History of Generations: Gen X

Generation X stands out from other generations in a few ways. This generation is an integral part of the current work force, but both the previous generation (Baby Boomers) and the next generation (Generation Y) are significantly larger. Because they are sandwiched between these two, Generation X will never be the largest generation at work, but they still have a significant influence.

Generation X is the first generation in which their parents either both worked outside of the home in large numbers or were raised in single-parent households. This had a lot to do with the fact that divorce was becoming more common in the Western world and more women started to work outside the home. These children thus grew up a lot more independent and are known in the United States as “latch-key kids” because they would come home from school to an empty house. They started their school years without computers, but many finished their schooling with computers so they were raised in the transition phase from the information to the digital age.

This generation also grew up during significant events that shaped our world today. Some examples are the Cold War, the Challenger disaster, Chernobyl, the Berlin Wall, the release of Nelson Mandela.

Generation X is known for being very entrepreneurial, partly because of their cynical attitude towards large companies who failed their parents, and partly because of their independence, adaptability, and flexibility. Their desires are focused on the smaller scale; for example, they want to save their neighborhood, not the world. Typically, Generation X marry later in life, sometimes after cohabitating, and are quicker to divorce. They see values as a relative concept but they have a strong belief that people should be open-minded and tolerate everyone.

 

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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.


 

Hello everyone.  It’s your baby-boomer, Catherine, again.  I’d like to share with you my experience of what it’s like to be the parent of children from the Gen X generation, and working with a Gen Xer.

As with most of our generations, there are varying dates of when the generation started and when it ended, so let’s make it simple and go with the mid 1960’s as the start of the Gen Xer’s, ending in the early 1980’s.

Parenting Gen Xers 

I’m the proud parent of two Gen Xers. My son Mitch is 45 years old, and my daughter Katie is 42. Just because they are sandwiched between two of the largest generations, don’t underestimate the Gen X generation!  As I researched generations and was writing a course on generations, (“DeCoding American Generations”), it became clear that my children shared in the experiences of this richly gifted generation.

This generation is often referred to as the “latchkey generation.”  My children, Mitch and Katie, were the typical grammar school Gen Xers because I was one of those divorce statistics.  As a single mom, they came home from school every day with their house key in hand.  They learned responsibilities, became very independent, and became street smart.

The Gen Xers were the first to introduce the other generations to the concept of work-life balance. Both Mitch and Katie place a high value on quality of life.  Over the years, both of them have moved from higher paying jobs to lesser paying jobs in order to improve the quality of their family life.

What I’ve learned working with Gen Xers

As a “Boomer,” my greatest learning from the Gen Xers is the importance of work-life balance. In my current position at ASCP, I’ve had the privilege of working with people of this gifted generation.  They not only walk the talk of work life balance; they encourage others to do the same. I’ve listened to their stories and they’re not afraid to change jobs or careers, which is so different from their Baby Boomer parents.  It is often written that they acquired a cynical attitude toward corporate America because of the diminished employee loyalty their parents experienced. However, the Gen Xer took the high road and overcame the fear of changing jobs.  They took what they learned through their childhood and developed courage, the kind of courage that it takes to receive feedback and be the forever continual learner.  I’ll always be grateful to co-workers like Carroll, who would walk by my office at 5:30 at night “tapping her watch.”  She sent the Gen X message that life is about more than just work.

 

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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: An 85 Year Old Man with Pancytopenia

Case History

An 85 year old man presented with pancytopenia and weakness. His labs include WBC of 3.2, HgB of 9.9 and platelets of 137.

Bone Marrow Biopsy

hairycellbm10x
Bone Marrow Aspirate, 10x
hairycellbm40x
Bone Marrow Aspirate, 40x
hairycellcore10x
Core Biopsy, 10x
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Core Biopsy, 40x

Flow Cytometry

hairycellflow

hairycellplasmacell

hairycellplasmacellgate

Diagnosis

The bone marrow aspirate shows multiple cellular spicules with a prominent population of lymphoid cells with oval to reniform nuclei, dispersed chromatin and abundant pale cytoplasm. Scattered plasma cells are also present.

