Lablogatory

Decoding Generations

When I started my professional life, nobody talked about generations. Experience was everything: none, little, some, significant or expert. Now, conversations about generational similarities and differences are integrated into professional and personal life.

There are currently five generations at work today: Traditionalists, Baby Boomers, Generation X, Generation Y/Millennials, and Generation Z.

generations

Understanding generations allows people to adapt their behavior according to certain preferences.Take, for example, communication styles. When communicating with someone from the Baby Boomers generation, picking up the phone might be appreciated, while sending an email to a Generation X is the best way to communicate with them. Always keep in mind, however, that generational preferences are generalizations, and knowledge about them does not substitute understanding each employee and colleague on an individual basis.

Another example of the differences between the generations is how they define their aspirations. Traditionalists value home ownership, Baby Boomers want job security, Generation X aspires to achieve work-life balance, Generation Y prefers flexibility and freedom, and Generation Z values security and stability. Understanding each generation’s aspirations allows leaders to tailor their communication style and job aspects to each individual.

lotte-small

-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.

As a former member of the ASCP Resident Council, I volunteered for the opportunity to serve as a beta tester for the ASCP Leadership Institute. To obtain certification, I completed 10 modules which often included a pre-course reading or interactive video assignment along with a pre-recorded webinar, post-test, and post-course evaluation. Some of these courses are also available in-person at live meetings and can include personal coaching live, online, or by phone.

A cursory internet search will reveal a plethora of written and video resources available on the topic of leadership. Additionally, many of us have participated in evaluations or trainings that sought to not only define our personal leadership skills/style but also help us to gain essential self-awareness and skills to better lead or be part of a team. Despite such experiences and even though I’ve held many leadership positions over the years, I still find it difficult to reconcile what it means to be a leader, both in terms of expectations that I hold for myself and those that others hold of me and how to build these expectations to realize a shared objective.

I was intrigued by the title of the module “DeCoding Generations”. This module was especially salient for me since I was a non-traditional medical student after initially studying to be a neuroscientist. I’ve generally been older than my fellow trainees and younger than the majority of my teachers. This generational gap has also been similarly evident within the teams I’ve participated in since I matriculated into medical school.

This module explored the core values of the following “generations”: traditionalists, baby boomers, gen X, gen Y (also known as millennials), and gen Z to help the learner understand what drives members of each group. The course then further defined the aspirations, attitudes toward technology and their careers, and preferred communication media and preferences of members of each generation. This was all with the goal of facilitating interactions, especially as a leader, with members from each generation. For instance, different generations prefer and respond better to different types of communication: in-person, phone, email, video conferencing, text, or a combination of these modalities. That’s where the “decoding” part of the module comes in. As leaders, we need to recognize how best to interact with each team member to acknowledge their core values and foster the most harmonious working relationships while working toward a shared goal.

I’m a very visual learner and intuitive person but not the most eloquent or at ease with verbal communication despite friends remarking that I’m a “social butterfly”. This module helped me evaluate ways to adapt my communication style especially when interacting with others in the two most numerous generations in the workforce: millennials (42%) and baby boomers (29%). I fall in the middle as a gen X’er (23%) and have often found myself confounded by the attitudes and behaviors of millennials and this module helped me to understand their perspective and preferred modes of communication. But what I learned most was to look at not only the differences that impair our interactions but also the similarities we share that can be used to prevent or resolve conflicts and to encourage team creativity and solidarity.

-Betty Chung, DO, MPH, MA recieved a BA from The University of Chicago, MA from Boston University School of Medicine, DO from UMDNJ-School of Osteopathic Medicine (now Rowan-SOM), and MPH from Columbia University and a decade of experience in basic science research. She completed her AP/CP residency at the University of Illinois at Chicago (PGY1-2) and Rutgers Robert Wood Johnson Medical School (PGY3-4). Her current interests lie in graduate medical education, quality improvement, hematopathology, and molecular genetic pathology.

Components of an Online CLS Course

When interviewing prospective candidates for Mayo Clinic’s program in medical laboratory science (MLS), I provide an overview of one of our blended courses and compare and contrast it to one of our more traditionally taught (lecture-based) courses. This gives me the opportunity to emphasize expectations and recommended study habits based on some of the “best practices” we’ve learned from our students.

