History of Generation: Traditionalists

Traditionalists make up the smallest percentage involved in the current workforce, but they are the organizational historians as they know and remember the organization’s past and founding goals. Traditionalists are typically born between 1927 and 1945 and grew up during the Great Depression, which was from 1933 to 1938. After that, the second World War started and the U.S.A got involved after the attack on Pearl Harbor in 1941.

These years had a significant effect on this generation. Traditionalists are known to work collaboratively, know how to do more with less, and are task-oriented. They typically have a strong sense of what is right and wrong, which was fueled by the historical events in their childhood and early adulthood. They have a strong sense of patriotism and respect for authority figures.

This generation is also one of the first major innovators; they created space travel, vaccination programs, and the foundation for modern-day technological innovations. They were the driving force of the civil rights movement of the 50s and 60s and were also the ones that started moving to suburbs. Currently, the are serving on many Board of Directors, as Presidents of organizations or as executive leaders. They have generally moved up in the hierarchy of organizations that they have spent years working for. They are loyal employees who require little feedback from their managers.

Because this is the era of pre-feminism women, the majority of women raised children and only had a job before marriage as teachers, nurses, or secretaries. This generation is self-disciplined, cautious, and self-sacrificing.

 

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.


 

This generation was born before 1945 and is the oldest generation in the American culture. However, not all of those born before 1945 are alike.  They either fought in WWII or were children through those war years.  The Traditionalist generation are really the first strong innovators and if they are still working they act as the historians of the organization because they have been there for a long time. They often serve on Board of Directors and are Presidents because of their organizational knowledge and expertise. They are typically very disciplined, consistent in their behavior and opinions, and are known for their loyalty.

The majority of Traditionalists are retirees and are the largest lobbyist group, which is the AARP.  If your parents or grandparents were of the Traditionalist Generation, you might have experienced a “waste not, want not” attitude with strong family values, conformity, and team players.

The Traditionalists are often referred to as the “Silent Generation.” This term came from the fact that during this era, the children were often expected to be seen and not heard.

As I pondered this generational topic, I found myself searching for an example of an “Active Working Traditionalist” that I could talk about because they might not have yet retired!  To my surprise I found myself thinking about my Uncle Tom.  This man has taken care of me and his family of five children with my Aunt Pat my whole life. He is a strong family man and then realized he is still working! Uncle Tom (he prefers to remain nameless) turned 83 year’s old this past April 16th.  He is still the principle owner of his own CPA firm and worked those long and hard CPA hours during this 2018 tax season.  As I mentioned early in this blog, all Traditionalists are not alike, and Uncle Tom never expected children to be “silent.”  He valued their opinions, and my Aunt Pat was both a stay home mom and a partner in their CPA firm.

Uncle Tom values the old-time morals of family first, safety, conservatism, patience and financial security.  I encourage you to look around for your Traditionalist at home, or maybe even in the workplace.  Let’s appreciate our Traditionalists while we still have the opportunity to learn from them!

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-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.  

Hematopathology Case Study: A 16 Year Old Male with Fatigue, Fevers, and Weight Loss

Case History

16 year old male with a history of chronic pilonidal cyst presented with fatigue, fevers and weight loss. He was febrile and noted to have cervical and inguinal adenopathy. Labs were significant for a white count of 77,000 with 85% peripheral blasts, anemia and thrombocytopenia.

MPAL1
Bone marrow aspirate
MPAL2
Bone marrow core biopsy
MPAL3.png
Flow cytometry myeloid markers
MPAL4
Flow cytometry cytoplasmic markers
MPAL5
Flow cytometry T-cell markers

Diagnosis

The bone marrow aspirate shows cellular spicules with sheets of intermediate-to-large sized mononuclear cells with irregular nuclei, distinct nucleoli, dispersed chromatin, and scant to generous amphophilic cytoplasm, with occasional vacuoles, consistent with blasts.

The bone marrow core biopsy shows a greater than 95% cellular marrow, hypercellular for age with approximately 90% of the cellularity composed of an interstitial population of intermediate-to-large sized mononuclear cells with irregular nuclei, distinct nucleoli, dispersed chromatin, and scant to generous amphophilic cytoplasm, with occasional vacuoles, consistent with blasts.