The core biopsy shows an infiltrating population of atypical lymphocytes with moderate amounts of pale eosinophilic cytoplasm and mature chromatin that stain positive for CD20. Frequent mononuclear cells consistent with plasma cells are also seen scattered throughout the bone marrow and stain positive for CD138.

Flow cytometry revealed that 80% of the lymphoid gate represented a kappa light chain restricted population that co-expressed B-cell markers CD19, CD20 and CD22 along with classic hairy cell leukemia specific markers CD11c, CD25 and CD103. A second population of kappa restricted cells fell in the plasma cell gate. The cells co-expressed CD138, CD56 and were largely negative for CD19 and CD20.

Overall, there is a hypercellular bone marrow with a prominent mononuclear lymphoid infiltrate consistent with hairy cell leukemia and a concurrent population of plasma cells consistent with plasma cell neoplasm.

Discussion

Hairy cell leukemia is a rare lymphoid neoplasm that accounts for only 2% of lymphoid leukemias. Patients tend to be in their 50s-60s with a 4:1 male predominance. The tumor is generally found in the bone marrow and spleen with rare circulating cells in the peripheral blood. Patients are generally cytopenic at presentation and symptoms include weakness and fatigue. Splenomegaly is common and hepatomegaly can also be seen.. 1

Hairy cell leukemia involves the clonal expansion of B-cells with a unique immunophenotypic profile. They are bright for CD19, CD20, CD22 and CD200, negative or dim for CD5, CD23 and CD10 and positive for CD11c, CD103, CD123 and CD25. Hairy cell leukemia must be distinguished from two provisional entities, hairy cell leukemia-variant and splenic diffuse red pulp lymphoma. These two entities do not have the classic morphology or staining profile of hairy cell leukemia.2

BRAF V600E mutations are detected in more than 80% of cases of classic hairy cell leukemia. The mutation is considered to be a driver mutation, but additional mutations are usually present that lead to disease progression. Hairy cell leukemia-variant is usually negative for BRAF mutations and has a more aggressive clinical course.3

Patients with hairy cell leukemia are given purine analogues as first line treatment and generally do well. However, patients who do not respond or who undergo relapse have few options. Increasingly, BRAF V600E inhibitors are being used for patients with hairy cell leukemia. Multiple studies have now confirmed the efficacy of vemurafenib and dabrafenib, however patients can be quick to relapse once off the drugs. Combination approaches should be considered for the most effective treatment. 4

References

  1. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoetic and Lymphoid Tissues (Revised 4th edition). IARC: Lyon 2017.
  2. Troussard X, Cornet E. Hairy cell leukemia 2018: Update on diagnosis, risk‐stratification, and treatment. American Journal of Hematology. 2017;92(12):1382-1390. doi:10.1002/ajh.24936.
  3. Maitre E, Bertrand P, Maingonnat C, et al. New generation sequencing of targeted genes in the classical and the variant form of hairy cell leukemia highlights mutations in epigenetic regulation genes. Oncotarget. 2018;9(48):28866-28876. doi:10.18632/oncotarget.25601.
  4. Roider T, Falini B, Dietrich S. Recent advances in understanding and managing hairy cell leukemia. F1000Research. 2018;7:F1000 Faculty Rev-509. doi:10.12688/f1000research.13265.1.

 

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

With Great Power Comes Great … Reliability

Hello again everyone! Your friendly neighborhood med student here, back with another clinical pearl from my hospital rotations. I usually keep a look-out for topics in clinical medicine that would be valuable learning experiences to share with you, my colleagues back in the lab. Last month I talked about the important cross-over between pathology and my current general surgery rotation.  This time around I’d like to discuss a topic that was brought up at the hospital’s in-house surgical mortality and morbidity meeting (M&M) on a recent Wednesday morning. (Side note: CNN Medical Correspondent, journalist, and Emory neurosurgeon Dr. Sanjay Gupta wrote a book on M&M meetings in 2012 called Monday Mornings. It was adopted as a TV series as well. The book was excellent, I highly recommend it! Some of you may remember that Dr. Gupta participated at the ASCP Annual Meeting in 2015 as a keynote speaker.) Aside from going over a few cases with reportable teaching moments and less-than-optimal outcomes, this M&M included an in-service on High Reliability Organizations (HROs) which really reflect a lot of parallels between working as a clinician, studying as a medical student, and working as a laboratory professional.

