Pathologist On Call: Fluctuating Parathyroid Hormone with Normal Calcium in an Elderly Man

Case:

A 75 year old Alzheimer’s dementia patient.  Parathyroid hormone (PTH) levels were ordered.

Analyte

(Reference

Range)

05/13 10/13 12/13 7/14 10/14 04/15 09/15 03/16 07/16
PTH

(10-65 pg/mL)

869 42 864 47 1180 48
Ca2+

(8.8-10.2 mg/mL)

10.3 10.5 10 10 9.6 10
Vit D

(2-100 ng/mL)

26 21 39 49 39 57 19

 

Why order PTH? 

PTH is ordered to assess for hyperparathyroidism.  There are two forms of hyperparathyroidism: primary and secondary.  Primary hyperparathyroidism can be caused by a parathyroid (PT) adenoma,  PT hyperplasia, or a non-PT malignancy such as squamous cell cancer or multiple myeloma.  Secondary hyperparathyroidism occurs in response to hypocalcemia which can arise from insufficient intake of vitamin D or chronic renal failure (which results in insufficient vitamin D).   There is weak evidence suggesting a positive correlation between PTH and cognitive decline.(1, 2)  Progression of cognitive decline is slowed when PTH and vit D levels are normalized.

Action of PTH: PTH is a peptide hormone that controls calcium levels in the blood. It is secreted as a prohormone and is cleaved in the blood.  The 34 residue N-terminal fragment is active and has a half-life of about 5 minutes.  The C-terminal end has a half-life or 2 hours and is diagnostically insignificant because it is physiologically inactive.  PTH activates receptors on osteoclasts which causes them to release bone calcium.  PTH also increases renal synthesis of 1,25 OH2 vitamin D which, in turn, increases intestinal absorption of calcium.

What would make the PTH level fluctuate so much?

This is most likely a case of incipient normocalcemic primary hyperparathyroidism (NPH).(3-5)  PTH levels are higher than normal but calcium levels are normal.  PTH levels tend to fluctuate. Calcium can also be sometimes elevated as well.   The disease is thought to be a mild or early form of hyperparathyroidism and 20 percent of patients go on to develop worsening hyperparathyroidism. How should NPH be managed?  Parathyroidectomy or monitoring are the primary alternatives; however, the best way to manage this disease is unknown.

 

References

  1. Lourida I, Thompson-Coon J, Dickens CM, et al. Parathyroid hormone, cognitive function and dementia: A systematic review. PLoS ONE 2015;10.
  1. Björkman MP, Sorva AJ, Tilvis RS. Does elevated parathyroid hormone concentration predict cognitive decline in older people? Aging Clinical and Experimental Research 2010;22:164-9.
  1. Shlapack MA, Rizvi AA. Normocalcemic primary hyperparathyroidism-characteristics and clinical significance of an emerging entity. Am J Med Sci 2012;343:163-6.
  1. Lowe H, McMahon DJ, Rubin MR, Bilezikian JP, Silverberg SJ. Normocalcemic primary hyperparathyroidism: Further characterization of a new clinical phenotype. Journal of Clinical Endocrinology and Metabolism 2007;92:3001-5.
  1. Crowley RK, Gittoes NJ. Elevated PTH with normal serum calcium level: A structured approach. Clinical Endocrinology 2016;84:809-13.

 

Schmidt-small

-Robert Schmidt, MD, PhD, MBA, MS is currently an Associate Professor at the University of Utah where he is Medical Director of the clinical laboratory at the Huntsman Cancer Institute and Director of the Center for Effective Medical Testing at ARUP Laboratories.

 

 

Forty Things Every Lab Professional Should know

Hello again everyone! Every few posts on Lablogatory I like to take a small departure from updates about my medical school experience and my Zika public health initiative. This time is more of a shameless plug: I am thrilled and honored to be considered one of ASCP’s Top 40 Under Forty for 2017!

