A Special Thanks

I am watching the sky turn brilliant shades of rose, gold, lavender and light blue as the sun rises over Fargo, North Dakota—(speaking of remote places) and I am reminded of so many sunrises I have enjoyed around the world.  When working in another country I often rise very early, make myself a cup of tea and watch the world wake up.  It is such a special time of day, a time of personal reflection and awe of the beauty in the world around us.  It never fails to remind me that no matter who you are, or where you are, “sunrises and sunsets” are universal and give us the promise of a new day, and the rest and peace of day’s end.

The American holiday of Thanksgiving is my favorite day of the year.  It celebrates friends, family, life’s blessings, and the chance to take time to be thankful for what’s been given, and to give in return.  And this year I am again thankful for the unique and exciting places, challenges, and experiences I have had working around the world, and seeing so many of the world’s most beautiful sunrises!

Pictures of course don’t do them justice…but they often find their way to my desktop as the wallpaper, so if you want to see a few, let me know at bsumwalt@pacbell.net , I’d be happy to share! In the meantime, I hope you had a Happy Thanksgiving, and perhaps I can encourage you to take a moment to enjoy a sunrise!

Beverly Sumwalt


On the Lab Medicine Website

We’ve got some content on www.labmedicine.com that is relevant to your interests.

Megan Harley writes about treatments and therapies for sickle cell disease.

Nicholas Moore reviews a color atlas of microbiology.

For the blood bankers out there, Charles Beavers writes a case study about an unexpected antibody in a 1-day-old.

What are Important Must-Haves in a Pathology Residency?

So, we’re about 1 month into our interview season for resident candidates for our 2014 PGY-1 cohort. Each year, answering prospective candidates’ questions over lunch forces me to re-evaluate what I was looking for when I was in their shoes and what opinions have changed since then. I’m always surprised at myself that some things that I thought were initially important are not so much now and vice versa. So I always tell the “prospies” (a word we used when I was in college) to try and figure out what is most important “must-haves” for them and at least make sure that the programs they are looking at have those characteristics and resources.

But as I’ve learned, as time passes, some of those things will change…while some will not. For me, coming from a research and public health background, it was important to me that I could do basic science, translational, and molecular epidemiology research during residency….and that I would have these types of opportunities and that my program and faculty would support me in these endeavors. I wasn’t as interested in the “brown stains” or case series type of research as much that I see coming out of virtually every program that also includes my own. Not because there is anything wrong with that type of research either but just that my exposure and interests weren’t along those lines.

One of the interviewees today said something interesting to me. He said that he read on the websites of the programs he is interviewing at how they supported resident research. But that when he specifically asked about it was discouraged and told that residents don’t really have time for research in between their service duties. To me that seemed contradictory to the branding that these programs’ website at least made an attempt to endorse which was interesting but not entirely surprising.

For me, “fit” was a lot more important than a prestigious name and I interviewed at some high-powered programs, too. But I wanted a program that worked with an underserved minority or immigrant population (most of my advocacy work has been with these groups), made changes based on resident feedback to improve their program (I don’t like or thrive in “top down” situations), and supported each resident’s unique needs and goals. I wanted a program that would support and didn’t limit conference attendance and participation in leadership roles, both within the program and within the profession…a program and faculty that would work with me to do those things that would benefit my professional goals and allow me these freedoms even if I was on a surgpath rotation and not try to fit residents into a “one size fits all” mentality. Don’t get me wrong, like all programs, mine has some very real kinks as well. But I think that I’ve found some great and supportive mentors, PD, and chair who allow me to create the non-traditional experience I seek.

So what did or do you are think are “must-haves” for a residency and did those ideas change over time? Leave me a comment if you like.

-Betty Chung

Reference Ranges

According to Wikipedia, reference ranges in health-related fields are generally defined as “the prediction interval between which 95% of values of a reference group fall into, in such a way that 2.5% of the time a sample value will be less than the lower limits of this interval, and 2.5% of the time it will be larger than the upper limit of this interval, whatever the distribution of these values.”

In other words, reference ranges are important! They provide the necessary context for medical analysis and diagnosis. Without a reference range (also sometimes referred to as reference value or reference interval) medical professionals have no comparison group for which to make diagnosis and advise treatment.