Flow cytometry shows leukemic cells that express immaturity markers (TdT, CD34, CD117, HLA-DR), T cell lineage markers (CD2, CD7 cCD3), and multiple myeloid markers (CD13, CD117, and variable CD15 and CD11b as well as MPO in a small subset).

Bone marrow core biopsy staining (not shown) had similar findings with blasts showing dim-to-strong positivity for myeloperoxidase, lysozyme, CD34 and CD117, as well as strong positivity for TdT. CD7 was weakly positivity, as well as CD3. CD4 and CD5 were negative.

MPAL6
Genetics diagnostics
MPAL7
NGS panel

With the expression of MPO by flow cytometric analysis and immunohistochemistry, a final diagnosis of acute leukemia with myeloid and T lymphoid phenotypic features, most consistent with T/Myeloid Mixed Phenotype Acute Leukemia (MPAL) was rendered. 

Discussion

Most acute leukemias are definitively assigned to either myeloid, T or B lymphoid lineages. However, approximately 2-5% of patients diagnosed with acute leukemia display an ambiguous lineage after immunophenotyping. A portion of these cases are classified under the category of mixed phenotype acute leukemia (MPAL) by the current WHO nomenclature.1

In a study of 117 MPAL patients by Yan et al, 55% of the cases had combined B/Myeloid, while 33% had T/Myeloid, and 12% had B/T/Myeloid. CD34 was strongly positive in 82% of cases, which reinforces the idea that the cell of origin is a multi-potent stem cell capable of differentiating into both myeloid and lymphoid progenitors. Cytogenetic analysis revealed no chromosomal abnormality in 36% of the patients with MPAL, while 64% had complex karyotypes (>3 aberrations). Translocation (9;22) was the most common abnormality, found in 15% of patients. Monosomy 7, a common finding in myelodysplastic syndromes as well, was found in 7.6% of patients. Mutational analysis revealed IKZF1 deletions in 13% of patients, ASXL1 in 6.5% of patients and a variety of other mutations including ETV6, NOTCH1 and TET2.2

In 2016, Eckstein and colleagues demonstrated epigenetic regulatory genes such as DNMT3A, IDH2, TET3 and EZH2 are the most commonly mutated in MPAL. RAS mutations including NRAS and KRAS and tumor suppressors, such as TP53 and WT1, were frequently identified as well.3

Interestingly enough, the genetic features of MPAL often overlap with early T-cell precursor acute lymphoblastic leukemia (ETP-ALL). ETP-ALL is a high-risk subgroup, representing 10% of adult T-lineage acute lymphoblastic leukemia. It is defined by a characteristic immunophenotype (CD1a/CD8 negative with weak CD5) and distinct gene expression associated with early arrest in T-cell development. This subgroup, called the LYL1 group, expresses the early hematopoietic marker CD34 as well as myeloid antigens (CD13 or CD33), but lacks expression of both CD4 and CD8. These leukemias are associated with a poor prognosis, with a 10- year overall survival of 19% compared to 84% for all other T-ALLs.4

Zhang et al in 2012 performed whole genome sequencing on ETP-ALL cases and found a high frequency of mutations in factors mediating cytokine receptor, tyrosine kinase and RAS signaling. It also showed inactivating mutations in genes encoding transcription factors (GATA3, ETV6, RUNX1, IKZF1) as well as genes involved in histone modification, such as EZH2.5

Overall, the genetic features of both ETP-ALL and MPAL display an identical genomic pattern that involves multiple pathways, including tyrosine kinase signaling, cytokine receptor response, RAS pathway activation, and loss of function in tumor suppressors. These findings give credence to the hypothesis that the early T-cell precursor actually displays more of a pluripotent stem cell profile that is similar to myeloid neoplasms, thus confounding findings found during molecular profiling. With this paradigm in mind, molecular diagnostics cannot differentiate between ETP-ALL and in this case, MPAL.

 

References

  1. Swerdlow, Steven H. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th ed., International Agency for Research on Cancer, 2017.
  2. Yan et al. Clinical, immunophenotypic, cytogenetic, and molecular genetic features in 117 patients with mixed-phenotype acute leukemia defined by WHO-2008 classification. 2012 November;97(11):1708-12.
  3. Eckstein OS et al. Mixed Phenotype Acute Leukemia (MPAL) Exhibits Frequent Mutations in DNMT3A and Activated Signaling Genes. Exp Hematol. 2016 August; 44(8):740-744.
  4. Ferrando AA et al.  Gene expression signatures define novel oncogenic pathways in T cell acute lymphoblastic leukemia. Cancer Cell. 2002. 1:75–87.
  5. Zhang J et al. The genetic basis of early T-cell precursor acute lymphoblastic leukemia. Nature. 2012 Jan 11;481(7380):157-63.