m&m1
Image 1a-1b. Sanjay Gupta, MD and his 2012 medical novel with realistic depictions of mortality and morbidity conferences surgeons participate in. This process of reflection and analysis is both preventative of mistakes and errors, but also effective as a comprehensive assessment of pitfalls and gaps in reliability. M&M meetings are a critical part of surgical teams and a useful HRO tool. Pictured (right) is Dr. Gupta at the 2015 ASCP Annual Meeting in Long Beach, CA where he discussed the ever-evolving nature of healthcare and his time as a medical correspondent.

What is a High Reliability Organization?

HROs are teams or organizations which operate under stress to produce a certain outcome or product. There is usually a tensely critical environment in which this outcome occurs within and its accompanied by a complex hierarchy of personnel accompanied by technologically advanced equipment or skill-driven work. To imagine the best examples of HROs, think of situations where something that could go wrong must never happen: air traffic control at a major international hub, the engineering department at a critical dam/levy/channel lock, the safety department for a nuclear reactor in a power plant, mission control at NASA, and—of course—clinical environments which include everything from surgical teams to critical laboratories! Basically all of these entities operate with the odds stacked against them with high potential for catastrophe, but they do their best to avoid failure and maintain quality controls. Essentially, I argue that health care organizations and, especially laboratories, are high-level HROs.

m&m2
Image 2. “Time Out’s” are called before every single surgical procedure. After a patient gets through various stages of clearance regarding fitness and appropriateness of surgery, the final step before that first incision is a time-out. This is a conference of review between nurses, anesthesiologists, OR scrub techs, medical students, circulation staff, and other inputs that would affect patient care. Details checked include patients’ names, MRNs, DOBs, procedure, locations, etc. Effective communication at all stages helps HROs achieve low error rates. (Photo: Mayo Clinic, Surgical Outcomes Program)

Connecting HROs, ASCP, and you…

I recently finished the Lab Management University (LMU) training offered by ASCP earlier this year. What I found interesting in many personnel-related modules was a mindfulness of the staff one might work with. This considered not just the skills, experience, or credentials that individuals may possess, but it also reflected their cultural background, communication preferences, potential talents or limitations, and insights into different points of view. Not only does LMU do a fantastic job exploring these personnel traits, it also turns the reflection inward to uncover possible biases one might have. This is mindfulness—a super trendy and upcoming philosophy of operating in the present with the full attention a moment deserves both personally and professionally. Mindfulness for the individual, the clinician, and the student are all great ways to center yourself as you encounter challenges. However, mindfulness for an organization takes on a different scope. What mindfulness does at an organizational level is essentially create an HRO: it creates a system in which reliability is created against adverse challenges in the setting of awareness, transparency, and complexity.

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Image 3. High Reliability Organizations (HROs) are built on a foundation of mindfulness—the same mindfulness individuals practice for effective centering and decision-making acts as a tool for efficacy in organizations’ attempts at self-awareness and process improvement. Reducing error and operating at high performance levels are held up by five major pillars which address problem detection and problem management/resolution. (Source: BioRAFT™ Safety and Compliance Consulting, Cambridge, MA)

Let’s Walk through an HRO in action from the desk, to the surgical suite, and in the lab:

The foundation of HROs is rooted in that mindfulness. It acts as a guiding tool to focus the principles or HROs which contribute to reducing errors buy integrating rigorous protocols, cross-examining complex clinical tasks and critical functions, and securing complex decision making in dynamic and fast-paced environments.

The Five Major Pillars of High Reliability Organizations (HROs)
1. Preoccupation with failure

This is a critical tenet of HROs as they constantly evaluate vulnerability of a process for errors and pitfalls. Collective mindfulness turns the obsession of not wanting to fail into a useful way to be aware of possible challenges and address them proactively and effectively.

