History of Generations: Millennials

Of all the generations, it is my personal experience that this generation has received the most pushback regarding their work style, work ethics, and its influence. However, this generation is absolutely essential in today’s work environments. They bring a different perspective to work because they care about self-expression and having a purpose.

Millennials are typically born between 1981 and1999.. Their parents are Baby Boomers or Gen Xers. This is the first generation that has never known work without computer, even though not every household had (and has) one. Schools started to invest in computer labs and computer training and it started to become mandatory in the Western World to submit homework that was typed instead of handwritten. This generation was young, or sometimes not even born yet, when the internet connected the world and information became was readily and widely available. One of the characteristics of Millennials is valuing instant gratification, because they are used to having the world at their fingertips. Another is self-expression, due in large part to the widespread use of cell phones and social media.

Because of the internet and globalization, this is the most diverse generation. This is another great benefit they bring to organizations, because they create a diverse work force with people from different ethnical, educational, and socio-economic backgrounds.

This generation was told that they could achieve anything they wanted, so they are creative, optimistic, and focused. They experienced tremendous academic pressures and school shootings, which caused many students to feel unsafe in school. This led many millennials to live by the notion “You Only Live Once” (YOLO), which is also embedded in their professional lives through a focus on purpose and professional development opportunities.

 

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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.


 

When the Millennial generation is discussed, most sources agree they share these common traits:

  • live in a world of technology, have never known a world without computers, and get most information from the internet
  • Are rewarded for participation, not achievement, yet are achievement and career oriented
  • Experience enormous academic pressure
  • Want to make a difference in this world and find a career with a purpose

I was thinking about writing this post as I went to the gym for a personal training session.  As I was stretching and lifting weights, I noticed all the millennials in the fitness center!  It occurred to me that instead of relying on what researchers say are important to them, I could do my own small survey. I decided to use the KISS Principle.  In other words, “Keep It Simple Stakenas!”  I focused on one question with three parts, “What are the three most important things to you in your life as a millennial?

When I was done with my workout, I began to walk up to people who looked like they could be millennials.  Of course I made a few errors, and fortunately, they were Gen Xers and received my first question as a compliment.

Those that I interviewed who chose to elaborate all seemed to center on one shared opinion.  They sought a cause greater than themselves and a strong desire for meaningful experiences, such as learning about different cultures, people, and travel.  One stated, “I want to be the best citizen of the world that I can be.”

The first response in the first interview took me by surprise.  When asked what the most important things to her were, she said, “wifi.” The second person I interviewed immediately said, the “phone,” then finished with Family and Friends. Five of the 12 interviewed stated that their career was important and work-life balance.

As I grouped the interview answers in topics of importance, I found a common thread. I learned that 11 of the 12 people I interviewed shared what I have called “The 4 F’s,” Family, Friends, Fitness and/or Faith.

Millennials will always be there if you need a “charge!”  They understand that “wifi and cell phones” carry with them opportunities for friendships, family connections, careers, education, and even access to ways of worship regardless of your faith.

God Bless Our Millennials!

 

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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 55 Year Old Woman with Fatigue, Nausea, and Vomiting

Case History

55 year old woman with no significant past medical history presented with two weeks of increasing fatigue, nausea and vomiting. She was subsequently found to have a leukocytosis (WBC = 31.1) and marked splenomegaly (19 cm).

Peripheral Blood

mcl-peri-1

mcl-peri-2

 

Bone Marrow Biopsy 

mcl-bm-20x
aspirate 20X
mcl-bm-40
aspirate 40X
mcl-bm-core-10
core biopsy 10X
mcl-bm-core-40
core biopsy 40X

 

mcl-core-cd20
core biopsy CD20
mcl-core-bcl1
core biopsy BCL1 (CCND1)

 

Flow Cytometry

mcl-flow

 

Cytogenetics

mcl-cyto-kary
Karyotype
mcl-cyto-IGH
IGH/CCND1 gene rearrangement
mcl-cyto-deletion
deletion of TP53
mcl-cyto-MYC
MYC amplification

 

Diagnosis

The peripheral blood shows a population of atypical cells that at first may look like blasts. However, the variable size, round to markedly irregular nuclear contours, large prominent nucleoli and mild to moderate amounts of cytoplasm favor lymphoma cells.