In all instances where reference ranges are used, context is key. In sub-Saharan Africa many labs use European established reference ranges which represent a primarily Caucasian population. This is because reference ranges specific to populations in sub-Saharan Africa do not universally exist. This presents a problem as many factors can contribute to what is considered “normal” in different populations. Genetics, dietary patterns, pregnancy, gender, age, ethnic origin, and prior exposure to pathogens all can influence reference range values.

Establishing accurate reference ranges for a given population takes time and an enormous amount of resources. It is often recommended that laboratories establish their own reference ranges based upon the population that they serve. This is cost and resource prohibitive for many laboratories in the developing world. In absence of region specific reference ranges, it is recommended that each lab validate existing ranges using their own population. However, even this can be prohibitive in resource (both physical and human) limited settings.

This can lead to egregious errors in disease diagnosis and treatment. Clement Zeh, Collins Odihiambo and Lisa Mills write that reference range research thus far reveals that African populations differ from their European/Caucasian counterparts with lower hemoglobin, red blood cell counts, hematocrit, mean corpuscular volume, platelet counts, and neutrophil counts  and higher monocyte and eosinophil counts (see http://www.intechopen.com/books/blood-cell-an-overview-of-studies-in-hematology/laboratory-reference-intervals-in-africa for their chapter on Laboratory Reference Intervals in Africa).

In addition to diagnosis and treatment of individuals, reference ranges are crucial components in drug and vaccine studies. Historically, clinical trials of drugs and vaccines have relied upon ranges developed in the Western world. This can have significant impact upon the research data resulting in health risks to study participants, poor data, and huge amounts of resources wasted.

Thus, while it is costly and time consuming, reference ranges specific to populations in countries in the developing world need to be established. This would help both the treatment of individuals, and the testing, study and development of important vaccines and drugs.

-Marie Levy

The Post-Antibiotic Era, Part 2

Linking to a few articles by Maryn McKenna because you need to read them.

In this blog post, Ms. McKenna writes about a man from New Zealand who died from a bacteria completely resistant to all antibiotics.

In this article, she imagines the post-antibiotic world. In a nutshell: it’s a scary place.

-Kelly Swails



Rising Cost of Send Out Tests

More and more in this day and age, the laboratory is encouraged to reduce costs and streamline operations by using available resources in the most effective and efficient manner possible. One of the areas of the lab that is increasingly becoming a problem when it comes to cost reduction is the send out area. Since most labs can now perform the vast majority of their testing on automated chemistry and hematology analyzers, tests that must be performed at reference laboratories are increasingly esoteric, manual, and/or molecular diagnostic tests. And those tests are expensive.

As an example, my own lab sent out about 10 chromosomal microarray (CMA) tests in 2008; that number increased to  400 CMA tests in 2011 and is  on track to be 865 in 2013. At $1400.00 each, the cost to the lab increased from $14,000 to $1.2 million over that time period. And that’s just one relatively inexpensive molecular diagnostic test. Some of the gene sequencing tests can run between $5000, and $10,000 per test.

Labs are trying a multitude of different schemes in order to try to curb these send out test costs. One method that is fairly effective is to have a “gatekeeper” – a person or persons who review and must approve every test that leaves the lab that costs over a pre-set amount. This particular method is probably one of the best for controlling send out costs, but it requires time and commitment on the part of the gatekeeper, and a willingness to interact with physicians who have ordered the tests that may be less than happy than someone is questioning their order.

Another method used for send out cost control is to include some indication of the cost of the test in the computer system. When the test is ordered, the ordering provider is aware of the exact cost of the test. Some institutions are using a dollar sign system to implement this. For example “$” may mean that a test costs under $50 and “$$$$$” may indicate a test costing over $5000, with other levels in between these two.

A third method is to have a lab “formulary.” Any test found in the formulary can be ordered with no problems. Tests that are not included in the formulary must be approved by the lab before being ordered and sent out.

Whatever method a laboratory uses, it is clear that some means of regulating the rising send out costs is going to be necessary for all labs. Until molecular diagnostic tests become automated and routine, they will continue to be expensive.

-Patti Jones