Surgical Teams Medical Students Laboratory Professionals
Surgical teams are always analyzing and reanalyzing how effective they are through M&M meetings and other metrics which reflect error rates. Near miss reporting acts as a functional model for proactive utilization of this mindful approach to improving outcomes. Med students are pro’s at being worried about failure; from board exams, to rotations, to performance in clinicals, and competing with other med students—it’s a strong motivator Labs are chock-full of dashboard metrics that delineate performance standards of equipment, materials, testing, and personnel. This often reflects itself in reimbursement, or administrative buy-in later.
2. Reluctance to simplify explanations

This is a tough one to understand. One would think simpler explanations of problems means an easier way to achieve a solution. But some problems are multi-faceted and complex, requiring different input from various sources/individuals. A balance must be achieved for efficiency’s sake.

Surgical Teams Medical Students Laboratory Professionals
While it may be tempting to want to reduce information to simple bullet points to get through more cases, each patient is different, and protocols must be addressed comprehensively and dynamically to identify best practice for each patient. There is a lot of input medical students are exposed to regarding knowledge intake. It can be overwhelming. Studying can be hard enough, but when your grades need a boost and “more” studying doesn’t help, it’s time to investigate new ways to put information into that hippocampus… How many times have you been asked, “Where are my results?” Identifying problems in TAT would be complex and require investigating a process in depth rather than dealing with blame shift from bad orders, to phlebotomy delay, transport delay, or even testing/reporting delays.
3. Sensitivity to operations

Being acutely aware of the processes involved in HRO-style decision making is critical. There is a reason for standardization and protocol wherein SOPs guide all staff to common output. Relying on this standardization is an effective way to insure success.

Surgical Teams Medical Students Laboratory Professionals
Time outs before surgery, protocols for various work-ups, and specific procedures regarding surgical interventions allow various clinicians to treat multiple patients with the same relative outcomes. Knowing how clinicals work and how to make them better allows opportunities for advancing not only your rotation, but future rotations. Standing up and owning ideas for operative improvement is great. Interdisciplinary bridges are effective tools for creating a culture of medical collaboration. Helping other clinicians understand the scope and tools available to them in the laboratory makes everyone’s job easier and safer.
4. Deference to expertise

In healthcare, a collaborative spirit allows more experienced clinicians to offer their expertise based on years of working and learning. Alongside this, concurrent literature is always looking at present-day standards and best practices. HROs rely on hierarchical models for decision-making.

Surgical Teams Medical Students Laboratory Professionals
Almost all surgeons are experts at something—just ask them! Joking aside, senior surgeons offer valuable insight on cases to junior residents. And combining experience with data in best practices improves outcomes dramatically. We are part of a medical system. We have knowledge that greener medical students might desperately need, and we also might be able to lend insight to senior attendings and teachers who were trained well before we were in school. That said, we defer to expertise a lot—we really know nothing, relatively speaking… The hierarchy of laboratory medicine lends itself to this pillar of HROs. Pathologists might helm the wheel of a particular lab, but there are section heads or experienced techs, or clinical managers who know the guts of testing and reporting that offer invaluable information for outcomes!
5. Commitment to resilience

This is at the heart of any clinical team. Medical error is a reality of the field we are in. Allowable medical error gives us some leeway, but ultimately, we hope to be error free for our patients. When mistakes do occur, it’s imperative to own up to them and use them as learning opportunities. When we do that, managers are thankful for not wasting resources on investigations, and we have the chance to quickly recover.

Surgical Teams Medical Students Laboratory Professionals
Mistakes happen. But failures should be rare. If events happen, they should be learned from. M&M meetings are great places for this to happen. Often times, surgical staff are pushed to the limits of abilities, hours in a day, demand of patient load, and of course response to trauma. We are archetypes of resilience. If we weren’t, we wouldn’t be wearing the short white coats. We constantly have to go through tests, checkpoints, and performance evaluations to make sure we can rise above and be responsible for our own clinical decisions tomorrow. There are errors because of instrumentation, errors because of quality control, and errors because, well, simply because. Sometimes the mistakes that occur in the lab despite binders of QC should represent teaching moments with staff re-training. (I’ve even made a few—but you bounce back and become better for it.)