The bone marrow aspirate shows the vast majority of the cellularity is composed of a pleomorphic population of lymphoma cells that are varied in size from small to large with mild to moderate cytoplasm, round to irregular nuclear contours and prominent nucleoli. Occasional maturing erythroid and myeloid precursors are present.

The core biopsy shows a marrow with a cellularity of approximately 70%. There is an interstitial infiltrate of atypical mononuclear cells with frequent scattered mitoses occupying 70% of the overall cellularity. By immunohistochemistry performed on the core biopsy, B-cell marker CD20 highlights the majority of the infiltrating lymphocytes, which co-express BCL1 (CCND1).

Flow cytometry revealed a population of CD19 and CD20 positive kappa (bright) restricted B-cells that were also positive for CD23 in a subset. They did not express any other characteristic antigens including CD5, CD10 and CD11c. Importantly, as there was initial concern for acute myeloid or lymphoblastic leukemia, no abnormal events were identified in the CD45 dim “blast” gate, with CD34 positive blasts showing normal maturation.

Cytogenetics revealed a complex abnormal karyotype. The most important finding was a translocation involving the long arms of chromosome 11 and 14 resulting in the IGH/CCND1 translocation that is characteristic of mantle cell lymphoma. Interestingly, the FISH probe showed that there were 4 IGH/CCND1 fusions indicating an extra copy of the derivative chromosome 14. Additional FISH probes showed a deletion of the TP53 gene on 17p13 and greater than 10 copies of the MYC gene on chromosome 8, consistent with MYC amplification.

Overall, the findings are consistent with a pleomorphic variant of mantle cell lymphoma with leukemic peripheral blood involvement. The cytogenetic findings portend an unfavorable prognosis.

Discussion

Mantle cell lymphoma is generally characterized as an aggressive lymphoma of mature B-cells. It accounts for approximately 3-10% of non-Hodgkin lymphomas and tends to occur in older men. Lymph nodes are the most commonly involved site; however the bone marrow and peripheral blood are frequently involved as well. There are multiple morphologic variants of mantle cell lymphoma. The two aggressive variants include blastoid and pleomorphic. The blastoid variant has cells that resemble lymphoblasts with dispersed chromatin and large prominent nucleoli. The pleomorphic variant is characterized by a spectrum of cells, with many large cells with irregular nuclear contours, pale cytoplasm and variably prominent nucleoli. These two variants are clinically significant because they portend a worse prognosis. 1

The patient’s cytogenetic findings also portend a poor prognosis. IGH/CCND1 is a translocation between the immunoglobulin heavy chain on chromosome 14 and cyclin D1 on chromosome 11. This translocation leads to the overexpression of cyclin D1. However, Cyclin D1 is a “weak” oncogene and is not sufficient by itself to lead to the development of lymphoma. There are numerous secondary chromosomal aberrations and mutations that must occur to result in the presentation of mantle cell lymphoma. A paper by Beà et al. performed whole genome and/or whole exome sequencing on 29 cases of mantle cell lymphoma. They detected around 3,700 somatic mutations per tumor. ATM, CCND1 and TP53, which have previously been described as drivers in mantle cell lymphoma, were found frequently mutated. TP53 mutations were found in 28% of the lymphomas.2

MYC is a potent proto-oncogene located on chromosome 8. It mainly functions as a transcription factor and its activation leads to increased DNA replication, protein synthesis and alterations in cell metabolism among many other changes. The ultimate effect is increased cell proliferation and tumorigenesis. MYC amplification or translocation was shown to occur more often in blastoid/pleomorphic mantle cell lymphoma variants. This finding was associated with a shortened overall survival and progression-free survival. 3

References

  1. Swerdlow, Steven H. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th ed., International Agency for Research on Cancer, 2017.
  2. Beà S, Valdés-Mas R, Navarro A, et al. Landscape of somatic mutations and clonal evolution in mantle cell lymphoma. Proceedings of the National Academy of Sciences of the United States of America. 2013;110(45):18250-18255. doi:10.1073/pnas.1314608110.
  3. Choe, JY, Yun, JY, Na, HY, et al. MYC overexpression correlates with MYC amplification or translocation, and is associated with poor prognosis in mantle cell lymphoma. 2016 Feb;68(3):442-9. doi: 10.1111/his.12760. Epub 2015 Jul 28.

 

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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.

Crisis Communication

It’s not every day, but most days it seems like I’m “putting out a fire”…. or two. I’m sure you know exactly what I’m talking about. Four people called in sick and now you’re extremely short staffed, your automated instrument just broke and now you have to process everything manually, you just found out that product X is contaminated and patient care could be jeopardized; the list goes on and on.