Our online MLS courses include the following components:

Syllabus
Weekly calendar
Online lessons
Homework assignments
Discussion boards
Study guides
Self-assessments
Practice exams
Resources (links to related online resources)

Our students are expected to review each online lesson before coming to class as preparation for their laboratory session. Since we teach “immersion style” courses, two at a time (where a typical four-credit course is condensed into six weeks), we recommended that our students plan to study a minimum of 4 to 6 hours per day.

Each lesson is presented in a written format, following instructional-design recommendations for online learning that includes “chunking” of the content—using bullets to convey information instead of complete sentences (where appropriate) along with concisely written text that emphasizes “key concepts,” graphics, and images. The lessons are straightforward and present basic knowledge, and the higher learning concepts are integrated into the discussion-board assignments.

Each online course is easy to navigate and is presented in such a way that it’s intuitive and requires little “outside” instruction. All the courses in our program follow the same format, so once the students become familiar with navigation of their first course, they do not have to re-learn the lesson format each time they start a new course.

We provide a study guide of objectives for every written examination. Our students are encouraged to create a learning document from the study guide that they can use for review over the duration of the program and to prepare for their national certification examination in medical laboratory science offered through the American Society for Clinical Pathology.

To give you an idea of how our online courses are designed in Blackboard Learn, I have taken a series of screen shots demonstrating the layout of a course and lesson plan (shown below).

When our students log into Blackboard Learn and open a course, they land on the home page, which includes a navigation menu and links to the syllabus and introductory discussion boards. The home page discussion boards include “student introductions,” “faculty expectations,” “updates and handouts,” “ask your instructor or classmates,” and an “MLS Café” (for social interactions).

1_Welcome

From the menu, our students can open the course content. The first page opens to the weekly course calendars. At a glance, our students can examine the week’s activities.

Clicking the “Course Week” link opens the week’s lesson plans.

3_Lesson Plan_Week 2 List of Lessons

Each lesson is formatted the same way and begins with a brief description, overview (goals or learning objectives), author, and references.

4_Lesson Plan_Overview

The second page is a table of “steps to completion” so that our students know exactly what is required of them.

5_Lesson Plan_ Steps to Completion

The lesson is presented in a written format. A table of contents allows the students to navigate the pages of the lesson.

6_Lesson Plan Introduction

The lesson concludes with a self-assessment. The self-assessment is embedded in the lesson, includes feedback loops, and is also linked to the home page menu. The students are able to take the self-assessments as often as they’d like, and the course grade book is set to record their highest score.

7_Example of Self Assessment

In this course, there is a weekly discussion board. The students are directed to work as a team in assigned groups to answer the questions in the discussion. Credit for this discussion is based on participation in the thread and “substantive” contributions to the dialogue. Students are encouraged to build upon one another’s commentary, generating comprehensive answers to the questions. Each group member must contribute at least two to three substantive answers to receive credit for the assignment. One group member is designated to post a summary of the discussion on behalf of the group.

8_Example of Discussion Board

There are 15 didactic courses in our MLS curriculum. All of our courses have an online component with approximately one-third of the courses applying the “reverse-lecture-homework” paradigm, one-third are lecture based (traditional), and one-third are a combination of both.

This variation in presentation of content provides our students a mixed learning experience, and the online format allows for us to map everything out for them. Additionally, the curricular model itself lends to the formation of study groups, which in turn helps our students build upon their teamwork and communication skills.

Since our program was instituted 10 years ago, we have seen excellent outcomes, with 100% graduation rates, 100% employment of our graduates, and 96% first-time pass rates on the national certification examination (based on a three-year average). Notably, the breakdown of the certification results by category demonstrates that overall student performance in content areas of the curricula that apply the reverse-lecture-homework paradigm are, on average, higher than those categories following a traditional course format (i.e, lecture-based).

Lehman_small

-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.

Pseudohyperkalemia in Patients with Severe Leukocytosis

It has been reported many times that falsely elevated potassium can be seen in patients with severe leukocytosis from chronic lymphocytic leukemia (CLL). Early recognition of factitious hyperkalemia is very important to prevent inappropriate and potentially hazardous treatment. One case we observed in our institution, again, emphasized the importance and urgency to recognize these instances.

