Up in Smoke

Hello again everybody, and welcome back! Last month, I was flattered by a double feature with my post about giving a TEDx talk and Dr. Razzano interviewing me for her global health series. This month, I’d like to address a topic that’s been literally everywhere lately and is just as hard to ignore as…well, second-hand smoke. So, fasten your seatbelts, ensure your seats and tray tables are in the upright position, make sure your biases are stowed in the seat before you, and (of course) please note the no smoking sign as we take off on the topic of vaping!

Image 1. What? I’ve been traveling a lot. There’s inspiration everywhere!

The Smoking Gun

You may have noted that in the past few weeks or months the topic of vaping has been a mainstay of nighttime news stories and front-page print articles. That’s because there’s a lot happening, and from a lot of different angles. It can be messy and confusing, especially because there’s a scientific and non-scientific debate: availability, marketing, health risk, research, and more—all happening at once. I’m going to talk a little bit about all of this, but mostly we’ll look at the medical aspect of vaping as some fantastic publications are making their way into medical journals, including our very own American Journal of Clinical Pathology (AJCP). Recently, friend, colleague, and fellow member of the ASCP Social Media Team and pulmonary pathologist at the Cleveland Clinic, Dr. Sanjay Mukhopadhyay (@smlungpathguy on Twitter) published a noteworthy article with AJCP demonstrating the histopathologic findings of vaping associated lung injury. In essence, vaping causes acute lung injury which is recognized in tissue, supporting the case that both further studies are mandated for health and safety and that vaping should currently be considered a potential critical health risk.

Image 2. About half of the official ASCP Social Media Team (#ASCPSoMeTeam!) from left to right Lab scientist and educator Aaron Odegard (@odie0222), myself (@CEKanakisMD), Dr. Sanjay Mukhopadhyay (@smlungpathguy), famous resident Dr. Adam Booth (@ALBoothMD), and Dr. Kamran Mirza (@Kmirza). If you want updates with great pathology and lab medicine stories and content—follow ALL OF THESE twitter handles!

In this paper, Dr. Mukhopadhyay, et al, tried to capture the direct tissue-related effects of vaping. EVALI, Electronic-Cigarette or Vaping use Associated Lung Injury, has received quite a bit of spotlight in the media as I mentioned. Case series featured in the New England Journal of Medicine (NEJM) highlighted patients in the Midwest with EVALI-type pulmonary disease, but the number of publications on the topic is currently scarce—let alone ones that demonstrate the actual pathophysiology in-process in those affected patients. In the AJCP paper, lung biopsies from a small number of male patients who havdrespiratory illness and concurrent histories of vaping were examined. With all other pulmonary pathology worked up and negative, their biopsies showed various patterns of acute lung injury. The NEJM cases were also worked up and found to be negative for the differentials of pulmonary disease whether infectious, inflammatory, or otherwise; adding credence to a developing body of research supporting the connection between vaping and EVALI.

Image 3. Here’s the mainstay paper I keep referencing. It’s part of a growing number of published works on the topic and part of our expanding understanding of EVALI and its health implications from both public health and pathologic/diagnostic viewpoints.

Where There’s Smoke, There’s…a Lot of Stuff, Actually

There are a ton of stories in the lay-press about vaping-related illnesses. The surveillance data from those NEJM case series and the CDC show a median age of 19 with an overwhelming 94% being hospitalized and roughly two-thirds of those requiring ICU intervention and one-third having to be placed on mechanical ventilation. Of note, 11% of these patients claimed that they vaped pure nicotine product, while 89% smoked cannabinoids/THC in their vape products. Most of them presented to medical care with oxygen saturations <89% on room air (normal O2 sats are variable by patient, but they should be above 95% in ideally healthy individuals). This is neither an endorsement or comment on the medical uses of cannabinoids or a statement on their health effects. Instead, it should be worth mentioning that not only are electronic-cigarette products a new way of smoking higher concentrations of tobacco-obtained or synthetic nicotine but also other products, which have very little data with regard to their associated health risks.

Image 4a. If you haven’t been able to read Dr. Mukhopadhyay’s paper yet, don’t worry I got you. Here are a few cases’ computed tomography (CT) scans that show clinically diagnostic evidence of pulmonary disease visible as (A) ground-glass opacity, GGO, with a pattern that mimics a peripheral eosinophilic pneumonia, (B) more GGOs with areas of consolidation, or solid-looking lung tissue, (C) lower lung GGOs and consolidation with some thickened tissue, and (D) patchy GGOs. All of these cases and more demonstrated some kind of pneumonia and lung tissue pathology but had been worked up and found negative for other causes of disease aside from their shared history of vaping.
Image 4b. Okay, this is a blog for medical laboratory professionals, right? So here’s some slides for the glass pushers! PLEASE NOTE: this is just a sample of a number of histopathologic findings published in the paper, so to see the rest go to the primary source. I’ve highlighted these images as they demonstrate the two major lung injury patterns seen in the EVALI entity: organizing pneumonia seen in (A) & (B) and diffuse alveolar damage (DAD) seen in figures (C) & (D).

Put This in Your Pipe and (please don’t) Smoke It

Okay, I mentioned cannabinoids. Now that I have your attention, I want to walk you through a unique piece of the EVALI discussion you may have seen in the media: the implication of Vitamin-E substances as a potential culprit for these lung-related injuries. The New York Times recently published a piece that cites the CDC’s consideration of Vit-E Acetate as a “a very strong culprit.” Think about it this way: the aerosol generated by vaping devices can reach very high temperatures (higher than traditional cigarettes), if a substance is inhaled at this temperature, and contains lipid-soluble-contents like Vitamin-E acetate, you’re breathing in a grease fire! Here’s an oversimplification: some studies of vaping came up with a theory that a grease fire would cause injury in the lungs similar to a pattern caused by inadvertent inhalation of mineral oil into the lungs known as “exogenous lipoid pneumonia”. However, when expert lung pathologists including Dr. Mukhopadhyay looked at lung biopsies from EVALI patients, they didn’t find even a single case of exogenous lipoid pneumonia. What does this mean? Not much at this point. It’s certainly possible that vitamin E acetate causes lung damage but not in the way mineral oil does. As the CDC materials state, this is early days if it is indeed a health epidemic (it probably is though, please stop vaping). More research is needed, as always, but you can read the NYT article and CDC primer article here.