Unfortunately, not everyone is prepared for crisis. This is a problem because poor crisis management can result in harm to the organization, its stakeholders (patients, clinicians, vendors, staff, employees), or its reputation. A major threat to good crisis management is poor communication. You can prepare a great plan, but if your plan is not communicated well/properly, then your crisis could turn into a major disaster. 

The Issue

Without proper communication, operational response can break down, which can cause a significant delay in crisis resolution (1). The financial and/or reputational effect becomes more severe the longer it takes to resolve an issue. Additionally, poor communication can cause your stakeholders to react in a negative way, such as get angry, become confused, or perceive your operation/department as incompetent, or even worse- negligent.

The Solution

Anticipate the crisis. Having a plan in place can really save the day. When planning, your team should consider pre-analytical, analytical, and post-analytical risk. To some extent, analytical risk assessments should already be in place as they are required for individualized quality control plan (IQCP). The IQCP assesses specimen, test system, reagent, environmental, and testing personnel risks (2).

Identifying a communication team can help to ensure that your crisis management plan is communicated properly. The communication team should be trained on the policies and crisis management plan. Make sure that staff and leadership know who the members of the crisis communication team are, so that when a crisis does occur everyone knows who to turn to or where to look for information.

Establish a crisis notification system. Most hospitals have notification systems, but does your laboratory or department have an established notification system? Depending on the situation you will need to contact different groups of people. Having a list prepared ahead of time eliminates forgetting to communicate to a particular group or individual in the heat of the moment. Pagers, phone numbers, addresses, text messages, emails. Make sure all information is easy to access and up-to-date.

Assess the crisis situation. Ask questions. Make sure you have all the appropriate information before reacting. Our gut reaction is to act fast, which is usually a good thing, but not to the detriment of your crisis management plan. Keep calm and carry on.

Perform a post-crisis analysis. After the crisis is resolved (not too long after), it is important to review the event and determine if the process was a success. Document lessons learned; key steps to keep and areas of improvement.

The Conclusion

The laboratory is like a box of chocolates- you never know what you’re going to get….so it’s best to be prepared. Organizational response to crisis should include a good communication plan. Lastly, don’t forget to test you plan and make sure it works. 

The References

  1. https://www.bernsteincrisismanagement.com/the-10-steps-of-crisis-communications/
  2. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/IQCP-Workbook.pdf

 

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-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.

Compliments in Disguise, More than Meets the Eye

Hello again everyone!

As with most clinical situations, there is often more going on than you can see on the surface. The classic example being the lab values that might have derangements that aren’t apparent clinically; something we rely on heavily in medicine. While most of the situations in these cases apply to diagnostic methods in patient care, sometimes those nuances exist outside of patient care. For example, a simple comment or phrase can hint at an individual’s potential biases and/or carry with them a weight of opinion that means more than what it sounded like.

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Image 1. Emerging from their laboratory, a pathologist, lab manager, and shift supervisor arrive ready to discuss clinical lab metrics with hospital administration. Many of us transform our roles within and outside of the lab, creating a complex team of clinicians all for the sake of our patients. (Source: Transformers: The Movie, obviously)
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Image 2. Instruments get routine service visits from industry reps, while supervisors oversee, and bench techs commiserate all in matching lab coats. Laboratorians often enjoy the exclusivity of the laboratory, working mostly “with your own” can sometimes facilitate an easier experience. But beware of comfort zones: if you don’t spend your time learning about others’ scopes, they won’t learn about yours. (Source: The Simpsons)

 

Last January, I brought up the topic of stereotypes in pathology which seem to reflect common misconceptions about the field of laboratory medicine. This time I think I’d like to explore that topic a little more in-depth, as I’ve noticed a few things during my clinicals as a medical student. Those of us with careers or histories of lab work or pathology experience know that we’re mostly regarded as a “behind the scene” crowd. That can be true, and to a certain extent a necessary part of patient care, but what happens when these stereotypes catch up with you? What happens when they become a part of your training? Since I have the great luck to have been on both sides of this question, here are my thoughts on what it really means when lab folks are thought of as a mysterious secret hospital-basement society.