 

Marcus, Chelsea_099-Edit

Chelsea Marcus, MD is a third year resident in anatomic and clinical pathology at Beth Israel Deaconess Medical Center in Boston, MA and will be starting her fellowship in Hematopathology at BIDMC in July. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Call for Editor in Chief for American Journal of Clinical Pathology (AJCP)

American Journal for Clinical Pathology is in need of an Editor in Chief.

Job Description

  • The Editor-in-Chief will have responsibility for the overall strategic direction of AJCP, one of ASCP’s most visible and important benefits for all Society members.
  • The Editor-in-Chief should have a national and international reputation, with publications in top echelon journals in the field and extensive contacts throughout the pathology community.
  • The Editor-in-Chief will have responsibility for actuating the editorial direction of AJCP and proactively soliciting and presenting timely significant research findings relating to both anatomic and clinical pathology.
  • This is a volunteer, term-limited, contracted position. A monthly stipend is provided. The work of the Editor-in Chief is reviewed annually.
  • The Editor-in-Chief will be expected to devote time daily to AJCP work, totaling approximately 10-15 hours per week.
  • The Editor-in-Chief will be expected to travel to major pathology and laboratory medicine meetings to solicit content and authors.

Qualifications & Requirements

  • Have a medical degree with a specialization in pathology (boarding in both AP and CP is particularly useful), or a doctorate in a laboratory discipline (eg, clinical chemistry).
  • A strong preference will be given to those with clinical experience, combined with research or academic experience.
  • Must have experience working with scientific, peer-reviewed journals; as a peer reviewer, and as an editor or editorial board member.

Application Content and Submission

  • Submissions will only be accepted prior to 4 July 2018
  • Please submit your full CV with “Personal Statement” that explains (in a summary paragraph for each point):
    • Your motivation and interest in pursuing this position
    • Your previous experience with peer-reviewed publications
  • Please prepare and submit a “Vision Statement” that explains (in 2 pages):
    • Your vision for the direction of the journal’s future content
    • Your view of the journal’s content strengths and weaknesses currently
    • Your understanding of the unmet needs for new types of journal content
    • A summary of the editorial agenda you would pursue to enact the vision
  • Please submit your full CV and statements to: AJCPsearch@ascp.org

Equal Opportunity Employer: /Individuals with Disabilities/Protected Veteran

 

Microbiology Case Study: 42 Year Old Female with HPV

Case History

A 42 y/o female G2P2002 patient presented to her Ob/Gyn for Colposcopy for monitoring of persistent High-Risk HPV. She was originally found positive for HPV in 2015, but has had never had a Pap with a squamous intraepithelial lesion, abnormalities on colposcopy, or dysplasia seen on endocervical curettage. Additionally, she endorsed a complaint of vague diffuse pelvic/lower abdominal pain for approximately the last 2 months. She states that the pain is mild and comes and goes and is not associated with anything in particular. She has noticed some clear to gray-white discharge now and then since she first noticed the pain, but nothing that really worried her. Pt denies changes in bowel or bladder habits, denies nausea, fever, or chills. Pt has been in a monogamous relationship with her partner for the last 12 years. She had a Mirana IUD placed 4 years prior, without complication, and has not had menses since placement. Prior to that, the patient had normal, regular cycles. She has 2 children with the same father, both were delivered by spontaneous vaginal delivery without complications. She has mild anxiety and depression for which she is treated, but no other medical problems. There is no surgical history. She has 1-2 glasses of red wine every week, denies tobacco use, and denies illicit drug use.