Image 5. Not all that glitters is…Vitamin-E Acetate. The paper includes images of exogenous lipoid pneumonia (not from the cases studied) and endogenous lipoid pneumonia (from an EVALI case) as a comparison. Note that from a tissue standpoint, the lipid- filled macrophages on the right from an EVALI patient do not resemble the lipid-filled macrophages on the left (caused by mineral oil). Sure, there’s lipid in macrophages in the EVALI lung, but is that because a lipid is causing the damage, or because lipid from the membranes of injured cells is being cleaned up by macrophages? Lung pathologists think that the latter is more likely.

Fired Up, Ready to Go and Sending Smoke Signals

So, imagine you’re a vaper. Imagine you started because it helped you quit traditional cigarettes. That’s fantastic, good for you. You’re on the road to smoking cessation and better health! But perhaps the vaping-associated lung injury cases has made you a little defensive. Trust me I learned the hard way as I joined in the discussion earlier this month on a live-tweet pathology journal club on the AJCP article featured here. They happen under the hashtag #PathJC and lots of folks jump into the discussion from different places, institutions, time zones, and across disciplines—but its not just a bunch of pathologists analyzing an article in an academic bubble. Twitter is a public forum and that brings with it public scrutiny and commentary. As such, there were lots of lay people participating in the discussion and many individuals who held a positive opinion of electronic cigarettes. So not only did we have a very comprehensive discussion in the merits and shortcomings of published literature on the topic of EVALI, we also had to field questions and engage in non-jargon conversations with concerned (and sometimes passionate) members of the non-scientific community. Suffice it to say, it’s a tricky tightrope to walk when you’re trying to balance your anti-smoking public health crusade with some good old-fashioned medical education challenged with a sprinkle of vitriol on the most open of forums, the internet. But that’s okay! I strongly think, that in the future of medical practice, those of us in any discipline (but especially pathology and lab medicine) should lead the charge as champions of truth to connect our revered medical data to people in real terms—basically translate translational medicine.

Image 6. Why am I showing you my twitter profile picture? Easy: one of those “incendiary” comments in discussing smoking and vaping in a public forum actually included someone screen capturing my profile and accosting my “smug” pose and taste for esophageal damage in drinking hot coffee, citing poor data references for caffeine related deaths versus that of smoking. How do you deal with this? Calmly, with open honest information and, most importantly, with humility to address the barriers in communication between opposing points of view. Champions of truth, remember? But once you notice you’re talking to folks online who represent companies in the tobacco industry, ABORT MISSION, you went too far, haha! (True story, yikes!)

Once the Smoke Settles

Basically, everything’s going to be okay. There’s always a crisis or an epidemic happening that we have to address with limited data, developing knowledge, and some cohort of representative push back. That’s the nature of public health. But I’ll pull straight from the authors’ conclusion in the AJCP paper and remind you that not only is this just one, single study with very small number of cases to measure clinical outcomes, but further study is needed to support what is just beginning to be a correlation between vaping and lung injury.

TL;DR – it might seem obvious to some that hot smoke burns your lungs, but we’ve got to prove it and take steps to protect our patients everywhere.

And the good news is there are lots of us working on this. Scientists, public health officials, researchers, reporters, medical professionals, and especially pathologists are here collecting data and adding knowledge to that growing body of evidence to address this …hot topic.

Image 7. Here’s at least two of those people. Spoiler: it’s my wife and me. Here we are the recent American Public Health Association (APHA) conference in Philadelphia where the topic of vaping, smoking, and lung injury were very much in the forefront of public health research as it fits into the context of social determinants of health, medical literacy campaigns, and other concurrently related health issues like asthma and COPD.
Image 8. I actually joined that live tweet #PathJC journal club discussion from the APHA 2019 conference and was lucky enough to have, in-hand, the official EVALI clinical information release from the CDC booth in the expo floor. Check it out on my Twitter feed.

Breathe Easy

What’s past this smokescreen challenge? The same thing as always: hard work, collaboration, innovation, and paradigm shifting. If you’ve read my previous posts, you know I like to wax a bit about the future of medicine and the humanity behind our profession. Taking everything into consideration with this newest and hottest of public health concerns, our role as diagnosticians and translational representatives is as important as ever. And, if we want to ensure the recognized contributions of pathology in the wider field of medicine (and health-at-large) we should work with our colleagues in and out of the medical profession to demystify this kind of research, cleanly communicate health data to the public, and push the boundaries of personalized health and improved patient outcomes. But beware: when you address big topics like smoking, vaping, EVALI, and THC use, it can be easy to get too hot, and even burn out.

Thanks again, see you next time, and hope you had a Happy Thanksgiving!

(This is absolutely stolen from @iHeartHisto on Twitter, but enjoy a slice of pump-skin pie!)

Constantine E. Kanakis MD, MSc, MLS (ASCP)CM completed his BS at Loyola University Chicago and his MS at Rush University. He writes about experiences through medical school through the lens of a medical lab scientist with interests in hematopathology, molecular, bioethics, transfusion medicine, and graphic medicine. He is currently a 2020 AP/CP Residency Applicant and actively involved in public health and education, advocating for visibility and advancement of pathology and lab medicine. Follow him on Twitter @CEKanakisMD

Hematology Case Study: The Story of the Platelet Clump: EDTA-Induced Thrombocytopenia

I belong to a Hematology Interest Group and always enjoy seeing the case studies and questions that other techs post. This group is multinational so I see posts from techs all over the world. It’s interesting to see the similarities and differences in standard operating practices and the roles techs play in different areas and different countries. It’s also interesting to see that we all come across the same types of problems and difficult specimens! In the last few months in this Hematology Interest Group, I have seen many questions and comments about resolving clumped platelets, and am therefore using this opportunity to shed some light on these tricky specimens. The case I am presenting, and the photos, are courtesy of Abu Jad Caesar, who is a Lab manager at Medicare Laboratories – Tulkarm branch, in Palestine.

The patient had a CBC performed on a Nihon Kohden 6410. WBC was 12.7 x 103μL, impedance platelet count was 20,000/μL on initial run, other parameters appeared within normal limits. The sample was warmed and a Na Citrate tube was requested to rule out pseudothrombocytopenia. After warming, the EDTA was rerun with a platelet count of 0/μL. The Na Citrate tube was run, and platelet count from the instrument was 189,000/μL. (Figure 1) Because of the blood:anticoagulant ratio in the Na Citrate tube, a multiplier of 1.1 was applied, thus making the Na Citrate platelet count 207,900/μL. Slides were made, stained and examined. Image 1 shows the clumping in the EDTA tube. Image 2 shows the smear from the Na Citrate tube, with no visual clumping.

