagement Month—A Different Perspective

Those of us who work in the international health field are connected in many ways. We come from a variety of healthcare and public health careers and so approach the needs of global health in different ways. The common thread is strengthening the quality of healthcare and increasing and improving the availability to those in need around the world.

December is designated as Global Health Engagement Month for the US Military communities. All of our branches of service participate in humanitarian assistance and disaster response, and their efforts during times of international need are often the first assistance that some countries receive. In addition to providing care for our military active duty members and their families, our military medical corps from each branch of service provides care, assistance, teaching and disaster response in many different venues. They often work with NGO partners, other countries, and the Ministries of Health and the medical communities of nations in need. It is indeed a “global health engagement” effort that makes a difference. It has been my privilege to work with ASCP laboratory capacity building as a volunteer consultant, and I’ve also had an opportunity to work with the US Navy to build their partnerships with NGOs when they send their hospital ships on humanitarian assistance missions. Seeing global health outreach from several different perspectives keeps me ever mindful of the good work we do, and how much there still is to do in the world!

If you are interested in what our military is doing in providing humanitarian assistance , read about the hospital ships USS Mercy and USS Comfort and see why “Global Health Engagement Month” is so important to our military health colleagues here and here. I’m sure you’ll be amazed and proud of our country and inspired by their stories!

–Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Dirty Winds

Over at Body Horrors, Rebecca Kreston writes about public health concerns of infectious disease and parasites. In this thought-provoking post, she discussions musicians (specifically, those who play wind instruments) and lung infections. She cites several small studies that found pathogens (Mycobacterium, Stenotrophomonas, and Cryptococcus) in instruments such as saxophones and trumpets.

The moral of the story: horn musicians, clean your instruments. And don’t ignore a persistent cough.

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Personal Genome Testing and You

The recent events with 23andme and the Food and Drug Administration have brought personal genomic testing into the spotlight. In case you haven’t been following the case, the FDA wrote a warning letter to 23andme—a company that will access various points on your genome and give you the results for around $99—that basically states that because the tests diagnose, mitigate, or prevent disease they require regulatory clearance. The FDA also said false positive results for certain breast or ovarian cancer markers could lead to unnecessary preventative surgery.

Since receiving the letter, 23andme as stopped marketing their genetic testing service. At this writing I’m not aware of the status of ongoing testing or if the company is still accepting new samples. 23andme has 15 working days from the date of the letter—which would be 12/13—to let the FDA know how they’re working to resolve the noted issues.

How does this affect laboratory medicine? On the face of it, not that much. Yes, clinical laboratory scientists and pathologists could lose their jobs of the 23andme labs were forced to close their doors. The field of personal genome testing is a relatively new one—23andme began testing in 2008—but even so, it’s important to realize that this type of testing can positively affect laboratory professionals and pathologists. More laboratories equal more jobs, after all, and not just for bench techs and pathologists, but for consultants, inspectors, and administrators as well. I know that I’ll be watching to see how this plays out.

-Kelly Swails

Acknowledging and Transforming Pathology Stereotypes

I find that in interactions with other specialties, even attending physicians who far surpass me in age, that many have very little idea of what pathologists do. Those who do not work closely with pathologists are the first to mention CSI, forensics, autopsies, and an office in a windowless basement morgue. In fact, I recently heard the story that when a group of attendings and residents from another specialty along with their medical students were told to meet a pathologist for a teaching session in the anatomic pathology department…that they waited outside the locked morgue door before realizing that no one was there and that the morgue was not probably not the intended meeting location.

And for those who work more closely with pathologists, there exists a spectrum of attitudes and perceptions about our profession. We have surgeons who were trained “old school” style with six months of surgical pathology during residency who will sit at the multi-headed scope during intra-operative consultations and who know more than beginning junior residents. Hematology/oncology physicians often stop by hematopathology to look over slides together or to discuss a case. And then there are those who think that pathologists exist to provide them only with diagnoses and who do not look at us as equal members of the patient care team. I’ve heard some even question a diagnosis without ever seeing the slide and others grumble or joke that pathologists take too long to render diagnoses.

I’ve more than a few times had to call attendings, residents, or fellows to recommend canceling an inappropriately ordered test or less commonly, to suggest ordering an indicated one. I found that this more often occurs when there is not a strong differential of diagnoses. Even so, I still have the person on the other end of the line bellowing at me that they just MUST have this expensive molecular test ASAP.

Recently, a medical student who is interested in pathology told me that some residents from a non-pathology rotation harassed and made fun of this student for choosing pathology as their future career. I could continue with more examples but instead I ask this question, “Why is pathology as a field not valued?” especially with respect to specialties like surgery where there is a heavy reliance on pathologists to provide them with diagnoses?

I believe part of the reason lies in lack of exposure to the practical and daily aspects of pathology as a legitimate medical field during medical school. Furthermore, those who chose pathology as a career are often not personality types who proactively engage in promoting or advocating on behalf of the profession, especially at the state and federal levels. We also subconsciously contribute to this issue. For example, we often refer to all non-pathologists as “clinicians” as if there is a difference between these types of doctors and pathologists even though we all completed four years of medical school.

So, what are other reasons do you think contribute to the undervaluing of pathology as a profession, and more importantly, what can we do to change these stereotypes and misconceptions? Let me know by leaving a comment.

-Betty Chung

Is Sample Quality in the Eye of the Beholder?

Here’s a simple experiment to try in your lab: Find a hemolysed sample and separately ask five different medical laboratory scientists to judge the amount of hemolysis present. What you’ll probably find is that “grossly hemolyzed” is most definitely in the eye of the beholder.

Along with hemolysis, lipemia and icterus are determined by judgment calls made by laboratory scientists. Considering that these three interferences make up the bulk of interferences found in patient samples, “eye of the beholder” may not be good enough. Luckily, with most modern chemistry analyzers, it does not have to be.

Most major chemistry analyzers now perform what we like to call “indices”. The HIL (hemolysis, icterus, lipemia) indices are directly measured by the instrument for a given sample. If any of these three interfering substances are present, the instrument will determine both its presence and its concentration. This last point is important also, because some analytes are only affected by a significantly large amount of the interfering substance. Being able to directly measure these interfering substances, allows the instrument to be set to deal with the affected sample in the most appropriate way. It can be set to not analyze those tests affected, or to not report the results on affected tests, or to simply flag the result for footnoting. Computer systems across the interface can likewise be automatically programmed to accept the HIL numbers and respond appropriately.

Analyzers measure the HIL indices in different ways and until recent years, pediatric labs have often been unable to take advantage of analyzer-measured indices. In pediatrics, especially in infant patients, sample volume is often an issue, and so this feature has traditionally been turned off in pediatric labs. However, there are instruments on the market that measure the indices through the pipet tip without using up any sample volume including most of the Ortho Diagnostics analyzers, like the Fusion 5,1 and the 5600. This feature is one of the reasons these instruments are so often found in pediatric labs. In addition, those instruments that use sample volume are now capable of using microliter quantities, like the Siemens Vista or the Roche Cobas 6000. Utilizing minimal sample volume for this measurement allows the HIL features to be used on these instruments in almost all situations.

Thus the good news is that the sample quality and appropriateness for any given test no longer needs to be in the eye of the beholder.

-Patti Jones