Pelvic exam revealed a benign appearing cervix that was not painful to touch or motion. There was a clear to white mild discharge that was suspected to be normal vaginal secretions. IUD strings were noted. Colposcopy revealed an easily appreciated transformational zone without any obvious lesions. A routine endocervical curettage (ECC) was performed followed by observed increased clear discharge from the cervical os. ECC was sent for routine pathology:

actinomyces1
Actinomyces, H&E, 20x
actinomyces2
Actinomyces, H&E, 40x

Discussion

Actinomycosis is an infection by a species within the Actinomyces genus, generally seen in dental and other oropharyngeal abscess formations. However, rare occurrences of pelvic Actinomycosis can be seen in women with intrauterine devices in place. Pelvic infections can result in cervicitis and endometritis and progress into abscess formation within the fallopian tubes and the ovaries along with salphigitis. The more profound disease consisting of abscess formation generally presents with fever, specific lower abdominal tenderness, and elevated WBCs, thus can mimic acute appendicitis, ovarian torsion, or ectopic pregnancy (1). The first case reported in the literature was in 1967 (2).

Three main species of Actinomyces have been found to be associated with IUD-associated pelvic infection: A. naeslundii, A. odontolyticus (3), and A. hongkongensis (4). All of these species are obligate to facultative anaerobes, catalase negative, and nitrate reducing. A sub-species group of A. naeslundii, however, can be catalase positive and is CAMP test-positive. All members of A. naeslundii are urease positive while A. odontolyticus and A. hongkongensis are urease negative.

References

  1. Joshi et al. Pelvic Actinomycosis: a Rare Entity Presenting as Tubo-ovarian Abscess. Arch Gynecol Obstet. 2010, 281:305-306.
  2. Brenner et al. Pelvic Actinomycosis in the Presence of an Endocervical Contraceptive Device. Obstet Gynecol. 1967, 29: 71-73.
  3. Woo et al. Diagnosis of Pelvic Actinomycosis by 16S ribosomal RNA Gene Sequencing and its Clinical Significance. Diagnostic Microbiology and Infectious Disease. 2002; 43: 113-118.
  4. Flynn et al. Identification by 16S rRNA Gene Sequencing of an Actinomyces hogkongensis Isolate Recovered from a Patient with Pelvic Actinomycosis. J. Clin. Microbiol. 2013, 51(8):2721. DOI: 10.1128/JCM.00509-13.

 

-Jeff Covington, MD, PhD, is a 1st year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-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.

 

History and Characteristics of Generations

History plays a significant part in the development of any person; we are changed and altered by big historical events that take place during our life time. Understanding history is therefore an essential aspect of understanding people, communities, cultures, and generations.

The oldest generation living today is the GI Generation. This generation was born between circa 1901-1926 and have gone through significant changes in life and work environments during their lifetimes. The term GI Generation stems from the fact that a lot of soldiers from both WWI and WWII came from this generation. This generation came of age during the First World War and the Great Depression and most grew up without electricity, refrigerators, and credit cards.

The Traditionalist Generation was born around 1927-1945, so during the Great Depression and at the end of WWII. This is the era of pre-feminism, so women generally stayed at home to raise children. If women had jobs, it was typically until they were married and in professions such as secretary, nurse, and teacher.

This started to change during the next generation, the Baby Boomers, who were born between 1946 and 1964. The timeframe for this generation is so large that there are essentially two main groups: the revolutionaries from the ‘60s and ‘70s and the yuppies of the ‘70s and ‘80s. Women began working outside the home in record numbers, which created double-income households. Divorce also became more accepted and people starting buying things on credit.

The following generation is Generation X, who are born circa 1965-1980. Because most of their parents both worked, this generation is known as the “latch-key kids”, because they would walk home after school themselves as both their parents were working or divorced. This generation experienced the transition to digital knowledge, but remembers a time without computers.

The Millennial Generation, also known as Generation Y, was born around 1981-2000. This generation grew up in a world of technology and they have experiences some significant technological advances, which typically are very natural to them. They also grew up with enormous academic pressure and also the notion that you might not be save at school due to school shootings.

The newest generation is Generation Z who are born after 2001. People born during this time have never known a world without cell phones or computer and they are very technological savvy. Growing up during the great recession of the late 2000s, Z’ers feel unsettled and a level of professional insecurity.

The events mentioned above are all focused on events that took place in the United States of America, with some worldwide events included. To understand generations from other countries, it is important to learn about important historical events that occurred, while there are also some events that overlap. For instance, internet and cell phone are more widely available worldwide and there might be some similarities across nations in terms of the effect on generational understanding.

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.