The CBC was reported with the following comments: Platelet clumping observed, 2 samples drawn to rule out thrombocytopenia. EDTA whole blood smear had many platelet clumps noted (EDTA induced thrombocytopenia). Conclusion: Platelets are adequate and estimated to be about 200,000/μL.

Figure 1. Results from warmed EDTA tube (left) and Na Citrate tube (right).
Image 1. Clumped platelets seen with EDTA.
Image 2. Normal platelet count with no clumping seen with Na Citrate.

Platelet counts in the normal range don’t usually give us too much trouble in reporting, even if some clumping is present, mainly because they are normal. Adequate platelet counts fall within a typical reference range of about 150- 450 x 103/μL. If there are instrument flags for a platelet abnormal scattergram or platelet clumps, it is recommended to repeat testing by another method. If the initial count is performed by impedance counting, many analyzers can also report optical or fluorescent platelet counts. With impedance counting, very small RBCs or fragments may be counted as platelets, thus giving a falsely increased platelet count. With optical counting, large platelets can be counted as RBCs, thus giving a falsely decreased count. Some Sysmex hematology analyzers use impedance and optical counts and also feature fluorescent platelet counts which use a platelet specific dye and give accurate platelet counts without the interferences of other methods. A normal platelet count, even with clumping seen on a smear, is still usually estimated to be normal (or may occasionally be increased.)

Thrombocytopenia, on the other hand, can be a challenge in the hematology laboratory. With thrombocytopenia, physicians need an accurate count to diagnose, treat or monitor patients. Even a small increase or decrease can be significant when there is a severe thrombocytopenia. With fewer platelets, every platelet counts!

One of the first questions we must ask with an apparent thrombocytopenia is if this is a true thrombocytopenia or if it is pseudothrombocytopenia (PTCP). A true thrombocytopenia represents a patient with a low platelet count who may need monitoring or medical intervention. It can be dangerous to miss true thrombocytopenia but is also dangerous to report a low platelet count in a patient with a spurious thrombocytopenia who is not actually thrombocytopenic. Pseudothrombocytopenia, or spurious thrombocytopenia, is defined as an artificially or erroneously low platelet count. In PTCP, the low platelet count is due to clumps that are counted as 1 platelet. (These large clumps can also be counted as WBCs, thus giving a falsely increased WBC count.)

We can divide PTCP into 2 categories Platelet clumping is most commonly caused by pre-analytic errors such as over-filled or under-filled EDTA tubes, clotted specimens, or a time delay between sample collection and testing. Techs should check the tube for clots and sample volume and do a delta check to help differentiate thrombocytopenia and PTCP. But, with an apparent ‘good’ sample, the next step would be a smear review. If there are clumps seen on the smear, then we need to decide what caused the clumps. Is it the first category, one of these common pre-analytical issues, or is it the 2nd category of PTCP, an in vitro agglutination of platelets? Conditions that can cause this in vitro agglutination of platelets include cold agglutinins, multiple myeloma, infections, anticardiolipin antibodies, high immunoglobulin levels, abciximab therapy and EDTA induced pseudothrombocytopenia. (EDTA-PTCP) Of these, EDTA induced pseudothrombocytopenia is the most common cause. (Nakashima, 2016).

When techs talk about platelet clump issues, it is usually because we are looking for ways to resolve or to accurately estimate the platelet count in these samples, and there doesn’t seem to be one easy answer. The clumping makes precise counting impossible and even estimates can be very tricky. How can we estimate these counts? Do we simply report the presence of clumping with “appear normal”, “decreased” or “increased”? Or, should we break our estimates into more ranges to give physicians more valuable information? And, what if the provider wants an actual count in order to give the patient the best care possible and we can’t resolve the clumping? What can we do to provide a count? Some of the first steps recommended include vortexing the sample for 2 minutes to break up platelet clumps, then re-analyzing. Warming samples may also help to resolve platelet clumps, particularly in samples with cold agglutinins or that have had a delay in testing and have been transported or stored at room temperature or below. If clumps persist and recollecting the sample still yields platelet clumping, then pre-analytical error can be ruled out an EDTA induced pseudothrombocytopenia may be suspected. Many labs will have an alternate tube drawn or use another method to help resolve the clumping.

So, what is EDTA induced thrombocytopenia (EDTA-PTCP)? This is not representative of a particular clinical picture, and is not diagnostic for any disorder or drug therapy, but is a laboratory phenomenon due to presence of EDTA dependent IgM/IgG autoantibodies. These antibodies bind to platelet membrane glycoproteins in presence of EDTA. EDTA induces and enhances this binding by exposing these glycoproteins to the antibodies. (Geok Chin Tan, 2016) Though it is an in vitro phenomenon, patients with certain conditions, such as malignant neoplasms, chronic liver disease, infection, pregnancy, and autoimmune diseases, do have increased risk of EDTA-PTCP. However, EDTA-PTCP has also been observed in patients who are disease free. (Zhang, 2018)

What are some alternate methods to help resolve EDTA induced platelet clumping challenges? Probably the most common is to redraw the sample in a Na Citrate tube. Both EDTA and Na Citrate tubes should be drawn. In a true EDTA-PTCP, as seen in our case study, you should see clumps on the smear made from the EDTA tube and no clumps on the smear made from the Na Citrate tube. Because of the volume of the anticoagulant in the Na Citrate tube you must also apply the dilution factor of 1.1 to the count from the Na Citrate tube to get an accurate platelet count. Note, however, that hematology analyzers are FDA approved and validated for use with EDTA tubes. If you wish to use a different anticoagulant, the method must be validated in your laboratory. Note also that alternate methods will generally only resolve EDTA -PTCP, and not clumping due to other cold agglutinins, medication or disorders. In addition, anticoagulant induced thrombocytopenia is not limited to EDTA. It can also occur with citrate and heparin. In a study, it was found that up to 17% of patients with an EDTA -PTCP also exhibited this phenomenon with citrate. In fact, researchers have found, and we have found in our own validations, that some samples that do not clump in EDTA actually DO clump in Na Citrate. Thus, alternate tubes may not resolve all platelet clumping. (Geok Chin Tan, 2016)