 

Well, if you made it this far you certainly have a commitment to resilience! This stuff isn’t the most exciting but it’s what makes our healthcare system work. At the base of it all are the ancillary staff working with everyone up the ladder to the chief of surgery, from the medical student to the attending, from the medical lab scientists up to the pathologists. Every part of an HRO (especially in healthcare) is a part of a dynamic and growing entity. As long as we are all aware of our roles, our scopes, and our impacts, out patients will only benefit!

See you all next time!

Post script: listen to the latest podcast in a series by a colleague and me where we discuss clinical stories and pearls of wisdom through medical school. These audio sessions are part of LectureKeepr an online resource for medical students, made by medical students. Check them out here: LectureKeepr. As the sessions relate to my posts here on Lablogatory I’ll include a link—this post will focus more in depth on what I presented here regarding HROs.

 

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–Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.

Microbiology Case Study: A 49 Year Old with HIV and CNS Lymphoma

Case History 

A 49 year old African American female was transferred from an outside hospital due to orbital cellulitis. Her past medical history was significant for HIV, CNS lymphoma, for which she was taking methotrexate & rituximab, and type II diabetes. Her vitals were: blood pressure 181/145, heart rate 145, temperature 98.6°F and respiratory rate 20. On physical examination, her right eye was bulging, with conjunctiva & eyelid swelling, and her iris was non-reactive. Scant serous drainage was noted. Admission labs showed a normal white blood cell count (9.8 TH/cm2), glucose of 211 mg/dL (normal: 74-106 mg/dL), hemoglobin A1C of 7.7% (normal: 4.2-6.0%) and platelets were low at 41,000 TH/cm2. An infection was suspected and the patient was started on vancomycin and piperacillin-tazobactam. She had a head CT scan which showed right periorbital cellulitis and diffuse sinus disease but no abscess formation. Nasal endoscopy was performed and extensive adhesions & black colored, necrotic tissue of the right nasal cavity was noted in addition to whitish debris, consistent with fungal overgrowth extending into the nasopharynx. Biopsies were taken for frozen section and bacterial & fungal culture and Infectious Disease was consulted for management of a probable rhinocerebral fungal infection.

Laboratory Identification

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Image 1. Biopsy of the right nasal wall showed tissue invasion and necrosis with broad, ribbon like hyphae that were pauciseptate and branched at right angles (H&E, 40x).
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Image 2. Fluffy, white fungal growth on Sabouraud Dextrose and Sabouraud Dextrose with Chloramphenicol agars at 72 hours of incubation at 25°C. There was no growth on the Mycobiotic agar slant.
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Image 3. Tape prep showed a round sporangium containing small sporgangiospores located directly below the rhizoids of the mold which is consistent with the diagnosis of Rhizopus spp. (lactophenol cotton blue, 40x).

Discussion 

Rhizopus spp. belong to the order Mucorales, are ubiquitous in the environment and are the most common etiologic agents of mucormycosis. Rhizopus spp. typically cause invasive infections in the nasal sinus, brain, eye and lung, particularly in patients that have uncontrolled diabetes, HIV or are immunosuppressed. Mucorales are angioinvasive, exhibit perineural invasion and there is usually thrombosis, infraction and necrosis of surrounding tissue. As the illness can progress quite rapidly, prompt diagnosis and treatment is necessary.

If a Mucorales is suspected, tissue specimens obtained during a surgical procedure should be sent for frozen section, direct examination with calcofluor white/KOH and fungal culture. On histologic exam or microscopic exam in the microbiology laboratory, the hyphae of Rhizopus spp. are wide & ribbion-like with few to no septations (pauci- or aseptate) and wide angle branching (90°) (Image 1). Further classification requires culture.

If a Mucorales is suspected, the tissue submitted for fungal culture should be minced into small pieces and directly applied to the appropriate fungal media. Grinding of tissue will kill the hyphae and result in no growth from culture. Mucorales will not grow on media containing cycloheximide. Rhizopus spp. grow rapidly within 1-4 days and start as white, fluffy colonies that become grey or brown in color as they mature (Image 2). The Mucorales are described as “lid lifters” due to their rapid growth and “cotton candy” like colonies that fill the plate. On lactophenol cotton blue prep, Rhizopus spp. have unbranching sporangiophores that terminate in a round sporangium and arise directly under well-developed rhizoids (Image 3). The sporangium ruptures when mature and releases many oval sporangiospores.