 

The GI generation experienced events that impacted their assertive characteristics. If you know someone in this generation, they probably worked until they couldn’t work anymore instead of retiring. This work ethic comes from growing up during the deprivation of the Great Depression and are often referred to as the “Greatest Generation.” This term was coined by the NBC Nightly News anchor, Tom Brokaw in his book by the same name.

The Traditionalist generation are, well, traditional.  The value old-time morals, safety, security and may try your patience, especially in the work place. They are still working and act as the historians of the organization and/or the family because they have been there for a long time. You still might see them serve on Board of Directors and are Presidents because of their organizational knowledge and expertise. They are also known as the Silent Generation for an interesting reason.  It was this generation that coined the phrase, “Children are to be seen, and not heard!”

Did you know there are two groups of Baby Boomers?  The first group was born between 1946 and 1964.  They are often called the “Leading-edge Boomers.”  Those born between 1955 and 1964 are often called the “Shadow Boomers or Generation Jones.” The Baby Boomers are the largest generation in the US today, but they are slowly overpowered by the Millennial Generation. The have a team-oriented attitude and take their self-worth from their job. They are driven and optimistic and are often willing to learn how to use technology, but it takes a process as it doesn’t come as natural to them as to younger generations.

The Generation X are often referred to as the “middle child.”  This generation is street smart because most grew up in homes where both parents worked or were divorced. They started school without computers, but are experienced with them. They change careers often and are independent, flexible, and can easily adapt to new circumstances. They have an entrepreneurial spirit.

The Millennial Generation is our fastest growing generation in the U.S. workforce. They are the most diverse and are also known as the “Echo Boomers, Millenials, or Generation Y. Millenials understand the world of technology and it comes natural to them. They are resilient, optimistic, and creative because they experienced enormous academic pressure. They are very focused on professional development and to learn and improve what they do.

Generation Z is just starting to enter the workforce and they are independent, open-minded, and determined. They also have an entrepreneurial spirit, like Generation X, and they are loyal and compassionate. This emerging generation will be our new teachers because their minds work in so many directions because of their technology skills and aptitude.

It is easy to see how working with multiple generations in one department offers a full range of experiences, work styles, ideas, as well as, challenges. How can you improve the generational diversity of your personal or professional life?

Stakenas-small

-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.  

 

 

Hematopathology Case Study: A 68 Year Old Man with Epidural Mass

Case History

A 68 year old man with no significant past medical history presented with 3 weeks of upper back pain and bilateral leg weakness. He denied numbness, tingling, leg pain or urinary or fecal incontinence. MRI showed severe cord compression at the upper thoracic spine with a T2-T5 epidural mass. Due to the patient’s decline, an urgent decompression was scheduled and the patient underwent T2-T5 thoracic laminectamies with resection of extramedullary epidural tumor.

MRI-t2
MRI T2 SAG T-Spine
frozhe2x
Frozen Section H&E, 2x 
frozhe20x
Frozen Section H&E, 20x

Imaging

Frozen Section Diagnosis

“Round blue cell tumor.  Await permanents for final diagnosis.”

Differential Diagnosis

Small round blue cell tumor is a term generally used for a group of neoplasms characterized by small, round, basophilic, relatively undifferentiated cells on H & E staining. The differential diagnosis is wide, but includes Ewing’s sarcoma/peripheral neuroectodermal tumor, mesenchymal chondrosarcoma, small cell osteosarcoma, desmoplastic small round cell tumor and Non-Hodgkin Lymphoma. 1

 he2x

H&E, 2x

he4x
CD20, 4x

 

cd20-4x
CD20, 4x
bcl2-4x
BCL2, 4x
cd10-4x
CD10, 4x
cd21-4x
CD21, 4x
ki-67
Ki-67, 4x
IGH
IGH/BCL2 double fusion FISH probe. White arrows: IGH/BCL2 fusion

Diagnosis

Sections show fragments of fibrous tissue and focal bone with extensive crush artifact. There is an abnormal lymphoid infiltrate with areas showing a vaguely nodular architecture. The lymphocytes are small to medium in size with irregular cleaved nuclei, inconspicuous nucleoli and small amounts of cytoplasm. Scattered centroblastic cells are seen but are <15 per high power field. Between the nodules, the cells are centrocytic appearing. Rare mitotic figures are identified.