Some labs have validated ACD (Citric acid, trisodium citrate, dextrose) anticoagulant tubes for EDTA-PTCP. Using this method, the EDTA tube and ACD must be run in parallel and a conversion factor applied, reflecting the difference in sample dilution in the 2 tubes. A parameter such as the RBC must be chosen to make this comparison. Using a formula that divides the RBC in EDTA by the RBC in ACD gives a ratio that reflects the dilutional differences between anticoagulants. This ratio can then be multiplied by the ACD platelet count to obtain the ACD corrected platelet count. (CAP Today, 2014). Some sources have recommended ACD tubes because the incidence of clumping with Na Citrate can be frustratingly high. It is theorized that the more acidic ACD tube may prevent platelet clumping better than Na Citrate. (Manthorpe, 1981)

Less commonly used tubes are CTAD (trisodium citrate, theophylline, adenosine, dipyridamole) and heparin. CTAD acts directly on platelets and inhibits platelet factor 4 thus minimizing platelet activation. Downsides to CTAD tubes are that they are light sensitive and must be stored in the dark, and can be costly. They also alter the blood/additive dilution ratio so calculations must be used, as seen with Na Citrate and ACD. Heparin tubes are less commonly found to be beneficial in resolving platelet clumping issues because heparin can active platelets. Heparin tubes are also more expensive, so have not generally been a first choice for EDTA-PTCP.

I have heard from techs that their labs have very good results using amikacin added to EDTA tubes to prevent spuriously low platelet counts in patients with EDTA-PTCP. Amikacin should be added to the EDTA tube within 1 hour after draw and testing is stable for up to 4 hours at room temperature. Results of a study done in 2011 showed that the addition of amikacin to the EDTA tube produced rapid dissociation of the platelet clumps with little or no effect on morphology or indicies. This method has proved very promising for reporting accurate platelet counts in patients with multianticoagulant induced PTCP. (Zhou, 2011)

The last anticoagulant tube that I have seen mentioned by many techs in the hematology interest group are Sarstedt ThromboExact tubes. I have seen many posts from techs who use these and they seem to have a very good success rate. ThromboExact tubes contain magnesium salts and are specifically designed to determine platelet counts in cases of PTCP. They are currently validated only for platelet counts and samples are stable for 12 hours after collection. Interestingly, before automated hematology analyzers, magnesium was the anticoagulant of choice for manual platelet counts. EDTA-PTCP has been recognized since EDTA automated platelet counts were introduce in the 1970s. A 2013 study in Germany used ThromboExact tubes with excellent results for resolving multianticoagulant induced PTCP. These tubes became commercially available during the study, in 2013. (Schuff-Werner, 2013) Unfortunately for us in the United States, these tubes are not available in the US. I was recently at a conference and went up to the Sarstedt representatives and asked about these tubes. I was told that they are available in parts of Europe and Asia but are not FDA approved in the US. I asked very hopefully if they were looking at getting FDA approval and was unfortunately told that “they didn’t think they had the market for them to pursue approval.”

Whichever alternative method your lab chooses to use, it is recommended to draw an EDTA and the alternate tube together. This way the 2 counts and the presence or absence of clumping in the tubes can be compared. We have many patients who had one incidence of clumping, yet when the provider orders a Na Citrate platelet count, we get a new draw of both EDTA and Na Citrate tubes together, and there is no flagging or clumping seen with EDTA. In these cases it is appropriate to result the EDTA results as there is no evidence of EDTA-PTCP.

When a patient has a low PLT count without any hematologic disease, family history, and/or bleeding-tendency identified, and pre-analytical errors have been ruled out, PTCP should be considered. This does not mean that a patient with PTCP will have a normal platelet count after the clumping is resolved. As stated above, many patients with EDTA-PTCP have hematological or other disorders and may be truly thrombocytopenic. Resolving the clumping in these patients allows us to give the provider an accurate platelet count, which is very important in thrombocytopenic patients.

The flow chart below (Figure 4) shows some things to consider when dealing with platelet clumping. It is our goal to resolve clumping so that we can report an accurate platelet count in a timely fashion. In the laboratory where I work, I have validated Na citrate tubes, but these seem to resolve clumping in less than 50% of patients. As a last resort, to get an accurate platelet count, some articles have suggested collecting a fingerstick and performing manual counts. I did include this in the chart as an option for multianticoagulant PTCP, however, due to the difficulty in collecting a good specimen and the subjectivity of counts, along with problems associated with necessary calculations, our pathologists have decided that we will not do manual platelet counts. For this reason, I am currently involved in platelet clumping monitoring and will be conducting a small internal study to compare ACD, CTAD and Na Citrate tubes in parallel. Depending on those results we may also then test amikacin. If we come to any enlightened conclusions I’ll write another short blog with our results!

Thanks again to Abu Jad Caesar, lab manager at Medicare Laboratories – Tulkarm branch, in Palestine, who provided me with this textbook perfect case of PCTP, which was easily resolved by collecting in Na Citrate. We wish they all read the textbooks and were as cooperative!

Figure 2. Flowchart for resolving and reporting of thrombocytopenia.

References

  1. CAP Today, January 2014. accessed online http://www.captodayonline/qa-column-0114
  2. Manthorpe R, Kofod B, et al. Pseudothrombocytopenia, In vitro studies on the underlying mechanisms. Scand J Haematol 1981; 26:385-92
  3. Nakashima MO, Kottke-Marchant K. Platelet Testing: In: Kottke-Marhchant K, ed. An Algorithmic Approach to Hemostasis Testing, 2nd ed. CAP Press; 2016:101
  4. Schuff-Werner,Peter, et al. Effective estimation of correct platelet counts in pseudothrombocytopenia using an alternative anticoagulant based on magnesium salt. Brit J of Haematol Vol 162, Issue 5. June 29, 2013
  5. Tan, Geok Chin et al. Pseudothrombocytopenia due to platelet clumping: A Case Report and Brief Review of the Literature. Case Reports in Hematology. Volume 2016
  6. Lixia Zhang, MMed,* Jian Xu, MD,* Li Gao, MMed, Shiyang Pan, MD, PhD. Spurious Thrombocytopenia in Automated Platelet Count. Laboratory Medicine 49:2:130-133. 2018
  7. Zhou,Xiamian, et al. Amikacin can be added to blood to reduce the fall in platelet count. Am Journal of Clinical pathology, Vol 136, Issue 4, Oct 2011.

-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.