First of all, these stereotypes aren’t anything new. We’ve all been sharing and resharing the same story every couple of years from article to article. I shared a few last January: Dr. Lori Rasca’s “Lonely Life of a Clinical Pathologist,” Dr. Sarah Riley’s call to bring the lab to the forefront of medical practice, and survey after survey about things like burn-out and wages. Go ahead and google things about careers in pathology and you’ll get a mixed bag. Often times, you’ll see programs or departments tout the importance of a profession in clinical pathology. Yale University School of Medicine conducted a survey last March where they asked middle-school students “what does a pathologist do?” The responses varied—and were mostly wrong. So the department wrote a piece about the clinical roles of those in laboratory medicine addressing specialization, patient contact, and tech-innovation.  One line that stuck out to me: “[you’ll] sometimes hear a surgeon say, ‘I’m only as good as my pathologist.’” Fantastic, I wrote about that last June where I talked about how the relationships between surgery and pathology are critical. The fact of the matter is, pathology is always changing; and with it, the roles of pathologists do too. An article from April 2011 in the College of American Pathology’s CAP Today featured Dr. Sylvia L. Asa and she wrote at length about the future of pathology in response to current stereotypes:

“The 2020 pathologist should not be someone who hides in the basement of a hospital and looks at glass slides or even whole-slide images, but someone who’s able to take all the information from the clinical pathology lab, from radiology, from endoscopy, from slides and the molecular lab, and sit down with the patient to explain the disease he or she has. That is how we will stay relevant in the public eye and every patient will know who their pathologist is. And we should make sure that the patient’s pathologist is the person who, when the patient searches the Internet, is an expert in the field.”

Next, medical students experience a myriad of sifted and specialized knowledge which changes scope and tone from one month/service/attending to another. When you’re in internal medicine, ID specialists are lazy; when you’re in surgery, IM residents are flustered; when you’re in ED, the other attendings don’t have as many thrilling stories; and when you’re in clinic with family medicine staff, you know no one else can handle the “front lines” like you guys do…right? Basically, everyone has a point of view and we naturally find ourselves working with other professionals who have specialized in the same field as us. But when you get too comfortable with your homogenous staff, that’s when those (otherwise normal) opinions can get complicated. Most of the time, pathology is viewed as an outsiders’ specialty. People might think you’re socially inept, or don’t like patients, or even can’t “cut it” on the wards. (That was harder for me to type than for you to read, trust me.) But it does happen; and when it becomes a conversation piece, med students have two classic options: Smile and agree with everything your attending says because their word is gold and they ultimately sign your evaluations or take the chance to address misconceptions and stereotypes—which do you think is easier? Earlier this year, a medical student from Ireland named Robert Ta wrote about his path to pathology in an article published in the International Journal of Medical Students (yes, it’s a real thing—and it’s great!). In it he discussed his enlightening experiences observing laboratory medicine for the first time and falling for the interdisciplinary work and diagnostic algorithms pathology offers. He even cited all-too-familiar classics we’ve all heard such as ““you must really hate dealing with people,” “[you must] have no clinical skills,” “[you have] no social skills,” “[you are] only interested in research,” “[you] must love working with dead people,” and everyone’s favorite “but you’re great with patients … why you would want to go into pathology?”

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Image 3. “I know you just finished—and honored—your surgery rotation but those scalpel-jockeys don’t really know how to take care of patients. Room 12B has gout and I am not about to cut his toe off!” Every time we switch rotations, medical students hear what everyone thinks about everyone else’s specialties. It can be exhausting keeping it all straight—I think by the time you graduate it just means you’ve lost track of who’s who… (Source: Medscape)

For the minority of students that figure out what specialty they like early on, those siren-songs can be a barrage to your patience. What ultimately happens is you could create a narrative of why you like pathology as an ad nauseum auto-pilot response, or you could try and engage people for their viewpoints and glean what insights you can—maybe you could even share some insight yourself. But something really interesting happens when you pursue these conversations a bit further: you learn a little more about the other person(s) and a little more about yourself in the process. I had heard the lattermost in the above list of “hits” a million times, and I used to think of it as a sort-of backhanded compliment. It wasn’t until I heard it from an attending I really respected, that my perception changed. I had done a full day’s worth of med student work in a particular clinic alongside my attending. It was full of difficult cases, challenging patients, biopsies, spot diagnoses, etc. On a few occasions I nailed a couple questions (a med student feather-in-cap moment) alongside interns and other students. At the end of the day, a conversation came up about interest in specialties, and I said pathology. Being greeted with a few comments/questions about it, along with a brief but great conversation, the attending finally said that they were impressed with me and to say that my skills would be wasted in the lab is a misnomer. Rather, my “clinical skills/work ethic” wherever I’d end up would be a valuable asset to patients anywhere in the hospital. (Um, that was a gold-star day. I think it was also a Friday, so just amazing overall.) So these stereotypic comments that used to make me feel frustrated, just got turned into one of my most memorable compliments—and I couldn’t be more grateful.