By immunohistochemistry, the neoplastic cells are immunoreactive for CD20 and BCL2. BCL2 is brighter in the vague nodular areas which are also highlighted by CD10 and BCL6. CD23 is variably positive in a large subset of cells. MUM1 is negative. CD21 highlights the enlarged and irregularly shaped follicular dendritic cell meshwork present in the areas with nodules. CD3 and CD5 highlights admixed T-cells. The proliferation index by Ki-67 is low and approximately 10%.

Cytogenetic analysis using fluorescent in-situ hybridization performed on paraffin embedded sections revealed numerous cells with an IGH/BCL double fusion probe signal pattern consistent with IGH/BCL2 gene rearrangement.

Overall, the morphologic and immunophenotyipic findings in conjunction with the cytogenetic results are in keeping with involvement by a B-cell lymphoma most consistent with a follicular lymphoma. The follicles present contain <15 centroblasts per hpf and the low proliferation fraction makes it most compatible with a low grade (WHO morphologic grade 1-2/3) follicular lymphoma.

Discussion

The differential diagnosis for an extramedullary epidural tumor is wide and can include anything from an epidural abscess to a metastasis. Although rare, lymphoma must be considered, especially when initial pathology shows “Round blue cells.”

Making the diagnosis of follicular lymphoma involves assessing the H & E slides for follicular architecture, characteristic immunostains including positivity for BCL2 within follicles and the typical t(14;18) IGH/BCL2 translocation, which occurs in 90% of cases. 2

Primary spinal epidural lymphoma (PSEL) includes extramedullary/extranodal lymphomas of the epidural space for which there are no other sites of disease at the time of diagnosis. As demonstrated in Figure 1 below, the lymphoma is seen entirely within the epidural space. 3

fig1
Figure 1. Primary spinal epidural lymphomas. Journal of Craniovertebral Junction and Spine (2011).

 

An epidural location for lymphoma is observed in 0.1-6.5% of cases. Patients tend to present in the fifth to seventh decade of life with a higher proportion of male to female cases. Presenting symptoms include weakness in the upper or lower limbs and back pain corresponding to the site of involvement of tumor. The most common tumor site is the thoracic spine (75%) followed by lumbar and cervical. Most epidural spinal tumors are B-cell lymphomas of intermediate and high grade, but low grade lymphomas have been reported. 3

Although rare, lymphoma is an important consideration in the differential diagnosis for tumors involving the spine. Surgical intervention is often necessary to relieve spinal cord compression and to make a histologic diagnosis. Treatment includes radiation and chemotherapy. Patients with primary spinal epidural lymphoma tend to have a better prognosis than patients with systemic lymphoma involving the epidural space, as well as patients with metastatic carcinoma. 3

References

  1. Hameed, Meera: Small Round Cell Tumors of Bone. Arch Pathol Lab Med (2007) 131: 192-204.
  2. Louis D.N., Ohgaki H., Wiestler O.D., Cavenee W.K. (Eds.): WHO Classification of Tumors of the Central Nervous System. IARC: Lyon 2007.
  3. Cugati G, Singh M, Pande A, et al. Primary spinal epidural lymphomas. Journal of Craniovertebral Junction and Spine (2011) 2(1): 3-11.

 

Marcus, Chelsea_099-Edit

Chelsea Marcus, MD is a third year resident in anatomic and clinical pathology at Beth Israel Deaconess Medical Center in Boston, MA and will be starting her fellowship in Hematopathology at BIDMC in July. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Lab Week 2018

star1

Labs: the final frontier. These are the voyages of lab-techs everywhere. Our continuing mission: to explore strange new orders, to seek out new tests and new sero-preparations, to boldly notify floor clinicians about sample hemolysis for redraw…

Or at least that’s close enough to Gene Roddenberry’s vision for futurism in exploration—except instead of starships, we’re talking Star Labs. Happy 2018 Lab Week everybody, and thanks for checking back in!

Okay, so here’s something a little bit different. Different from my usual Zika or medical school posts, this piece is a celebration of several lab “truths” which I know many of us share. It seems like one of the overarching themes I’ve encountered regarding laboratory operation (and appreciation) is communication. Expectations and needs aren’t always communicated effectively across different medical disciplines and scopes. A while back I thought of 40 things every lab professional should know, but I’d like to expand on that a bit.