A Med Tech Gives a TEDx Talk

Hello again everyone!

After a lot of positive responses and sharing on social media, my article last month got lots of people talking about annual meetings and how great they are for networking, learning, and advancing our profession. Not too long after the ASCP Annual Meeting in Phoenix, I was back in my Manhattan apartment working on my speech and graphics for a real life TEDx session hosted at my medical school.

Let’s pause here: if you either haven’t heard of the TED/TEDx brand or if you binge watch their 18 minute videos and want more links to watch now, now, now!

TED is a non-profit organization whose mission is to share “ideas worth spreading.” They’re about 35 years old and based in NYC stateside, and Vancouver in Canada. Basically, over the last few decades they hold conferences at those flagship sites called “TED talks” where selected speakers present on a myriad of topics. TEDx conferences are officially licensed but off-site events which operate under TED protocol and guidelines. There have even been spin-off conferences like TED MED, which focus solely on healthcare.

Image 1. What’s a TEDx talk? Basically, an off-site, officially sanctioned, “idea sharing” conference.

Some of the students at AUC School of Medicine, organized such a conference with official TED licensing and recruited me to join their list of speakers to deliver talks on their chosen theme: resilience. Officially called TEDxAUCMed, this conference included community members, students, artists, activists, and more discussing the human capacity for resilience in ways not commonly discussed. “Weathering the Storm” was the official event title, as the school located in the island nation of St. Maarten displays daily resilience especially since being hit by Hurricane Irma in 2016. Among their list of incredible speakers, I was humbled to be included! I titled my talk “Unrecognizable Medicine” and wanted to deliver a talk to students, clinicians, and those of us in medicine witnessing first-hand a tidal wave of new technologies and paradigms that redefine the way we discuss health. Oh, and since I’m a huge fan of #GraphicMedicine more and more each day, I hit that hashtag hard and decided to illustrate my whole talk!

Image 2. Title Card from my TEDx talk.

So what did I talk about, exactly…and what’s the big deal? I’m not going to re-hash my presentation for you in text—that’d be boring, and I’m obviously going to put a link at the bottom for you to watch it yourself. I got you, lab fam! But essentially, what I set up was a three-tiered template to assess and navigate that tidal wave of tech. Tools, skills, and strengths—three things inherent to the practice of medicine in any specialty.

Image 3. Red back-ligting. So intense. Thanks for coming to my TEDx Talk, literally!

There are untapped topics in medicine which are looming over the horizon. As medicine continues to evolve and change, the problems we face and the needs we must meet will become moving targets. New specialties will emerge, and new technologies will replace centuries old tools we cling to today. A shift in thinking is both proactive and healthy in a profession that mandates our commitment to preserving health and quality of life. I have spent years battling stereotypes in medicine and hope to challenge the fabric that places individuals in professional or academic boxes. Fresh first-years at some schools are already using point-of-care ultrasounds (POCUSes) instead of stethoscopes—which student sounds like they have better info on morning rounds, a student who maybe kinda-sorta heard some non-descript murmur, or a mini-pocket echocardiogram with an ejection fraction of 45%? Stereotypes have too long shaped the way students choose specialties, equating some areas to colloquial high school cliques! No offense to orthopedics or dermatology. Troponins used to be something you could hang your white coat on, but not anymore. What do you do with a new 5th generation Trop of 39 with a delta of 18? ACS or acute MI? Cancer therapy is exploding with personalized treatments being added every day! Any student right now would impress their heme/onc attending on rounds if they suggested PDL-1 and other immunotherapy testing for patients with newly diagnosed lung cancers. *Deep breath*

Ok. My point is, tomorrow’s medicine is going to have a lot of different therapies, tools, and even vocabulary that schools may never catch up with. How do you prepare for this explosion of knowledge? You look to yourself to take an inventory of your strengths and use those to guide your clinical sails. Addressing stereotypes head-on, learning on the spot, dealing with complex identities in your patients, and always practicing with compassion will lend itself to staying ahead and staying fulfilled.

Image 4. If you’re drawing cartoons of pathologists for an educational series, you probably make them look like you. Or in this case me, I guess. Keep an eye out for my #PathDoodles on social media!

Pretty heavy stuff right? But there’s something else that caught my attention in reflection on the TEDx talk… I’ve searched the TED library of videos, and while there are plenty of doctors, scientists, and pioneers in research discussing medical ideas, I haven’t seen any medical laboratory scientists. If you find any, please correct me. But, as I understand it, it’s just me. And that’s something special.

Image 5. My wife and I check-in for rehearsal at the TEDxAUCMed conference in sunny St. Maarten.

There’s a culture shift in our profession, and a lot of us are talking about it. Pathology and laboratory medicine are stepping out from behind the healthcare curtain and asserting itself as a champion for patients, truth, and the importance of data-driven medicine. Not only do I talk to groups of folks every time I get a stage, but I use social media to reach clinicians and patients! Yes, I’m one of few medical students-turned-residency applicants who didn’t change their name to hide their online presence for the winter. But instead of a secret twitter hibernation, I’ve used social media as a tool to network, engage, and connect.

One of my favorite new projects is something I call #PathDoodles where I break down the aspects of pathology and some specialty topics for those outside of medicine (and sometimes just outside our profession). I’ve already covered things like “what is pathology?” and the importance of autopsies, the role of medical laboratory scientists, and I continue to add more regularly!

Image 6. One of a growing list of #PathDoodles.

There’s a culture shift in our profession, and a lot of us are talking about it. Pathology and laboratory medicine are stepping out from behind the healthcare curtain and asserting itself as a champion for patients, truth, and the importance of data-driven medicine. Not only do I talk to groups of folks every time I get a stage, but I use social media to reach clinicians and patients! Yes, I’m one of few medical students-turned-residency applicants who didn’t change their name to hide their online presence for the winter. But instead of a secret twitter hibernation, I’ve used social media as a tool to network, engage, and connect.

One of my favorite new projects is something I call #PathDoodles where I break down the aspects of pathology and some specialty topics for those outside of medicine (and sometimes just outside our profession). I’ve already covered things like “what is pathology?” and the importance of autopsies, the role of medical laboratory scientists, and I continue to add more regularly!

Follow me on Twitter (@CEKanakisMD) and check out my TEDx talk:

My talk begins at 5:00:00. Enjoy!