Turns out, medicine is full of moments like this. Where suddenly you learn or adjust a small piece of information and your point-of-view shifts to a new outlook. Dr. Justin Kreuter, a clinical pathologist, at the Mayo Clinic in Rochester, MN, recently wrote a perspectives piece for Mayo Medical Laboratories. It was all about taking the time to critically reflect. He linked to a few interesting articles and talked about how he takes time each day to reflect on moments and experiences he had. A mindfulness of “deliberate practice” (one of the various ways we can practice becoming better at something) shows us that being aware of opinions, cause-and-effect relationships, and our roles in certain situations can shape how we move forward from various experiences. Check his articles out and take his advice; who knows what you might learn about frustrating moments in your day, when instead you might change the entire conversation?

See you all next time!

 

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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 actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.

Microbiology Case Study: A 10 Month Old Female with Fever and Shoulder Pain

Case History

A 10 month old African American female presented to the emergency department with fever (101.9°F) and a two day history of left shoulder pain. Her mother reported guarding and refusal to move the left arm. There was no history of trauma and no other relevant past medical history. On examination, there was tenderness with gentle manipulation of left shoulder but no erythema or swelling were noted. She had full range of motion of elbow, wrist and finger joints with adequate sensation and pulses. Lab work showed a normal white blood cell count and increased ESR (52mm/hr, normal range: 0-20 mm/hr) and CRP (1.5 mg/dL, normal range: <1.00 mg/dL), suggestive of an infectious or inflammatory process. X-ray of the shoulder showed no bony abnormalities. Orthopedic surgery ordered an MRI which revealed a joint effusion concerning for septic arthritis. She underwent an aspiration with irrigation of the glenohumeral joint with drain placement and was subsequently started on clindamycin. The fluid was sent to the microbiology laboratory for Gram stain and bacterial culture. Multiple blood cultures were also collected.

Laboratory Identification

kingking1
Image 1. Two gray colonies grew in the first quadrant of the chocolate agar after 48 hours of incubation at 35°C in 5% CO2.
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Image 2. A sub from the above plate grew as small, grayish white colonies on blood and chocolate agars after 24 hours incubation at 35°C in 5% CO2. There was no growth on the MacConkey agar plate.
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 Image 3. Gram stain prepared from the chocolate agar plate showed gram negative bacilli in pairs (100x oil immersion).

The initial direct Gram stain from the fluid showed rare white blood cells and no organisms were identified. Two colonies of the organism grew on chocolate agar as small, grayish colonies after 48 hours incubation (Image 1). Upon subculture, the organism failed to grow on MacConkey agar (Image 2). Gram stain identified the isolate as gram negative bacilli, predominantly arranged in pairs (Image 3). The isolate was positive for oxidase and negative for catalase. MALDI-TOF MS identified the isolate as Kingella kingae. All blood cultures were negative.

 Discussion

Kingella kingae is a short, gram-negative bacilli that occur in pairs or short chains and require increased CO2 for optimum growth. K. kingae is the most common species responsible for human infections and is characterized as a fastidious gram negative rod of the HACEK group. K. kingae is a component of the normal flora in the oral cavity, throat, and upper respiratory tract of children and adults.

Bone and joint infections are the most common clinical manifestations of K. kingae infection in children and can present as bacteremia, septic arthritis, osteomyelitis and discitis. Children usually show symptoms including fever, swollen joints and decreased mobility with a recent preceding history of an upper respiratory tract infections or stomatitis with K. kingae gaining access to the bloodstream through damaged mucosa. In adults, those with poor dental hygiene, immunosuppression, or recent chemotherapy with mucositis are at risk for subacute bacterial endocarditis.

In the microbiology laboratory, K. kingae are facultative anaerobic gram negative bacilli that grow well on blood and chocolate agar plates after 48 hours. There is a small but distinct zone of beta-hemolysis on blood agar.  Unlike enteric organisms, K. kingae does not grow on MacConkey agar. Biochemical tests for K. kingae show a negative catalase reaction, positive oxidase positive reaction and they are non-motile. K. kingae is negative for indole and urease reactions. Automated identification instruments and MALDI-TOF mass spectrometry are able to identify K. kingae.