In this case, patient was a 58 year old male with recently diagnosed CLL. His potassium level rose from normal levels at admission to 8.9 mmol/L on repeated blood draws. Patient was asymptomatic with good strength on physical exam, and had no abnormalities on EKG or telemetry. Insulin/glucose and calcium gluconate was administered to correct potassium level and to prevent cardiac effect of hyperkalemia. The hyperkalemia result was initially thought to be due to emerging tumor lysis syndrome and was not brought to our attention until another specimen obtained had a potassium level greater than the measurable range (10.0 mmol/L). Specimens were not hemolyzed and white blood cell count was as high as 455K/µL.

Given his history of CLL, we suspected pseudohyperkalemia, an entity that has been attributed to the combination of the fragility of the leukemic lymphocytes and the mechanical stress on the cells during specimen transportation and centrifugation. Our clinical team was notified immediately, and a whole blood specimen was collected and hand carried to the laboratory. Without centrifuging, the whole blood specimen was analyzed on a blood gas analyzer and showed a potassium level of 4.2 mmol/L!!! Potassium-lowering treatment was discontinued.

Artifactually elevated potassium level is commonly seen due to red blood cell hemolysis, but not well appreciated is its occasional occurrence in patients with extreme leukocytosis from CLL. It is important for laboratorians to recognize this pattern and to notify our clinical teams so that patients are not inappropriately treated.

Xin-small

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

Microbiology Case Study: A 55 Year Old Female with Respiratory Failure

Case History

A 55 year old female with a history of chronic obstructive pulmonary disease, alpha-1 antitrypsin deficiency, and current tobacco use was transferred to our hospital due to acute hypoxemic respiratory failure. She had a gradual six day onset of cough, fever, malaise, weakness, dizziness and wheezing. At the outside facility, she was hypoxic with an oxygen saturation of 67% at room air, hypotensive with a blood pressure of 80/50. She was intubated en route to our facility.

Labs were significant for a positive influenza B swab, leukopenia (WBC 1.2) with 59% bands, and acute kidney injury with a creatinine of 1.4 mg/dl and hyponatremia with a sodium level of 129 mEq/L. Blood cultures grew Streptococcus pneumoniae, sensitive to ceftriaxone. At our facility, she was started on ceftriaxone and azithromycin. She completed 14 days of ceftriaxone; however, she continued to have intermittent fevers above 38 degrees Celsius. Due to the patient’s continued fever, infectious work up was initiated and showed Candida in her urine and HSV lesions on her lips. She was started on a 14 day course of fluconazole and valacyclovir.

Tracheal aspirates on two occasions were also cultured and grew mixed gram positive and negative organisms as well as Syncephalastrum species. Four weeks after being admitted to our facility, she developed a right-sided hydropneumothorax in which 500 mL of exudative fluid was drawn and subsequently cultured. These cultures also grew Syncephalastrum species as well as Staphylococcus epidermis.

synrac1 — Image 1: *Syncephalastrum* growing on a blood agar plate from the patient’s pleural fluid.

synrac2 — Image 2: Lactophenol cotton blue stain of *Syncephalastrum* demonstrating the sporangiophore with tubular sporangia on the large round vesicle. The sporangia contain chains of round spores.

Discussion

Syncephalastrum racemosum is thought to be the only species out of the two Syncephalastrum species known to cause mucormycoses in humans (1). The only proven reported cases of infection have been due to percutaneous inoculation after trauma, however whether this is due to low pathogenicity, no case reports, or interpretation as a contaminant remains a mystery (1).

Syncephalastrum is a saprophytic fungus isolated throughout the world particularly in environments with decaying organic matter (1, 2). It is found in low levels in the air and has been reported to colonize both immunocompromised and healthy individuals after natural disasters (3).

Diagnosis of Syncephalastrum can be made by visualizing pauci-septate, ribbon-like mycelium and a merosporangial sack surrounding sporangiospores from the cultures using a lactophenol cotton blue mount preparation (1). Caution should be used in distinguishing Aspergillus niger from Syncephalastrum using a direct KOH mount due to the similarities in their fruiting bodies (1). On a petri plate, it begins as fast growing white fluff and then turns dark gray to almost black with the reverse side being white (4).

References

Gomes MZ, Lewis RE, Kontoyiannis DP. Mucormycosis caused by unusual mucormycetes, non-Rhizopus, -Mucor, and -Lichtheimia species. Clin Microbiol Rev. 2011;24(2):411-45.
Ribes JA, Vanover-sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev. 2000;13(2):236-301.
Rao CY, Kurukularatne C, Garcia-diaz JB, et al. Implications of detecting the mold Syncephalastrum in clinical specimens of New Orleans residents after Hurricanes Katrina and Rita. J Occup Environ Med. 2007;49(4):411-6.
Larone DH. Medically Important Fungi, A Guide to Identification. Amer Society for Microbiology; 2011.