40under40

Looking through the rest of the honorees, I can certainly say I’m in great company. Each person on that list is a prime example of the working values, lessons, and vision that ASCP recognizes in our dynamic field. So, to celebrate my and others’ place on this list, I’ve put together a few thoughts that truly reflect our hard work, talent, and potential as laboratory professionals and what that might mean for each of us. Here are what I consider the “Top 40” lessons that a career in medical laboratory science and laboratory medicine have taught me:

  1. The laboratory is the best melting pot –How many awesome pot-lucks have you had in your breakroom? How many words in new languages have you picked up? All that cultural exposure really contributes to a profound sense of community and humility.
  2. If everything is STAT, nothing is… – need I say more? We know the value of prioritizing and triaging what’s important for patients.
  3. You know a little about a lot of things, and sometimes a lot about a few things – To all my fellow generalists and specialists out there: how good does it feel to directly contribute to a patient’s positive outcome?
  4. Everyone’s got a different TAT – To turn a phrase, we’re all at various stages. Some laboratorians are just starting out and some can “smell” a tricky differential…
  5. Quality control protects everyone – If QC is good, instruments are good. If instruments report good values, results are good.
  6. Accountability is key – Owning up to failures and successes are both important!
  7. Record everything – This is how we protect patients and ourselves as well as improve.
  8. Teamwork is a necessity – It takes a village or, in this case, a full staff…
  9. Serotypes and Stereotypes – We’re not shy! We’re not afraid to jump in and collaborate!
  10. We’re not magicians, but sometimes we are – Impressing other clinicians with our ability to analyze and get results is just part of what we do.
  11. Nurses are our friends – Really, when you’ve got great relationships with the nursing staff you know just how that can make an enormous difference in your work.
  12. Doctors are our friends, too – The best doctors value the laboratory, and its staff!
  13. Ultimately, we’re here for our patients – That’s what it’s all about!
  14. We celebrate each other – How many of your labs have a ‘tech of the year’ award, or service awards? We make sure that we recognize each other’s talents.
  15. We share everything – Life events, stories, experiences, swapping shifts…
  16. Toxic techs are real, but they can be your friend too – All too real in many labs; often they’ve got lots of experience and can be a positive voice for change. Are we listening?
  17. What happens if everyone retires? – Staff turnover can be a challenge, but a combo of great training and communication are key.
  18. What happens if no one retires? Ever? – This occurs too, staff gridlock can be tough to manage and laboratory leadership is part of our role as well.
  19. We ALL have prior experiences – From brand new to near retirement, we’ve all had experience in healthcare; even as patients!
  20. Sometimes, QC just won’t come in range – That’s why relying on protocol and documentation can make all the difference.
  21. Sometimes, things happen even when QC was perfect – Bad days happen! Our drawing board is based on what we do best: analyzing, interpreting, and taking action.
  22. No one can tolerate as much as we can – How many of you have been blamed for hemolysis, or scrutinized for TAT statistics? Let’s call it “character-building experience.”
  23. Trust your training – It’s really your best resource.
  24. Taking initiative is a built-in perk – There will be times when it comes down to one lab tech on a night shift, or one pathologist who’s been paged, to take charge and make decisions.
  25. Watch something, do something, teach something – What better place than a clinical lab to see everything, learn it hands-on, and teach the next person?
  26. Never ending details – All those SOPs really make one appreciate the vast number of details that go into planning anything.
  27. We’re the best part of the hospital for metrics and progress – Diagnostic data comprises 70% of patient information, and 100% of laboratory performance.
  28. Lab week is the best – It feels great to be part of a large family of clinicians in this shared field. It’s also usually around my birthday, so that’s been a personal perk…
  29. Some teachers have years of experience on you – They’ve seen things you may never get the chance to!
  30. Some people will teach you something, even if you’re their supervisor – Everyone brings something to the table, or lab bench, or conference table, or shared microscope.
  31. We choose our words carefully – “These cells are suspicious and require pathology consult with further clinical correlation…” We know our scopes and practices.
  32. We word our choices carefully too – “This specimen was forwarded for pathology review because of our criteria…” We know we’ve got to back up our actions with evidence.
  33. We know office politics, just a little more intense than most people realize – Every hospital has a hierarchy, but laboratorians know we’re all on the same team.
  34. We’ve got an SOP for that – Literally, we have one for everything.
  35. We can come up with solutions with very limited information – Requisitions don’t always carry the highest level of clinically relevant guidance. (Test: Hgb A1c, Note: repeat from 1 hour ago).
  36. Sometimes we cannot find a solution, despite endless information – There are times when laboratory data is not enough to definitively make diagnoses, that’s just part of medicine.
  37. We all have the potential to be laboratory leaders – We’ll all have moments to take initiative and demonstrate our talents at one point or another.
  38. We are all real clinical scientists – The change to calling it “medical laboratory scientists” is one of the best changes ever. In my opinion, we are true clinical and critical scientists.
  39. It’s our job to promote our role and our field!
  40. Never stop learning!