Beta-lactamase testing should be performed on K. kingae isolates as production among members of the HACEK group is well known. If the isolate is beta-lactamase positive, this predicts resistance to ampicillin, penicillin and amoxicillin. In general, K. kingae is susceptible to 3rd generation cephalosporins (and combinations with beta-lactam inhibitors), macrolides, fluoroquinolones and trimethoprim-sulfamethoxazole.

In the case of our patient, pediatric infectious disease was consulted and her antibiotic therapy was changed to IV cefazolin. She was discharged home with PO cephalexin for 3 weeks. On return to clinic, she was healing well with no complications.

 

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-Anu Abraham, MD, is a first year Anatomic and Clinical Pathology resident at the University of Mississippi Medical Center.

Stempak

-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 Clinical Pathology as well as the Microbiology and Serology Laboratories.  Her interests include infectious disease histology, process and quality improvement and resident education.

Blood Bank Case Study: Once Upon a Discrepancy

I have taught Transfusion Medicine to MLS students for a number of years, and one of the more challenging concepts for my students is that of ABO discrepancies. We use ‘dry’ labs for ABO discrepancy examples because it would be difficult to create actual samples that illustrate the various scenarios. Without seeing this in the lab, and actually performing the steps to resolve, visual learners in particular can be at a disadvantage. In reality, some of the more unusual ABO discrepancy problems are found more often on exams than in real life. Consequently, in the Blood Bank lab, when a technologist comes upon an ABO discrepancy, it can be something they are not very experienced with and it can be more scary than exciting. I have always felt that one of the best things about being a medical technologist is that we get to solve puzzles and find answers. So, let’s put on our detective hats and follow along with our case history story of an ABO typing discrepancy.

Once upon a discrepancy… a forward typing did not match a back typing. The first thing the tech did was to repeat the typing. Many labs recommend using a different method in the repeat, so if typings are routinely done by an automated method, a repeat testing might be done by tube typing. In this case, we can see the results of the initial testing and the results of the tube typing below:

Automated typing

Reagent Anti-A Anti-B Anti-D A1 Cells B Cells Interpretation
Results  4+  0  4+  1+  3+  ??

Repeat tube typing

Reagent Anti-A Anti-B Anti-D D Control A1 Cells B Cells Interpretation
Results  4+  0  4+  NT  1+  4+  ??

 

As you can see, the repeat typing simply rules out technical or clerical errors and confirmed that the testing was performed correctly. So far so good. However, since we got the same results on repeat testing, what is the next step in resolving this discrepancy?

I teach my students to think of a few ground rules when working on ABO discrepancy problems. The first is that, typically in these situations, it is the weak reaction that is the discrepant one. We have a patient who front types as an A, but the back type looks like an O. With ABO typing we usually get fairly strong reactions, so the 1+ reaction with A1 Cells is the suspect one. The second rule of thumb is that antibody problems are much more common than antigen problems. Having and extra antibody reaction or missing an antibody reaction is more common than extra or missing antigens. In this case we have an extra antibody reaction. This patient looks like a group A who is making anti-A1 which has reacted with our A1 cells.

Our next step is to discover why we have an extra antibody. I would like to emphasize the importance of looking up the patient’s history to help you resolve a discrepancy. This is the third thing that should always be done when investigating an ABO discrepancy. Accurate patient history including any previous Blood Bank results, age, pregnancy history, medications and diagnosis can all be used to help resolve these problems.

At this point techs are probably thinking ‘This is easy!’ and thinking about A subgroups. Remember that about 80% of group A people are group A1 and about 20% are group A2. There are also other less common subgroups of A, but A2 is the one that we encounter most often. Some group A2 people can make anti-A1, either naturally or as an immune response. This patient is a 30 year old woman who is in the Emergency Room and has just been scheduled for surgery. The physician has ordered a type and crossmatch for 2 units of blood. A look at her medical history shows she has never been pregnant nor has ever received blood products. We have no previous Blood bank history on the patient. While an anti-A1 can be from previous transfusions or pregnancy, it can also be naturally occurring. This seems to support our speculation that she is an A2 subgroup with a naturally occurring anti A1, so while we are waiting for our screen results, we perform A1 lectin testing. The results are shown below:

abo-disc

If our patient was group A2 as we thought, her A2 cells would not react with anti-A1 and her plasma would not have anti-A2 and would not react with A2 cells. Our results do not match our original hypothesis that the patient is group A2 and we can rule out a subgroup of A. What is her type, and what is causing the discrepancy?