Constantine E. Kanakis MD, MSc, MLS (ASCP)CM completed his BS at Loyola University Chicago and his MS at Rush University. He writes about experiences through medical school through the lens of a medical lab scientist with interests in hematopathology, molecular, bioethics, transfusion medicine, and graphic medicine. He is currently a 2020 AP/CP Residency Applicant and actively involved in public health and education, advocating for visibility and advancement of pathology and lab medicine. Follow him on Twitter @CEKanakisMD

Hemoglobin Electorphoresis in Children

This last month, I rotated through our Children’s hospital, which included reviewing hemoglobin electrophoresis tests. I’d learned about them before in residency, but they can be quite more interesting (complicated) than I expected.

Hemoglobin electrophoresis is a blood test to look at different types of hemoglobin to determine if there are any abnormalities. In a children’s hospital it is frequently ordered as a reflex for an abnormal newborn screen or when a child is incidentally found to be anemic. The test is performed in 2 stages. 1st lysed blood samples are run on gel electrophoresis and different types of hemoglobin are separated as they move at different speeds. Several types of hemoglobin will run within the same region, so a secondary method of separation is always employed.

Below, you can see how some bands in the same area of an acidic gel (agarose) are actually very different on the alkaline gel (cellulose acetate) and vice versa.

At our hospital, we use HPLC and measure retention times of the hemolysate to quantify and identify different hemoglobin types present. As a basic primer you should recall that hemoglobin is a tetramer with a pair of alpha globin + a pair of either beta, delta or gamma globin (each separate genes).

Alternative hemoglobins are enriched in populations where malaria is endemic as these variants may provide improved fitness by promoting resistance to the malarial parasite that reproduces inside red blood cells. Thus, many people of African or south east Asian descent may carry these variants.

Our case is that of a 2 year old girl with anemia who had testing sent by her primary care doctor for the following CBC:

This is indicative of microcytic anemia, but unlike some Thalessemias the RBC isn’t very high. More on this later.

Looking at the gel result, there is a large band in the area coinciding with Hgb C. We also see the normal Hgb A2 and a small amount of Hgb F. We know Hgb F can be increased in Hgb SS and thus could also be present if she had Hgb C trait or disease.

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Looking at the next HPLC result, we see there is a similar very high level of Hgb C (68%) with corresponding levels of Hgb F and Hgb A2 (note: acetylated Hgb F and Hgb F are added together). Thus, this fits with a homozygous C with some compensatory A1 and F, right?

Remember Hgb C is a β -globin variant and you only have 2 β -globin genes, so if you are homozygous for the C variant on the β-globin gene (HBB), then Hgb A1, which is made of normal β-globin would be impossible to produce. Also you might be bothered by all of these small peaks. However, there are often small peaks that can’t be definitively identified and are likely post-translationally modified hemoglobin. But in the context of an abnormal Hgb A1 that shouldn’t be there, we dug deeper.

One of the most common hemoglobinopathies is Beta Thalassemia (β-Thal), which clinically manifests when less of the beta hemoglobin protein is produced. Heterozygous mutations lead to Beta Thalassemia minor with minimal symptoms, while homozygous mutations lead to β-thal major with symptoms of anemia. Mutations in the β -globin gene, HBB, can lead to complete loss of β-globin (β0 variant) or partial of β-globin (β+ variant).

As this patient has less than 50% of Hgb A present (expected amount), they could also have a β+ variant as well. This would make them compound heterozygous for C and β+.

One of the hallmarks of Thalassemia is an increase in Hgb A2 (normal 2.5-3.5%). Hemoglobin A2 is a normal variant of A that is composed of two alpha and two delta chains (δ2α2). We see in our case that the Hgb A2 is normal at 2.5%. So it seems the patient doesn’t display a typical Thalassemia picture.

One condition that could create this scenario is if there is a variant in the delta chain of A2 that causes it to elute differently. Indeed, there is a delta variant that creates hemoglobin A2 prime (A2’) that moves near the S region of the HPLC. And when we look back at our unknown hemoglobins, Hgb X is marked at 1.03 of the S region and has an abundance of 3.9%. This supports it being the Hgb A2’ and if we add this together with the Hgb A2 we get an elevated 6.6% A2 total, which would be consistent with Beta Thalassemia. Lastly, one would wonder if we could find this third hemoglobin variant A2’ on the alkaline gel. Previous studies have shown the A2’ variant is more negatively charged, so on a basic gel, it should move further from the negative anode than the other hemoglobins. We don’t see anything to the left of the HgbC, but if we flip the gel over and look under the patient label, you can see a faint band that is likely the A2’!

In summary this case arose from 3 separate mutations in a single patient. She was compound heterozygous for a Hgb C and β+ variants in the β-globin gene and she was heterozygous for an A2’ variant on the delta-globin gene.  This was certainly a case where paying close attention mattered.

References:

  1. Abdel-Gadir D, Phelan L, and Bain BJ. Haemoglobin A2′ and its significance in beta thalassaemia diagnosis. Int J Lab Hematol. 2009 Jun;31(3):315-9. doi: 10.1111/j.1751-553X.2008.01038.x. Epub 2008 Feb 21.
  2. https://ghr.nlm.nih.gov/condition/beta-thalassemia

-Dr. Charles Timmons MD PhD is a pediatric pathologist at Children’s Medical Center in Dallas, TX. His responsibilities include signing out hemoglobin electrophoresis, HPLC and globin sequencing, and has been residency director for 17 years.

-Jeff SoRelle, MD is a Chief Resident of Pathology at the University of Texas Southwestern Medical Center in Dallas, TX. His clinical research interests include understanding how the lab intersects with transgender healthcare and improving genetic variant interpretation.

Fighting Fire with Fire

In 1939, the first issue of Marvel Comics introduced the original Human Torch, an android named Jim Hammond who would burst into flames when exposed to oxygen. Fourteen years before that, President Calvin Coolidge proclaimed the first National Fire Prevention Week to commemorate the Chicago fire of 1871 which killed over 300 people 54 years earlier. In that entire span of 68 years, from 1871 to 1939, over 17,000 people died in fires in the United States. Because of fire awareness campaigns over the years, the number of home and work place deaths have greatly decreased, and the risk of fire in your lab goes down when fire safety awareness increases as well.