Treatment of patients with mucormycosis is usually a dual approach with wide surgical excision and amphotericin B, which has been shown to be an effective anti-fungal drug in the majority of Mucorales. In contrast, voriconazole has poor activity against these isolates. If susceptibility testing is needed, CLSI provides reference broth microdilution guidelines. In the case of our patient, due to the grave prognosis of her condition, in addition to her other comorbidities, the family elected for comfort care measures only and board spectrum anti-fungals were not started.

 

Stempak

-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the Director of Clinical Pathology as well as the Microbiology and Serology Laboratories.  Her interests include infectious disease histology, process and quality improvement and resident education.

Leading in a VUCA World

Leading people can be a challenging task regardless of the industry or size of an organization. Adding volatile, uncertain, complex, and ambiguous (VUCA) environment into the mix and the leadership challenge increases. Today’s organizations are increasingly complex, ambiguous, uncertain, and volatile because change is accelerating and intensifying. How can leaders equip themselves to manage a VUCA workplace? The first step is understanding what each terms means.

Volatile Situations describe circumstances that change constantly and unexpectedly, and a certain level of instability of a task or challenge is present. However, the best leadership approach is to use available information, be proactive, and have multiple plans and strategies in place. An example of a volatile circumstance is a natural disaster. In such a circumstance not only is the natural disaster a volatile situation, but also the constantly changing nature of the aftermath; which emergency agencies are coming and when, where are people stuck, etc. There are a lot of changes occurring in a volatile situation.   Being proactive and prepared in volatile circumstances can be expensive, but that preparation is necessary to handle these situations.

Uncertain Situations are situations known for a lack of information, so on some level they are the opposite of volatile situations. In uncertain circumstances there is no reliable information about cause and effect and it is not known if change will happen, can happen, or have a positive effect if it does happen. The best approach in these circumstances is to find more information, more data, and more analytics. Once leaders have access to more data, they need to make sure the data is analyzed and implemented into new strategies and change processes. An example of an uncertain situation is when a competitor suddenly emerges that takes direct aim at your company by undercutting prices. In this case, it is important to collect as much data and information as possible to respond to the situation appropriately through new strategies.

Complex Situations have several interconnected and interdependent aspects which have a clear relationship. In these situations, there is partial information available but because everything is interlinked, it is a challenge to process the information in a way that reliably predicts the future. The approach is to reduce the number of linkages, or at least to make them clearer, so the complexity of the situation or task is easily understood and managed. An example of a complex situation is when implementing a process change affects all departments in an organization. In such a circumstance, everything is interconnected and it can be hard to predict how this change will impact everyone and to prepare for it. The key here is to make the change as simple as possible and to assess the impact it makes on every aspect of the organization before implementing the change.

Ambiguous Situations are situations which have relationships that are completely unknown and ambiguous; there appears to be no rhyme or reason. The phrase that comes to mind in these situations is “you don’t know what you don’t know.” In such ambiguity, leaders need to learn from mistakes, hypotheses, and test rounds so it is important to experiment in order to gain information. An example of an ambiguous situation is when you are launching a new product or starting a new business. There are a lot of unknowns in these circumstances so making hypotheses and learning from mistakes is essential for leaders’ success.

In order to lead in a VUCA world, leaders need to analyze these four situation types to confirm which one they are currently leading in. Next is to find the right approach in order to lead people, a department, or an organization through the volatile, uncertain, complex, or ambiguous situation. Knowing is half the answer, so the next time you find yourself in a VUCA situation, start by not only analyzing the situation and possible solutions, but also by analyzing your own reaction to each of the four situations. Being able to understand and control your own reaction will increase your leadership skills in all VUCA and non-VUCA worlds.

 

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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.