To help solve this discrepancy, the tech looked at the solid phase screening results only to find that the screen was negative, thus making this puzzle even more perplexing. He repeated the screen in tube at IS, 37C and AHG and found positive reactions. Working up the panel, Anti-M was identified!

So, what type is this patient? She is group A1 pos with an cold reacting anti-M antibody. The policies of the medical center would determine if this patient should be given cross match compatible units that are not antigen typed or crossmatch compatible M negative units.

Anti-M is a naturally occurring cold antibody. Most examples of Anti-M are IgM, do not react at 37C and are not considered to be clinically significant. However, anti M can also present with an IgG component and react at 37C and AHG. In this case, it would be considered clinically significant and any units transfused must be negative for the M antigen.

This patient’s anti-M was only reacting at IS and determined to be not clinically significant. Despite this, we have seen that non-ABO alloantibodies can and do interfere with ABO typing and are a common cause of unexpected reactivity in ABO reverse typing. Performing the ABO testing at warm temperatures or repeating the reverse grouping with reagent A1 and B cells that are negative for M antigen can eliminate the cold reactivity and help resolve the discrepancy. It is important to remember that we must not only recognize discrepant results, but also resolve them adequately. Correct blood typing of patients is essential to prevent ABO incompatible transfusions and to help prevent alloimmunization.

References

  1. http://www.haabb.org/images/14_Hamilton-Neg_Ab_screen_For_website.pdf
  2. Harmening, Denise M. Modern Blood banking and Transfusion Practices, 6th Ed. 2012
  3. Safoorah Khalid, Roelyn Dates, et al. Naturally occurring anti M complicating ABO grouping. Indian Journal of Pathology and Microbiology. Vol 54, Issue 1, 2011. P 170-172

 

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-Becky Socha, MS, MLS(ASCP)CM BB CM graduated 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.

Stress: When to Use It and When to Reduce It

To be honest, the word “stress” makes me feel stressed. As soon as this little six-letter words pops up in my head, my heart rate increases, my blood pressure increases, and I lose focus. Even the good type of stress, called eustress, does not sound good in my ear. It evokes thoughts of panic, of too much to do and too little time, and of shutting down.  I want to turn off all the lights and hide underneath my bed so that the stress-goblins can’t find me.

There many types of stress, including acute stress, episodic acute stress, and chronic stress. Acute stress is short, but it can be frequent. It happens for example when you make a mistake at work or when you are about to give a presentation. Acute stress is not necessarily detrimental to your well-being, but it can become harmful is you experience it a lot. Episodic acute stress is when this type of stress occurs often. It makes people irritable, short-tempered, and aggressive because they live in a constant feeling of running behind, as if they can never catch up with life. Chronic stress is when you experience stress over long periods of time. It has a significant impact on a person’s mental, emotional, and physical health and it can lead to burnout. Burnout is the physical and/or mental collapse caused by prolonged or chronic stress. It can take weeks or even months to fully recover from it, during which a person is typically not able to work. Needless to say, it is critical to avoid burnout at any cost.

Knowing how to recognize and reduce symptoms of stress has become a critical part of today’s professional life. The constant pressure to be reachable can create or increase stress, so what we really need to learn is how to create a balance between work and taking time to rejuvenate so that we are more productive during the hours we need to focus.

People develop coping resources to handle stress throughout their personal and professional lives. When you experience stress, keep track of what work best for you so that you end up with a personal coping resource list. For example, when I am stressed, exercise helps me feel better. I also know that I at times I need to check my email first thing when I wake up to get a sense of any urgent issues, and sometimes I need to delete my work email off my phone in order to cope with my stress levels. Knowing what works for YOU is the key, so trying new things and exploring different options is a great way to keep your stress levels at bay.

Work is never done. However, knowing when and how to take a break to clear and refresh your mind needs to be part of everyone’s long-term professional goal. Life and work is a marathon, so developing coping skills to handle both acute and chronic stress is essential to make sure we all make it across the finish line.

Note: Stay tuned for the upcoming release of our ASCP Leadership Institute course called Stress Analysis and Coping Resources!

 

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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.