In the laboratory, fire safety begins with a look at the physical environment. It is important to make sure the department is set up to prevent a fire from starting and to keep one from spreading if a fire ignites. The electrical wiring in the lab plays a large part in fire safety. Frayed cords are the number one cause of laboratory fires, and daisy-chained extension cords or multi-plug adaptors are fire hazards as well. Damaged outlets can also present danger. Because equipment may move often in the environment, it is a good idea to check for safety in the lab electrical set up regularly. In audits I have performed this year alone, I have discovered three damaged electrical cords just waiting to cause a fire. Things change rapidly in the lab physical environment, so looking for these potential safety issues is vital.

The next aspect of the lab physical layout that needs attention is flammable chemical storage. There are complicated regulations about that, and multiple classes of flammable liquids, but you can simplify storage rules to make it easy to understand. In general, there should be no more than one gallon of a flammable liquid out in the lab per every 100 square feet. If there are automatic sprinklers in the department, that amount can go up to two gallons. If safety cans are used, the amount can be doubled again. Any excess volume of flammable liquids should be stored inside of a flammable safety cabinet with self-closing doors. Remember, the point of these storage limits is so that if a fire occurs, there is not a large amount of flammable material in one location. That slows the spread of the fire and allows automatic fire extinguishing systems to be able to perform their job effectively.

Fire-fighting equipment should be available as well, and staff are required to have training to use that equipment if it is available in the department. The best training includes a regular hands-on return demonstration and periodic fire drills. Making sure staff can use fire extinguishers and know how to respond to a fire situation may be the one of the most important safety training policies you can implement. Fire blankets are typically not required per local fire code, but if they are in place, be sure staff is aware of how to use them should the need arise.

The last actions in a departmental fire situation include evacuating and preventing the spread of the fire. To that end, it is important to keep aisles clear and wide for safe travel, and all exit routes and stairwells should be checked to make sure no obstructions exist. Staff should be aware of their primary and secondary evacuation routes, and all exits should be adequately marked. Make sure employees know to close fire and smoke doors during a fire situation.

Even in modern times there are structure fires in the work place, and unfortunately, laboratories are not excluded from that list. The Human Torch could catch fire and not get burned, but we all know that is science fiction, and burns from a fire are no joke. The best practice is to be prepared for a fire-provide training, conduct physical environment rounds, and run drills often. That will protect your staff and make you a true safety super hero.

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.

Making Meetings Matter

Hello again everyone!

I’m writing to you now back in Manhattan after visiting sunny Phoenix, AZ for this year’s ASCP Annual Meeting. Last month I talked about downtime, pathology emergencies, and introduced you all to our insightful and dynamic colleague, Jalissa Hall. It was great working with her and one of the last things we talked about was getting to go to professional society meetings. We also talked about the upcoming meeting next year in Austin, TX! And that’s exactly what I’d like to talk about with you this time: why going to meetings like ASCP is not only educational, but an excellent way to network with your laboratorian peers from around the country.

Image 1a. My wife and I made it to the Phoenix Hyatt Regency on registration day! ASCP swag on, obviously.
Image 1b. Behind the Scenes – Hosting the ASCP 2019 Facebook Live broadcast with two fantastic colleagues, Dr. K. Mirza and Dr. A. Booth! Did you catch us? But more about social media later…

I couldn’t go to every single session—there’s just too many—but I did learn so much valuable, practical information at the educational sessions. Here are just a mere few insights from the long list of fantastic speakers I had the chance to visit!

I participated in an interactive session on the ASCP/CAP/ASH guidelines for lymphoma workup…

Figure 1. All the multidisciplinary expertise must go through rigorous adjustment and evaluation all the way throughout the process of seeking out and publishing proper guidelines. (Source: ASCP 2019 session 5007-19; Kroft, S., Sever, C., and Cheung, M.)

Drs. Kroft, Sever, and Cheung discussed updates from the WHO 2016 guidelines as well as relating any changes in concurrent literature to appropriate diagnostic accuracy with evidence-based guidelines. If it sounds familiar, it’s because I talked about these guidelines a few months ago! In my month clerkship at The Mayo Clinic in Rochester, MN I presented a therapy-related AML case in the setting of Li-Fraumeni disorder. In my discussion I stressed the utility and importance of having organized and algorithmic guidelines to diagnose patients accurately, effectively, and timely. This time, instead of just talking about the guidelines, I got to listen to some of the folks who actually put them together—and, according to them, it’s no easy task!

I learned about culturally appropriate leadership training…

Figure 2. The panelists each had something insightful and moving to contribute to this wonderful discussion on female empowerment in our profession, and ultimately how it relates to improving patient care! (Source: ASCP 2019 session 8012-19; Mulder, L., Upton, M., Vuhahula, E., Abedl AlThagafi, M., Papas, F., and Sanford, K.)

This year’s ASCP president, Dr. Melissa Upton moderated this fantastic panel and opened with an old proverb: “If you want to go fast, go alone. If you want to go far, go together.” This was definitely a theme for each of the mini-sessions’ discussions. ASCP’s own Lotte Mulder discussed her research on culturally applicable leadership training using her Leadership Institute Initiative. She talked about countries that are culturally different and developmentally different up and down the spectrum can all benefit from leadership development and opportunity. Next came Dr. Edda Vuhahula, an accomplished physician, educator, and advocate in Tanzania. She related her experiences of women in leadership roles, and challenges on the horizon as more women rise to these positions every day. Dr. Malak Abed AlThagafi talked about her “hats:” as an entrepreneur, a medical director, and a researcher in her whirlwind story of empowerment and accomplishment. Finally, medical laboratory scientist and former Philippine Army colonel, Filipinas Papas gave her personal perspectives on sexism, education, bias, and opportunity.

Celebrated my colleagues and my contributions to the 6th Choosing Wisely list of recommendations…

Figure 3. My totally biased favorite slide from Dr. Lee H. Hilbourne, chair of the ASCP Effective Test Utilization Steering Committee. It’s an honor to be included in this year’s list, alongside so many accomplished contributors.

The Choosing Wisely initiative, partnering with the American Board of Internal Medicine and many other specialty organizations, is one of my favorite programs at ASCP. To date, our lab medicine organization has the highest number of effective test utilization recommendations. ASCP seeks active contributions to our expanding lists of recommendations to eliminate wasteful, unnecessary testing and to improve patient outcomes. This talk was also a great opportunity to honor the ASCP 2019 Choosing Wisely Champions: Dr. Gary W. Procop from the Cleveland Clinic, Dr. Lucy Nam from the Inova Lab best practice team, and Dr. Alyssa Ziman from UCLA Health. Want to read the most updated list of recommendations ASCP made to the Choosing Wisely initiative?