-Angela Theiss is a pathology resident at the University of Vermont Medical Center.

Wojewoda-small

-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.

Poll Friday: Thalassemia

A Chemical Conundrum

In 1983, OSHA established its first version of the Hazard Communication standard. These regulations were made law in response to a lack of hazard information given to over 30 million United States employees working with chemicals. OSHA estimates that 650,000 chemicals are used in over three million work places across the country. Recognizing that the work performed in laboratories is unique—relatively small quantities of hazardous chemicals are used on a non-production basis—OSHA promulgated the Chemical Hygiene standard (more simply known as the Laboratory standard) in 1990.

The Chemical Hygiene standard regulations supersede HazCom standard regulations in the laboratory setting. However, there are still several HazCom rules that affect labs such as those involving hazard determination, chemical labeling, and Safety Data Sheets. The Chemical Hygiene standard brings another layer of exposure protection to the lab employee through the required establishment of a series of chemical safe work practices. Understanding how both sets of laboratory regulations work together is important in creating an overall lab chemical management program.

The regulations for creating a chemical inventory are expressed in the HazCom standard. OSHA requires a list of hazardous chemicals in every work place where they are manufactured, stored, or used. This inventory can be a useful tool for many reasons. Use the list to document the required chemical risk analysis. Review the chemicals in the lab for their hazards, and indicate on the inventory list any applicable hazard warnings such as the signal word and pictograms. CAP requires that you determine which chemicals in the lab are carcinogenic or reproductively and acutely toxic. Once that analysis is complete, it can also be documented on the inventory list. Record average volumes of the chemicals stored in the lab as well. This information may be helpful in a fire situation so that the fire department or other rescue workers will be aware of what they may encounter.

Laboratories must designate a Chemical Hygiene Officer, a point person who is qualified and responsible for providing technical guidance for the implementation and operation of the entire lab chemical management program. The Lab Standard even mentions the establishment of a Chemical Hygiene Committee if the lab or chemical program is larger. Details of this lab chemical safety structure should be spelled out in the lab’s required Chemical Hygiene Plan.

If you read the actual Chemical Hygiene Standard on OSHA’s web site, you can see it is not very long (unlike the HazCom standard or others). Because of the volume of chemicals used in labs, the standard’s main focus is protecting employees from those chemicals via written procedures, physical barriers (such as PPE and engineering controls), and health monitoring. A model Chemical Hygiene Plan must include exposure control methods, a chemical fume hood maintenance process, a detailed training program, and medical consultation and follow-up when chemical exposure limits are exceeded. Appendix A of the standard (called National Research Council Recommendations Concerning Chemical Hygiene in Laboratories) was created to assist laboratories with the development of a complete and compliant Chemical Hygiene Plan.

A third set of OSHA regulations that affects labs and chemical safety is the Formaldehyde standard. The exposure monitoring section gives instructions on how to perform vapor monitoring for this carcinogenic chemical. The laboratory has an option to monitor each employee individually, or it may set up a representative sampling strategy and measure exposures within each job classification and for each work shift. The purpose of this strategy is to properly characterize the exposure of every employee without having to monitor each one. Simply stated, that means if Jane and John perform the same duties and are equally exposed to formaldehyde in their work day or for a specific task, you may monitor only Jane’s exposure and share the results with both employees. That said, the CAP standard on the Anatomic Pathology inspection checklist states that each new employee should have formaldehyde vapor monitors performed. While it references the OSHA formaldehyde regulations, the standard fails to include OSHA’s wording about representative monitoring. That can be an issue if a CAP inspector follows strict adherence to those standards and does not subscribe to OSHA’s intent. Clearly representative vapor monitors make sense and are safe, but you may have to challenge the case with certain inspectors.

Chemical management in the laboratory can certainly seem daunting, and there are many regulations (federal and otherwise) that affect how the lab program may be run. The basic safety strategies exist for the purposes of protecting the employee from chemical exposure, but so many details are involved with the process. Proper storage of flammables and corrosives, labeling, and waste handling are just some of the topics not even touched upon in this article, but they also must be considered for safety purposes. If operating the chemical management program is your duty, be sure to understand the regulations, and build a team of staff who will work together to ensure safe chemical processes in the laboratory.