I think the last two points need no explanation. Thank you for taking the time to read my “Top 40” Laboratory Lessons. If you have a great lesson you’ve learned, add it to the comments below! Don’t forget to check in next month for another update on my work and don’t forget to vote for ASCP’s Top Five! All the Top 40 Under Forty nominees are eligible to be in the Top Five based on your votes and comments!

Visit HERE, click on my face, and vote today!

Thanks, and see you next month!

 

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.

 

Conflict Resolution and Prevention

When it comes to the herb cilantro, people either love it or they hate it because it tastes like soap. Conflict is much the same way: either you see it as constructive or destructive. In my case, I used to think cilantro tasted like soap and it would ruin any food it came near. When I became a teenager, my taste buds changed. Now I will eat an entire bunch of cilantro on top of a taco or khao tom. Similarly, I used to feel conflict was a destructive force, and now I sometimes even look forward to a conflict (assuming it’s handled effectively) because it is an essential stage of team development.

The Thomas-Kilmann Conflict Mode Instrument (TKI) gives you insights into how you prefer to manage conflict, whether that is through:

  • Competing
  • Collaborating
  • Compromising
  • Avoiding
  • Accommodating

Knowing what your go to method is for handling conflict allows you to actively increase your skills in the other conflict modes and applying each mode when the situation requires it. Having more than one or two management skills will allow you to respond to different types of conflict effectively and nip unnecessary conflict in the bud.

 

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.

———–

Do you know that we have a comfort zone when we are handling conflicts? The Conflict Management course conducted by ASCP’s Leadership Academy offers an assessment of your conflict management style using the Thomas-Kilmann Conflict Mode Instrument (TKI). This assessment is eye-opening and helped me gain a better appreciation of my management style.

I scored high on “accommodating skills” on the TKI, meaning that when in conflict, I tend to be reasonable and accommodating with others, creating goodwill in the process. This method is particularly helpful for managers who inherit a new department through restructuring and aim to preserve harmony and avoid disruption to the work process. It is also helpful for building social credits to be use in the future for more important tasks that need larger buy-ins. As companies in the healthcare and diagnostic testing sectors evolve and adapt to the new regulatory and fiscal environment, departments within companies will continue to be restructured to ensure efficiency and relevancy. In my current position as a manager, I find these skills to be immensely useful, particularly as I’m recently given oversight responsibilities of new departments. The skills are helpful to ensure seamless transition while continuing to provide patients with unsurpassed diagnostic insights and innovation.

The course also asks us to look at our blind spots. I find that I tend to spend too little time discussing issues in depth and hashing out personal differences. “Collaborating mode” encourages us to work through issues, think outside the box, and to create a win-win solution. I’m learning to set aside time to proactively reach out to others with varying views and to understand their thoughts and evaluate their viabilities and applications. This gives me an opportunity for integrative solutions to merge insights from people with different perspectives on a problem and gain commitment from various stakeholders.