Check it out here: https://www.ascp.org/content/docs/default-source/get-involved-pdfs/istp_choosingwisely/2019_ascp-30-things-list.pdf

I watched some cutting-edge exchanges about cellular therapy…

Image 2. Here I am with laboratorian S. Malakian and Dr. Gastineau with The Mayo Clinic after they discussed the future of complex cell therapies.

One really effective take-home message from this seminar was that, if we’re going to rely on cellular therapy in the future—especially as it relates to “individualized medicine”—then who do you think should be in charge? Who’s got the most experience and knowledge when it comes to cell storage, transfusion protocol, patient outcomes, and high reliability? Short answer: it’s us. Long answer: go back and check out a piece I wrote about high-stakes responsibility in and out of the lab!

Popped into fascinating hematologic cases at our neighboring SHEAHP2019 meeting…

Listen, I like hematopathology, I’ll be the first to tell you that. There were so many people giving presentations in this near standing-room-only meeting, that I recognized from papers, abstracts, and journals that I’ve read in the past year alone! There were so many interesting sessions at this meeting, I wish I could have seen more…

Image 3. Here’s Dr. J. Dalland from Mayo Clinic Pathology discussing a lymphoproliferative disorder with associated eosinophilia. These talks go deep into morphology and photypic patterns, so that Hemepath colleagues have a chance to assess their workup and protocols. It’s also great learning for avoiding pitfalls—this case shows architectural changes in lymph nodes which could cause someone to misdiagnose!

Learned how to create an impactful dialogue with patients directly…

What do you do as a pathologist when a patient wants to speak to you? Yes, you. Not a typo! This was the last talk I went to and it was a great way to close out this awesome conference.

Image 4. Me with (left to right) Dr. K. Sanford from VCU, Patient Champion Anthony Reed, Dr. M. Sitorius from the University of Nebraska, and M. Mitchell. All of these individuals had amazing things to say about bridging the gap between the bench and the bedside!

In their own ways these patient advocates demonstrated that if you want to represent our lab profession as one of accuracy, answers, and hope, we’ve got the skills and resources to do it! Dr. Sanford sees so many patients in her transfusion services and discusses their care plans regularly. Mr. Reed is an ASCP patient champion who, after being diagnosed with ESRD, became a learned lab ally. Dr. Sitorius is a family medicine physician at a pathology conference, talking about empathy and connection! Ms. Mitchell has done fantastic work with her pathology colleagues after beating cancer and fighting for patient education every day! These folks have taken our field of laboratory medicine to its outer edges, touching patients’ lives directly—and I left energized to take it further in the future.

And of course, I learned so much about the utilization of social media as a practical tool for education, advocacy, and outreach…

I can’t list every single session, lecture, keynote, presentation, or panel in this article. This was just a glimpse of what meetings like this have to offer. You will learn, obviously, but you’ll also gain access to new perspectives and meet people who reinvigorate your passion for your profession in ways you didn’t even consider. One of the most fulfilling experiences of this meeting was being on the ASCP Social Media Team! Posting to Instagram, Facebook, and Twitter with the hashtags #ASCP2019, #ASCPSoMeTeam, or the scavenger hunt #ASCPiSpy was a great way to bolster our enthusiastic network. This was my third ASCP Annual Meeting, and I met so many wonderful people I can’t wait for the next one! Here’s a few of my favorite snaps from the meeting:

Image 5. Here’s part of our amazing #SocialMediaTeam: (left to right) A. Odegard from Baptist Health, myself, Dr. S. Mukhopadhyay from the Cleveland Clinic, Dr. A. Booth from the University of Texas, and Dr. K. Mirza from Loyola Chicago!
Image 6. At my first ASCP meeting in California, Jeff Jacobs, ASCP’s Chief Science Officer, gave me some of the best advice for my own personal and professional growth, “Stay Humble” he told me. Nearly 5 years later, he added “Don’t Give Up” on goals, yourself, or anything in life. You can’t pick that up in a path review book. I feel lucky to know people like him.
Image 7. #SoMe FTW (Social Media for the win!) At this great talk, Dr. C. Arnold, Dr. L. Shirley, and Dr. D. Gray III, all from the Ohio State University discussed how to use social media to build a reputation and expand your impact as a pathologist, educator, and advocate!
Image 8: Conferences are a great time to run into old friends and colleagues whom you may have spent a month rotating with! If you read about my time at Danbury Hospital in Connecticut, Drs. O. Olayinka and G. Kuar were part of it and I’m glad to call them friends!
Image 9: Presented by the ASCP Resident and Pathologist Councils, this was a great networking session to discuss fellowships, employment, and how to plan for the first 100 days of working in laboratory medicine from PGY-1 and on! I certainly learned a lot!
Image 10: (left to right) Dr. K. Chaztopoulos from the Mayo Clinic, myself, and K.C. Booth, RN in front of his finalist poster in the scientific category! Another valuable professional connection and friend made through my experiences in laboratory medicine.
Image 11. When one of your mentors (Dr. K. Mirza) is signing copies of The Pathologist magazine that featured him on the cover, you get in line for one …obviously.
Image 12. Dr. M. Upton is an inspirational speaker and insightful individual both on stage and in person. She had words of encouragement for my upcoming residency interview season and made sure I felt I could rely on ASCP for whatever I needed professionally. Thank you, Dr. Upton!
Image 13. Some more colleagues from Mayo Clinic Pathology (left to right): Dr. A. Ravindran, Dr. D. Larson, Dr. J. Dalland, and myself. These folks were very busy with all the great hematology sessions at the SHEAHP2019 meeting.
Image 14: No ASCP Annual Meeting would be complete without the leadership, passion, and vision of our CEO Dr. Blair Holladay. He, his leadership team, and this organization have been integral in my path to pathology and I can’t wait to see what’s in store for the future!

Social media has become so valuable in our field. Not just for networking, but sharing cases, impressions, publications, and more! It’s so easy to rally behind a hashtag and support a cause in so many instances—why not in our profession? Get involved, be an active voice for your own practice as well as your colleagues.

If you want to learn more about the sessions you may have missed, download the ASCP2019 app from the Apple App Store or Google App Store!

Thanks for reading! See you on social media, because when we communicate and collaborate, we are #StrongerTogether! I’m on twitter at @CKanakis, until next time!

–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.