Scungio 1

–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.

Library Preparation – The First Step in a NGS Setup

Welcome back! Last quarter we discussed why Next Generation, or Massively Parallel, Sequencing is the next big thing in the world of Molecular Diagnostics. The sensitivity, the depth of coverage and the ability to interrogate many different areas of the genome at the same time were just a few of the benefits of these types of assays. Next, I would like to describe a couple different methods of library preparation, which is the first step necessary to run an NGS assay.

First of all, let’s define “Library.” I find this is the most common question technologists new to this technology ask. Essentially, a library is a specimen’s collection of amplicons produced by the assay that have been barcoded, tagged with appropriate platform adapters and purified. These will serve as the input for the next part of the NGS workflow, clonal amplification (the topic of next quarter’s blog!). How these libraries are prepared differ depending on platform (i.e, Ion Torrent vs. MiSeq), starting material (RNA vs. DNA), and type of assay (targeted amplicon vs. exome).

Before we begin the library prep discussion, a note about the input specimen. The DNA must be quantitated using a method that is more specific than spectrophotometry – it must be specific for double-stranded DNA. It will lead to an overestimation of the amount of DNA in the specimen, which will lead to over-dilution and consequently, lower quantity of final library. Real-time PCR and a double-stranded kit with fluorometry are two examples of assays that will give accurate concentrations of double-stranded DNA.

Our lab has begun using NGS for some of our oncology assays, so I will focus on the two types we perform currently, but keep in mind, there are many other types of assays and platforms.

Image 1: ion torrent amplicon library preparation. Source: Ion AmpliSeqTM Library Preparation User Guide – MAN0006735, Rev. 10 September 2012.

The assay we use for our Ion Torrent platform is a PCR amplicon based assay. The first step is to amplify up the 207 regions over 50 genes that contain hotspots areas for a number of different cancer types. This all occurs in one well for each specimen. Once those areas are amplified, the next step is to partially digest the primer sequences in order to prepare the ends of amplicons for the adapters necessary for the sequencing step. As shown in the figure above, two different combinations of adapters may be used. The top one, listed as the A adapter (red) and the P1 adapter (green), would be used if only one specimen was to be sequenced on the run. The A and P1 adapters provide universal priming sites so that every amplicon of every sample can be primed with the same primers, rather than having to use gene specific primers each time. The second possibility is listed below that, with the same P1 adapter (green) and a Barcode Adapter labeled X (red and blue) – it still contains the A adapter necessary for sequencing (red), but it also contains a short oligonucleotide sequence called a “barcode” (blue) that will be recognized during the analysis step based on the sequence. For example, Barcode 101’s sequence is CTAAGGTAAC – this will be assigned to specimen 1 in the run and all of the amplicons for that specimen will be tagged with this sequence. Specimen 2 will have the barcode 102 (TAAGGAGAAC) tag on all of its amplicons. During analysis, the barcodes will be identified and all of the reads with the 101 sequence will be binned together and all of the reads with the 102 sequence will be binned together. This allows many specimens to be run at the same time, thus increasing the efficiency of NGS even more. Lastly, the tagged amplicons are purified and normalized to the same concentration.

library2 — Image 2: MiSeq amplicon library preparation. Image source: https://www.illumina.com/content/dam/illumina-marketing/documents/applications/ngs-library-prep/for-all-you-seq-dna.pdf

The assay we use for our MiSeq platform is a hybridization followed by PCR amplicon based assay. The first step is to hybridize probes to 568 regions over 54 genes that contain hotspots for a number of different cancer types. This occurs in one well for each specimen. Once the probes have hybridized, the unbound probes are washed away using a size selection filter plate. Next, the area between the probes is extended and ligated so that each of the 568 amplicons are created. These are then amplified in a PCR step using primers that are complimentary to a universal priming site on the probes, but also contain adapters plus the two indices required for paired end sequencing (the Ion Torrent platform utilizes single-end sequencing – this will be discussed in the sequencing portion in an upcoming blog!). As in the previous method, after PCR, these tagged amplicons are purified and normalized to the same concentration in preparation for the next step – clonal amplification.

Stay tuned for next quarter’s post – clonal amplification!

rapp_small

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

Hematology Case Study: Crystal of Death

Case History

A 56 year old female presented with symptoms of sepsis. During surgery, patient bleed profusely and received blood products. However, the patient expired.