The ASCP Leadership program and the TKI gave me important revelations into my conflict management comfort styles and provided insights into my blind spots. While my favorite conflict behaviors are results of both my personal predispositions and the requirements of my work situations, I try to utilize other management styles based on the specifics of the situation. I have no doubt that the leadership program has augmented my management tool box. Now I have different tools at my disposal, whether it be “kill your enemies with kindness” (accommodating), “two heads are better than one” (collaborating), “Leave well enough alone” (avoiding), “might makes right” (competing), or “split the difference” (compromising), to approach future conflicts.

Chiou-pic-small

-Paul Chiou, MPH, SCT (ASCP) CM is a supervisor of Cytology and FISH at Miraca Life Sciences. Paul is a CAP inspector and an active member of the laboratory community having served on various professional committees over the years.

Is ASCP’s Wage Survey Helpful to You?

Recently, Lab Medicine published ASCP’s 2015 Wage Survey. If you have a chance to read it, take a few moments to answer the poll:

 

Safety Success in the Anatomic Pathology Laboratory

The pathologist walked into the histology laboratory every morning to say hello to the staff. As he did so, he drank from his cup of coffee.

The gross room was very small, and the eyewash station was placed on the faucet in the only sink in the room. One foot above the sink were the sharp ends of all of the cutting tools that hung on the wall. That was also the hand washing sink.

The morgue was the only space in the hospital where chemical waste could be stored before being picked up. The waste containers were not dated, and a funnel was left in the opening of one of them.

It can be difficult to oversee safety for a clinical laboratory, but often the people responsible for it have a clinical lab background, so the understanding of the regulations is clear. However, if you are responsible for the anatomic pathology (AP) areas as well, you may need to broaden the scope of your safety learning. Each of the lab safety situations mentioned above are real, and detecting and resolving those and other issues is important. Knowing the regulations for histology, cytology, and the morgue settings is a good place to start. Next, spend some time in those areas, and learn the processes that occur every day. Ask questions and look at procedures.

Bio-safety regulations in the AP lab are no different than for clinical laboratory staff. Many specimens, body parts and cadavers may be handled, and Standard Precautions should be used. That includes the use of gloves, lab coats, and face protection.

Chemical hygiene is also important in the AP lab, and since these areas tend to utilize many more chemicals than others, the management of them can seem daunting. Be sure to keep an updated chemical inventory which designates carcinogens, reproductive toxins and acute toxins. Ensure all staff have access to Safety Data Sheets (SDS) and that they have been trained to properly store chemicals. That means strong acids and bases should be stored near the floor, and they should never be stored together. Other incompatible chemicals should be separated as well. Ensure that proper spill supplies are available, and that staff can clean up various types of chemical spills. Conducting spill drills is a great way to keep staff ready for the real event.

Exposure monitoring should occur depending on what chemicals are used in the area. Managing chemical safety also includes ensuring proper labeling of all chemical containers. Primary container should have current Globally Harmonized System (GHS) compliant labels, and secondary containers also need adequate labeling. Secondary containers may be labeled using a GHS format or NFPA and HMIS conventions may be used.

Chemical or Hazardous waste handling must also be monitored closely in AP areas. If chemical waste is stored in the lab in a Satellite Accumulation Area, the containers should not be dated, and they should be stored at or near the point of waste generation. Central Accumulation Areas are areas where waste is stored before it is removed from the site. In these areas, containers must be dated, and a log should be kept for weekly checks of the areas. Weekly checks include looking for container leaks, dates on containers, and making sure containers remain closed. All chemical waste containers must remain closed unless someone is actively working with them. Never leave an open hazardous waste container open or with a funnel in it while unattended.