How many times have you said or encountered any of the following:

  • Why does the blue top have to be full, if the other ones weren’t as full?
  • I just put some blood from the lavender top into the tiger top—patient is a hard stick…
  • I’m checking on results for the patient in room 123…no, I don’t have their MRN…
  • There’s a trauma patient coming in via helicopter, I need crossmatched units before they’re here.
  • Can you please add on a serum lactic acid, there was a BMP from yesterday?
  • This C. Diff sample is solid…
  • Why are some hospitals’ rapid flu-tests done with just the swab of a swab kit, a little aliquot of saline from an IV push syringe, and a wasted no gel SST?
  • Are the results ready for the biopsy we did just now?
  • Do we have a critical value range for ESR?
  • We haven’t had an in-service on running POCT Glucose controls, so we haven’t done them yet
  • I didn’t want the tubes to leak in transit, so I used the labels as tape to keep the caps on!
  • In order to get SUPER GOLD STAR STROKE AND GOUT CENTER accreditation, we have to slash TATs by 40%

 

star2
Captain Hematologist Jean Luc Picard (front) pleads with a clinician that only wants the WBC and H/H from a clotted CBC. Second Officer Riker (bottom left) smiles because he knows clots are dangerous for most analyzers. Lt. Operations Officer Worf (top right) agrees firmly for the sake of honor and quality assurance. An ensign trains on urinalysis (top left). [Source: Star Trek TNG]
I’m sure by now you realize I could go on, and on, and on…There are always issues in laboratory medicine that don’t always translate well between floor clinicians and laboratory staff. It’s a tale as old as time. And, until we do develop universal translator technology, it will remain somewhat of a barrier to improving workflow. So how to we fix it? I argue it starts with Lab Week.

Lab Week is supposed to celebrate the clinicians, laboratory professionals, and ancillary staff that work diligently to produce results. Hundreds of thousands of laboratorians work throughout the country and are highly-trained, well educated professionals who use their expertise to diagnose and monitor treatments. Quality medical testing and exceptional care are part of the core values that each of us are celebrated for every year in April! Let me be clear, we are not support services for other clinical professionals—we’re all on the same team. Don’t be angered by the misinformed questions above, or by the stereotypes you might encounter in pathology, try and use them as teaching platforms within our community.

star3
Capt. Hematologist Jean Luc Picard (right) takes endorsement from Chief Instrument Engineer Geordi LaForge (left) and while examining active Laboratory Data (center) speaks with clinical staff regarding temporary procedural changes for sending and holding PTT mixing studies while maintenance is being completed.  [Source: Star Trek TNG]
The whole point is that we’re in this together. Not just interdisciplinary teamwork that makes this year’s Star Lab theme so poignant, but teamwork across scopes. Those calls and messages we get in our managers’ offices or various bench top phones are part of our team too. It’s about the patients. We already know we contribute over 70% of clinical relevant information in every patient’s chart—some diagnoses like cancer rely completely on pathologist interpretation for screening, diagnosis, staging, and treatment recommendations.

star4
While EMH Drs. Mark I and Mark II receive their “bad” results, it’s all part of a larger picture. As a note, “panic results” rarely illicit the expected reaction in the nurses and physicians we report them to. These doctors would think our current medical practice standards medieval, anyway… [Source: Star Trek Voyager]
Here are a few examples of effective communication you could keep in mind.

For any Laboratory Professionals reading:

  • Instead of this: “Our policy is to reject clotted CBCs, we need a redraw, sorry.”
  • Try this: “While policy says to reject clotted CBCs, it’s not just because it could affect your PLT count. Other cell counts may be affected, and micro-clots can jam up the sensitive lines in the analyzers shutting them down for a while and affecting other patients’ results.” Try and realize that clinicians really do rely on those results! First and foremost, many clinical decisions are made on that last pending result for the next step of treatment. Whether it’s a PLT count or an acetone level, every result matters.
  • Instead of: “Room numbers aren’t adequate for patient and sample identification, sorry.”
  • Try this: “Because room numbers can change so quickly, we can’t use them to properly identify a specimen or patient. Do you have any of the following information…?” Understand that doctors, nurses, etc. aren’t always calling the laboratory from a private area. Thus, with so many people walking around a medical unit, a name might not be an option for them to use—room numbers are a sort of code for HIPAA compliance.