Laboratory Findings

WBC: 18.8 x 10⁹/L
Hemoglobin: 5.6 g/dL
Lactate: 8.3 mmol/L
AST: 1485
ALT: 1625

The blood smear was reviewed for these white blood cell inclusions:

green-incl-1 — Image courtesy of Georgia McCauley, PhD, MT(AMT)

Image courtesy of Georgia McCauley, PhD, MT(AMT)

Discussion

The image presented reveals to be the “blue green crystal of death”. Medical literature has documented an association between acute hepatic failure and coarse, bright-green neutrophilic inclusions. Upon identification of these unique inclusions patients have been reported to have poor outcomes and usually die within 24-72 hours (Haberichter KL, 2017). The exact nature of these inclusions has yet to be determined; it is postulated that they arise from lipofusion-like substance. Bright green inclusions in neutrophils have been reported as a sign of impending patient death (Hodgson, 2015).

Refractile bright-green irregular inclusions within neutrophils have been reported as a marker of impending patient death. In the three reported cases, death occurred within 2 d of recognition of the inclusions (Harris et al, 2009; Jazaerly & Gabali, 2014). Disease associations with green neutrophil inclusions included acute liver failure secondary to acetaminophin overdose, lactic acidosis with multisystem organ failure subsequent to trauma (Harris et al, 2009) and Escherichia coli-associated septic shock (Jazaerly & Gabali, 2014). Harris et al (2009) suggested that the inclusions were related to blood-borne bile products.

These findings on the peripheral smear should be reported and considered a critical finding. Laboratory professionals and hematologists should acknowledge these inclusions; patients are noted to be seriously ill at the time of detection of neutrophil inclusions and have an ominous 24-72 hour survival period.

References

Haberichter, K. L., & Crisan, D. (2017). Green Neutrophilic Inclusions and Acute Hepatic Failure: Clinical Significance and Brief Review of the Literature. Annals of Clinical & Laboratory Science, 47(1), 58-61.
Harris, V.N., Malysz, J.& Smith, M.D. (2009) Green neutrophilic inclusions in liver disease. Journal of Clinical Pathology, 62, 853–854.
Hodgson, T. O., Ruskova, A., Shugg, C. J., McCallum, V. J., & Morison, I. M. (2015). Green neutrophil and monocyte inclusions–time to acknowledge and report. British journal of haematology, 170(2), 229-235.
Jazaerly, T.& Gabali, A.M. (2014) Green neutrophilic inclusions could be a sign of impending death! Blood, 123, 614.

ledesma_small

-Carlo Ledesma, MS, SH(ASCP)^CMMT(ASCPⁱ) MT(AMT) is the program director for the Medical Laboratory Technology and Phlebotomy at Rose State College in Midwest City, Oklahoma as well as a technical consultant for Royal Laboratory Services. Carlo has worked in several areas of the laboratory including microbiology and hematology before becoming a laboratory manager and program director.

Microbiology Case Study: A 75-Year-Old Man with Polymicrobial Bacteremia After Hemicolectomy

Case History

A 75-year-old male with a past medical history of hypertension, hyperlipidemia, and benign prostatic hyperplasia underwent an elective right hemicolectomy at an outside hospital after a cecal polypectomy demonstrated an intramucosal adenocarcinoma (in situ) arising in a background of a sessile serrated adenoma. On post-op day 6, he was transferred to our institution for management of an ST-elevation myocardial infarction that was treated with placement of a drug-eluting stent to the right coronary artery. After the cardiac catheterization, he complained of acute-onset abdominal pain and was tachypneic (49/min), hypotensive (72/48 mmHg), and febrile (39.4°C). He was emergently intubated, given vasopressors, and started on vancomycin and piperacillin/tazobactam empirically for septic shock. A chest X-ray showed atelectasis but no pulmonary consolidation. An abdominal X-ray did not show definitive evidence of pneumoperitoneum and abdominal CT showed some free fluid but no acute abdominal pathology. The WBC count was 3,640/cm³ with an absolute neutrophil count (2,880/cm³) within normal limits. The anaerobic bottle in one of two blood culture sets drawn on post-op day 7 became positive at 27 hours and Gram staining (Image 1) demonstrated gram negative bacilli. Subsequently, the bacilli detected in the anaerobic blood culture bottle were identified by MALDI-TOF as Clostridium clostridioforme, requiring a laboratory corrected report. On post-op day 8, two sets of repeat blood cultures were both positive with Clostridium tertium (Images 2 and 3) and Escherichia coli, consistent with bowel flora. Therapy for the patient’s polymicrobial bacteremia, thought to arise from an ileocolic anastomotic leak, was switched to piperacillin/tazobactam and Metronidazole. Blood cultures on post-op days 10 and 14 were negative. Meanwhile, the patient developed diarrhea, secondary to Clostridium difficile colitis, treated with oral vancomycin and oral thrush treated with micafungin. His hospital course was further complicated by formation of intra-abdominal abscesses, containing E. coli, C. tertium, and C. albicans, that required percutaneous drain placement.