Special safety consideration should be given to tissue cutting in the histology area. Microtome and cryostat use presents specific sharps dangers because of the large sharp blades in use. If a blade guard is included with the equipment, train staff to always engage it before placing hands near the blade. Use magnet-tipped implements to remove the blades and rubber-tipped forceps to install new ones. Follow manufacturer guidelines for cryostat decontamination, but avoid using formaldehyde fumes for that purpose.

If laboratory staff is exposed to formaldehyde concentrations greater than 0.1 parts per million in their routine work, there is a safety training program that is required by OSHA. This formaldehyde training needs to be administered at the time of initial job assignment and whenever a new exposure to formaldehyde is introduced into the work area. The training must also be repeated annually.

As a lab safety officer, I learned over time how to work with and coach pathologists for safety. There is no more coffee consumed in the lab. The cramped gross room was remodeled to improve safety. Understanding the issues and reporting them was the key to getting this done. It took a difficult inspection by the EPA to teach me how to properly handle chemical waste. Today the representative from the state is my best reference, and she is willing to come to the labs and help us with waste regulation compliance. If your background is clinical, don’t ignore the special considerations in the anatomic pathology areas. Use your resources to learn what happens there, and understand the regulations so that employees in every area of the lab can work safely.

 

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.

Applying the Flipped Classroom to Medical Laboratory Science

Our Medical Laboratory Science (MLS) program curricular model applies the “reverse-lecture-homework-paradigm” (more commonly known as “flipping the classroom”) to the majority of our didactic courses. For our MLS program, this model works best for those MLS courses that we are able to provide strong hands-on laboratory lessons in our classroom setting. For those courses that are not amenable to this (like clinical chemistry where the laboratory procedures are highly automated), we provide the learning content in a traditional lecture-based format with supplemental laboratory lessons. This combination of approaches to instruction and learning—whereby we provide both traditionally designed courses (live, synchronous, “face-to-face” learning) and online courses (virtual, asynchronous, distance learning)—ends up supporting all of our students’ varied learning styles.

As an example, in our course in bacteriology, we can teach hands-on laboratory lessons using manual procedures for identifying bacteria that can be readily instituted in our program classroom/teaching laboratory. Because we can easily reproduce these techniques for our students, we use the flipped-classroom approach in this course and provide all of the lecture material as online learning lessons that our students complete as homework before the next day’s laboratory session. By having our students complete the lecture material as homework, we can dedicate more classroom time to learning laboratory techniques that are more closely anchored in what our students are going to do for a living.

From the standpoint of education theory and Bloom’s cognitive domain of learning, lesson content that requires basic recall of information (knowledge and comprehension) is presented as homework in the online lesson. In the hands-on laboratories, more of the higher level cognitive domains of interpretation and problem solving are applied, and the lab techniques are performed in the presence of the instructor, allowing for greater instructor-student interaction, questions, and joint problem solving.

The instructor role radically changes in this model, and he/she is no longer put in the position of “expert at the lecture podium,” allowing for greater opportunity to partner with the students in the classroom as a facilitator or guide in their learning. The literature commonly refers to the redefining of the instructor’s role in educating the student as moving away from being the “sage on stage” to that of facilitator or “guide on the side.” Our instructors have more time to help the students hone their laboratory techniques and apply the learning material in context and also answer questions.

Our instructors have found the experience rewarding, and they have been very successful using this format. They are able to partner with our students more collaboratively, and they can assume more of a mentorship role. It should be noted that there is a substantial amount of front-end time required to build the courses. Each lesson plan includes learning objectives, an online lesson, a hands-on lab, and a self-assessment. Our courses also include online discussion boards, homework assignments, and study guides for exam preparation (both written tests and laboratory practicals). Once an online course is built, however, we have found that it is easier to update and maintain versus a lecture-based course that may need redevelopment when instructors change.

The students’ role in the classroom also changes. When they are presented with the lecture material as online homework, they gain a newfound control over the material that doesn’t exist in a face-to-face traditional lecture format. They have control over when they study the learning content and the length of time they study. They can go in and out of the online lecture content as often as they want. The lesson material can include links to additional resources that they can delve further into if they desire. This format places each student in the “driver’s seat,” and the student moves from being a passive learner to active.