Beyond the CBC and Reticulocyte Count: Early Detection of Iron Deficiency Anemia

In my May 2018 post (Not your Grandmother’s Hematology), I discussed the history of hematology and chronicled how far we have come in the last 60 years. We have progressed from manual counting of cells to the first Coulter Counter in 1956, which revolutionized hematology by being able to automate the counting of red blood cells, to modern instruments that can report up to 30 parameters and perform up to 400 CBCs an hour. Among these parameters are what are termed advanced clinical parameters, new parameters which provide physicians with additional information about the state of blood cells. In this blog I will explore how one of these advanced clinical parameters, the Reticulocyte Hemoglobin content, can provide physicians with information that can assist them with earlier detection, differential diagnosis and better management of iron deficiency and iron deficiency anemia. 

Case Study 

A 29 year old female was seen by her gynecologist reporting a history of heavy menstrual bleeding with current bleeding lasting 15 days. The doctor discussed various treatment options with the patient and a CBC was performed. CBC results are shown below.

Test Result Flags Reference
WBC 7.23   4.5-10.5 K/CMM
RBC 4.38   3.70-5.30 M/CMM
HGB 12.0   12.0-15.5 GM/DL
HCT 36.2   36.0-46.0 %
MCV 82.6   80-100 FL
MCH 27.4   27.0-34.0 PG
MCHC 33.1   32.0-36.0 %
PLT 243   150-450 K/CMM
MPV 11.0   9.6-12.0 FL
RDW 12.5   0-15.1 %

This CBC shows no abnormal flags. Based on patient history and presentation, the physician questioned iron deficiency despite normal hemoglobin and hematocrit, MCV and MCHC. He ordered a reticulocyte profile on the same specimen with the following results:

Test Result Flags Reference Range
Retic 1.55   0.5-2.0 %
Abs Retic 0.0679 H 0.0391-0.057 M/CMM
Imm Retic Frac 14.9   2.3-15.9 %
Ret-Hgb 24.6 L 30-35 PG

Reticulocyte counts are the quantity of the youngest red blood cells released from the bone marrow into the peripheral blood. Reticulocytes are reported as a % and the absolute reticulocyte count is calculated by multiplying the Retic% by the RBC. The immature reticulocyte fraction (IRF) is the rate of production of reticulocytes and depends largely on the ability of the bone marrow to respond to erythropoietin. The reticulocyte hemoglobin (Ret-He) content is the amount of hemoglobin in newly formed red blood cells. (There are two different hematology systems that report reticulocyte hemoglobin content. The two nomenclatures used for reticulocyte hemoglobin are Ret-He and CHr and studies have been done that demonstrate their equivalence)

Note that the Ret-He reflects the quality of the newly formed reticulocytes. Ret-He is a direct measurement of the amount of hemoglobin in each reticulocyte, which indicates the amount of iron available for incorporation into the precursors of mature red cells. This patient’s retic% and IRF are within normal ranges, but her absolute reticulocyte count is high. A Ret-He less than 29 pg in an adult is indicative of iron deficiency. With a normal CBC and low Ret-He, this is an early indication that iron deficiency is indeed present. With the absence of sufficient iron, this patient would eventually develop a microcytic, hypochromic anemia. Therefore, Ret-He can measure and indicate inadequate hemoglobin production before the hemoglobin and hematocrit decrease.

In this case the importance of clinical awareness is illustrated. This physician remembered a recent laboratory technical bulletin announcing implementation of a new hematology analyzer system with the availability of new parameters for reticulocyte counts. When the CBC results came back from the laboratory, the patient had already gone home, and no serum had been drawn to perform a ferritin level. Rather than calling the patient back to have another sample drawn, the Ret-He could be done from the same blood sample already in the lab. Ret-He is a faster, easier and less expensive test than additional iron studies and bone marrow iron stains. Ret-He can easily be used at a very low cost to get that first piece of information to decide whether or not iron deficiency is a concern. A high or normal Ret-He would have ruled out an iron deficiency with a fairly high confidence level. In this case, the low Ret-He could be used to guide further workups. A subsequent blood drawn revealed a low ferritin and iron deficiency was confirmed. The patient was advised to take an iron supplement along with ongoing treatment for the bleeding.