clos1

Image 1. Gram stain of Clostridium clostridioforme from a positive anaerobic blood culture bottle demonstrates thin gram negative bacilli with pointed ends arranged in pairs (100x, oil immersion).

clos2

Image 2. Gram stain of Clostridium tertium from a positive anaerobic blood culture bottle demonstrates gram variable bacilli arranged in short chains (100x, oil immersion).

clos3

Image 3. Clostridium tertium colonies are β-hemolytic on an anaerobic (Schaedler) blood agar plate and appear circular with slightly irregular margins, matte, and grey-white.

Discussion

The genus Clostridium contains approximately 200 species, of which approximately 32 have been associated with human pathologies (1). These organisms are normal members of the human gastrointestinal and cervical-vaginal microflora. Clostridia are also ubiquitously present in nature within soil. Thus, human infection may occur via endogenous or exogenous means. They are classified as gram positive rods and, as such, they do not grow on media that inhibit the growth of gram positive organisms (ie. MacConkey agar). However, upon gram staining, Clostridia may appear gram positive, gram variable, or gram negative. Due to the gram stain variability, inconsistent presence of spores, and atypical colony morphologies, laboratory identification of Clostridum species is problematic.

Clostridium clostridioforme was initially detected in the anaerobic blood culture bottle at 27 hours. Gram staining (Image 1) demonstrates gram negative long, thin bacilli with pointed ends, described as “elongated football shaped” that are arranged in pairs but may also lie singly or in short chains. Oval spores may not be seen but they can be central or subterminal. As obligate anaerobes, C. clostridioforme may be cultured on anaerobic blood agar plates where the gamma-hemolytic colonies appear small, convex to slightly peaked, translucent to opaque, and grey-white. They possess peritrichous flagella that confer motility. It is believed that C. clostridioforme may represent three different species that are frequently isolated anaerobically from blood cultures, particularly in association with mixed cultures, typical of colonic flora (2).

Subsequent blood cultures one day later were positive for both Escherichia coli (detected at 18 hours) and Clostridium tertium (detected at 21 hours). The anaerobic blood culture bottle gram stain (Image 2) demonstrates C. tertium staining as gram variable bacilli arranged in short chains. Terminal spores, only produced under anaerobic conditions, are not seen in Figure 2. C. tertium is one of the aerotolerant clostridia and was cultured on an anaerobic blood agar plate (Figure 3). Colonies appear circular with slightly irregular margins, low convex, matte, and grey-white. Hemolysis can be beta, alpha, or gamma. It was likely overgrown by the E. coli on the aerobic plates. This species is generally considered a weak human pathogen but it has been implicated as a cause of bacteremia in immunocompromised patients. In non-neutropenic patients, C. tertium bacteremia can occur in the setting of gastrointestinal mucosal injury due to gastrointestinal tract pathology or surgery (3).

References

Tille PM. Bailey & Scott’s Diagnostic Microbiology, 13th ed. Elsevier Health Sciences; 2014. pp458-479.
Finegold SM, Song Y, Liu C, et al. Clostridium clostridioforme: a mixture of three clinically important species. Eur J Clin Microbiol Infect Dis. 2005;24(5):319-24.
Miller DL, Brazer S, Murdoch D, Reller LB, Corey GR. Significance of Clostridium tertium bacteremia in neutropenic and nonneutropenic patients: review of 32 cases. Clin Infect Dis. 2001;32(6):975-8.

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

Wojewoda-small

-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.