For any Clinicians reading:

  • Instead of this: “I really need you to rush that type and cross, quickly.”
  • Try this: “What can I do to help facilitate quicker turn-around for getting these units available for my patient?” Not only will you have started a conversation with the bench tech working on crossmatches, but you’ll demonstrate awareness of the complex process of safety/reportability blood bank goes through. Understand that Blood Bank is one of the more highly regulated aspects of laboratory medicine; FDA guidelines treat blood products as both a controlled substance and a tissue transplant, effectively.
  • Instead of this: “You have to run these samples because the patient is a hard stick.”
  • Try this: “What would be the minimum amount sufficient to run a particular test?” and if you need more information, simply ask! You’d be surprised how much the lab scientist on the phone would know about a particular testing method. Understand that QNS guidelines for specimens are not arbitrary amounts for the sake of covering repeats or mistakes in analysis. They are there to ensure quality results based on research and efficacy for a given instrument or method.

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We all get angry. Especially at work, when our labs might be understaffed, overloaded, and dealing with instrument failures or evil advanced genetically modified arch-nemeses on the floors like Laboratory Manager Capt. Kirk (pictured). [Source: Star Trek the Wrath of Khan]
So, it’s okay to get frustrated. It’s human. But I’ve got to tell you, I have been on both sides of this now—as a laboratorian and a clinician—and what I see time after time are simple gaps in communication. If we want to get better, not just for us, but for our patients, we should play an active part in helping close that gap.

I gave a few examples above, but how do we really change anything? My answer: interdisciplinary collaboration—and that’s not just a buzz word from my finishing LMU! If we want to really change anything, we should start it. If you’re a bench tech, start a discussion with your senior staff, supervisors, and managers about what you feel could be improved. If you’re a manager, seek out those barriers and be an active advocate for your staff—you’re already an advocate for the lab. If you’re a clinical pathologist, coordinate with your colleagues on the floor, develop more relationships, reach out for more than just consults on sign-outs.

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Don’t be afraid to be a voice for change. Staff meetings, in-services, and self-aware improvement can be facilitated with good leadership, organization, and clear goals! Even if things look grim and you’re on downtime with a full ER, or stuck in the middle of a volatile asteroid field, noted barriers to improved communication will always GET RESULTS. [Source: Star Trek TNG]
Want to change the knowledge gaps between clinical staff and laboratory staff? Hold an in-service or distribute messages with the missing information. When I was at Northwestern Medicine’s Blood Bank, I was an instructor once a month for nursing staff regarding blood products and transfusion protocols. We walked through the process with new nurses from proper phlebotomy and labeling, to order sets, to transfusion, to dealing with transfusion reactions. It was excellent! It was a great time to answer many questions and also gain insight into the clinical side of transfusion medicine.

Want to make sure no more sideways or crooked labels get sent to your specimen receiving stations? Instead of relying on the shear number of rejections to speak for themselves, discuss policy changes with your management, find the barriers to this change of specimen labeling, even send flyers out with “best dressed” tube images—it’s worked, I’ve seen it!

Want to make sure pathology stereotypes aren’t continued into the future? Change them! I plan to! Everyday I think of new ways to facilitate a new model of inclusion for pathologists into clinical healthcare teams. They’re an integral member already, why not reach past that tumor board, or biopsy report?

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It takes a village to run a lab, or a space station. An interdisciplinary team is the only way healthcare can continue to improve. Shapeshifting flexibility, shrewd business deals, passion for quality assurance, creative license, and scientific knowledge are only as good as the teamwork they are a part of—even if you have religious emissaries on your staff. Sharing knowledge and effective communication are critical for labs, clinicians, and our patients. [Source: Star Trek DS9]
The bottom line: if laboratorians want to grow and advance into the changing fronts within healthcare, we should take this opportunity during Lab Week 2018 and really embrace our profession as part of an interdisciplinary team. We deliver exceptional care and advocate for patients through our quality work in detecting, reporting, and preventing illnesses. I recommended laboratory professionals become more actively involved with fellow clinicians to directly improve patient outcomes. Let’s teach, let’s change policies, let’s have interdisciplinary rounds, let’s have roundtable discussions, let’s advocate together.

Because, after all, aren’t we advocating for the same thing: our patients.

Thank you! See you next time, and Happy Lab Week!

 

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