As for our students, they consistently come to class prepared for each hands-on activity, ask questions, and perform well on their written and practical examinations. Our students tend to form study groups outside of the classroom, and they review and process the online content with their peers, which results in a classroom environment that is collegial, team-oriented, and mutually supportive.

Reference

Bloom, Benjamin S., (Ed.), Taxonomy of Education Objectives: Handbook I: Cognitive Domain, N.Y., David McKay Company, Inc. 1956.

 

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.

Leading Lab Safety

The number of medical laboratory scientists is dwindling. Baby Boomers have begun their retirement, and even before that started, there were more job openings than people to fill them. That means more opportunities in the lab world, and in some cases leadership roles are being obtained by less experienced people than in years past. Whether or not one has a long lab history, one aspect of any new leadership position that will be important to grasp is management of the lab safety program.

The first step for a new lab leader is to ensure the existence of a functional laboratory safety program. Do this by looking for specific components of the program, a laboratory safety manual, a safety committee, and lab safety indicators. If these items are in place and functioning as they should, you’re off to a good start.

The laboratory safety manual may be in paper or in an electronic format. It should be separate from the hospital or facility safety manual as there are many lab-specific safety policies and procedures that are required. Maintain document control of these safety policies, ensure they have medical director (or designee) approval, and review these policies in a timely fashion. It is important to remember that while some lab regulatory agencies (like CAP) allow bi-annual policy review, OSHA requires annual reviews. OSHA covers many safety policies in the lab such as the chemical hygiene plan, the exposure control plan and many more.

The laboratory should have a functioning safety committee, no matter the size. If the lab staff is very small, the leader may play a role in the larger hospital or facility safety committee. If the lab is larger, a committee composed of just lab staff is advised. If the hospital or lab is part of a system, the committee should include at least one member from each lab site. The safety committee should meet at least monthly. It is important not to skimp on meetings or cancel them on a regular basis. Let staff know this is a priority for the leadership in the lab. During the meetings provide education, review lab incidents, and raise safety awareness. Train committee members how to perform safety audits, how to develop “safety eyes,” and most especially how to coach each other and their peers in the department.

Another important component of a functioning lab safety program is the use of safety indicators. Much like quality indicators, this safety data can be used to help determine the overall safety culture in the department. A good example indicator includes monitoring the employee exposure and injury rate. By using the laboratory’s OSHA 300 log information, a lab can compare its reportable injury data to national benchmarks. Many safety indicators are typically reactive data (or lagging), but tracking safety meeting attendance can actually serve as a leading indicator for the lab.

Once you’ve assessed the lab’s safety program, the next step a new leader should take is to assess the overall lab safety culture. This can be performed in many ways. One part of performing the assessment is by using your “safety eyes” that was mentioned earlier. Scan the lab visually. What immediate safety issues are seen? What is on the walls of the department? What types of interactions are observed? What is the physical layout? With practice and experience, a leader may be able to do the visual portion of the culture assessment quickly.

Another safety culture indicator tool is a laboratory safety audit. The results of an audit can provide much information about safety practices in the lab such as PPE use, chemical storage, and awareness of fire safety issues. One good model safety audit that can be used is located in the appendix of CLSI’s document Safety in the Clinical Laboratory (GP17-A3). This is a very comprehensive laboratory assessment and it can tell you much about your overall safety culture. As stated before, audit results can be discussed at the lab safety committee meetings, and ideas for improvements can be considered.

Managing the overall lab safety program is a big job, and it is often only one task of many that belongs to a laboratory leader. Change occurs daily in the field of lab medicine, and new leaders are coming aboard. Whether you are new or experienced, however, utilizing these basic first steps will provide a leader with the information needed to identify the safety culture and to understand how the program is operating.

 

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.