Logistics, Meetings, and Evacuations

Almost perfectly timed during my classroom-to-clinicals transition period from American University of the Caribbean School of Medicine (AUC), the 2017 ASCP Annual Meeting in Chicago was an excellent opportunity to get back to my lab roots. The Annual Meeting is always an excellent opportunity to expand lab-related knowledge, learn some new clinical skills, and easily network with colleagues. Professional societies like ours are highly dependent on the partnership and collaboration of our fellow scientists, sponsors, and clinicians. I have been fortunate enough to attend two of these meetings as an award recipient bookending my pre-clinical years in medical school. In 2015, I attended the ASCP Annual Meeting in Long Beach, California as a Regional Member of the Year. This year’s Annual Meeting was held in my hometown of Chicago, where I’m proud to say I attended as a 2017 ASCP Top 40 Under Forty honoree! But these meetings are more than just conferences with awards ceremonies—at every ASCP meeting I reconnected with old friends in workshops, shook hands with our great ASCP leadership, and collaborated with colleagues in roundtables or other sessions. There is a place for all of us in laboratory medicine. Our respective insights bring something valuable to the final outcomes of improved patient care. Nowhere is this more evident than the Annual Meeting.

annualmeeting1 — Image 1. ASCP Annual Meeting Chicago 2017, Top 40 Under Forty, and ASCP CEO Dr. Blair Holladay

Among the endless list of educational events and sessions, I especially enjoyed being a collaborator in round table discussions including “The Benefits of Data Integration in Clinical Decisions.” I truly enjoy these roundtables and wish I could have done more of them! Topics included effective feedback, utilization and evaluations, education, and global health initiatives—all of which I’m sure I’ve written about in one way or another this past year. Seeing some of the content in my online Lab Management University (LMU) modules applied in real-life situations was reaffirming. Attending sessions and meeting renowned experts from informatics to hematopathology was exciting. The keynote speakers were captivating. Dr. Birx’s discussion on PEPFAR and global health initiatives clearly piqued my interests, and Drs. Caliguiri and Pritchard’s lectures on analytics and resources spoke directly to my work in cancer research. And don’t forget: it’s all worth continuing education credit—can’t beat that.

I would just like to simply thank ASCP again for all the work that goes into these meetings. I know from experience that planning large events involves quite a bit of logistics. And in managing these events ASCP truly provides an excellent environment to collaborate and learn. What brought this appreciation for logistics to the forefront was a disaster that had unfolded in the week prior to the meeting. On the island of Sint Maarten, the location of my medical school and my home for two years, was absolutely decimated by hurricane Irma. The school managed to withstand for the most part intact and acted as a shelter for students, faculty, and family. While being sheltered from that storm, endless homes, apartments, and business were destroyed. Taking nothing but a suitcase or two to campus ended up the only possessions many people in the AUC community had left. The school and its administration did a spectacular job creating a stable, safe, and even comfortable environment for students and their families while evacuation efforts were organized. While AUC managed to get students off the island via military assistance and/or charter flights, evacuees were taken to the Chicago suburbs. Right after the ASCP Annual Meeting I began having conversations with contacts in the Chicago Department of Public Health and Emergency Preparedness to offer assistance. I provided contact data, relayed satellite telephone numbers to the right contact points, and provided relevant information regarding demographics, health, and needs. Both my wife (a trained nursing leader) and myself were happy to be involved with connecting critical points in this process. All the students and their families were accounted for and taken care of in the Chicago suburbs, and were later moved to the new school location relatively unscathed. Logistics from a distance can be difficult, especially when it’s behind-the-scenes. A lot of lab decisions are made that way, and ultimately we do our best for our patients.

annualmeeting2 — Image 2. Resort and villas halfway between my apartment and AUC campus on Sint Maarten before the hurricane.

annualmeeting3 — Image 3. Resort and villas halfway between my apartment and AUC campus on Sint Maarten after the hurricane.

The take home message: be flexible, be humble, and be helpful. If we want to improve patient outcomes, we need to work with evidence-based approaches matched with intelligent compassion. As laboratorians, we apply our scientific approach to critical life-saving algorithms. This was no exception. Lessons discussed at the Annual Meeting between networking colleagues and official sessions are accurate. Tap into your resources, keep an active and dynamic network, know what you can do and what you cannot, and always try to help. That’s what makes a good laboratorian, a good clinician, a good friend, and hopefully a good physician.

Thanks for reading! If you’re interested in donating to disaster relief for anyone affected by this year’s violent hurricane season in Sint Maarten, visit www.rotarysxm.org.

ckanakisheadshot_small

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