This case is just one example of the clinical utility of the Ret-He. Using the Ret-He, physicians can determine iron deficiency before iron deficiency IDA develops. A low Ret-He can alert a physician to iron deficiency without the presence of anemia, microcytosis or hypochromia. Ret-He can also be used to monitor and show early response to iron therapy before any other parameters change. A case example is that of a 5 month old who was brought to the emergency room with a Hgb of 7 g/dl and a Ret-He of 11.9 pg. In pediatric patients, a Ret-He less than 27.5 is an indicator of IDA. In this child, treatment with oral iron showed that the Ret-He had risen to 24.6 pg seven days after the onset of iron therapy, while the CBC remained virtually the same. This provided a very early indication that the iron therapy was effective.1 The Ret-He can also been used to minimize transfusions. The AABB Choosing Wisely Campaign lists 5 things that physicians and patients should questions before transfusion. One of the guidelines states “Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.“2 Historically, physicians have used a ‘wait and see’ approach and watched Hgb levels drop before they start looking at iron. Using a Ret-He, iron deficiency could be determined, for example, in a patient with a Hgb of 11 g/dl. Oral or intravenous iron could be started before the Hgb drops below 7 g/dl and transfusion becomes necessary. The AABB Choosing Wisely Campaign emphasizes this by stating that patients with chronic iron deficiency or pre-operative patients with iron deficiency should be given iron therapy before transfusion is considered.2 Ret-He can give the earliest indication of iron deficiency and can be used to monitor the response to iron therapy. Another clinical utility of Ret-He has been to help diagnose or rule out iron deficiency in oncology patients. Additionally, Ret-He has been included in guidelines for anemia management in end stage renal disease patients on dialysis and who get erythropoietin.

The Ret-He parameter has proved clinically useful in early determination of functional iron deficiency. Traditionally ordered chemistry iron studies are indirect measures that have certain inherent inaccuracies due to the presence of inflammation and infection, or in patients on iron therapy. Ret-He is a direct and very effective screening tool and physicians can use Ret-He with other RBC indicies to improve anemia diagnosis and management in many patient populations. Ret-He can be used as a screening measure, and used to reflex for iron studies. Therefore, laboratories who have instruments that can report Ret-He and CHr should develop an education program to help clinicians effectively use Ret-He. Together physicians and laboratorians can develop their own guidelines for reflex testing and improvement for patient care.

References

  1. Case Studies Demonstrating the Clinical Application of the Advanced Clinical Parameters (1/20/2016) Chantale Pambrun, MD, FRCPC, Head of Division of Hematopathology and Assistant Professor of Pathology and Laboratory Medicine, IWK Children’s & Women’s Health Centre and Dalhousie University
  2. https://www.aabb.org/pbm/Documents/Choosing-Wisely-Five-Things-Physicians-and-Patients-Should-Question.PDF
  3. Advanced parameters offer faster, surer guidance to cancer care. Anne Paxton. CAP Today. Sept 2017
  4. The Value-driven Laboratory. Reticulocyte Hemoglobin Content (Ret-He): A Parameter Well-Established Clinical Value. Sysmex America White Paper.
  5. Sysmex Clinical Support Team. Utility of RET-He, August 10. 2015
  6. Brugnara C, Schiller B, Moran J. Reticulocyte hemoglobin equivalent (Ret-He) and assessment of iron-deficient states. Clinical Laboratory Hematology 2006;28:303 – 308.

 

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-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

Microbiology Case Study: A 22 Year Old Female with Wound Infection

 

Case History

22 year old female with a past medical history of scoliosis presents for routine follow-up after hospital discharge for post-op wound infection following a spinal fusion surgery. Patient had an anterior and posterior spinal fusion with allograft and hardware on 1/18/18. She had a laminectomy and irrigation for post-op epidural hematoma on 1/19/18. Subsequently, she developed a lumbar spine abscess and underwent irrigation and debridement of the abscess on 3/1/18. Two operative cultures of the left paraspinal musculature grew only tiny clear colonies on the anaerobic blood plates. Gram stain of these colonies did not show any organism. MALDI-ToF MS identified these colonies as Mycoplasma hominis which was confirmed at a reference laboratory by PCR. The patient was given daptomycin plus levofloxacin. Since discharge from the hospital, she had wound healing with intermittent discharge.

Lab Identification

Mycoplasma hominis requires a specific rich and complex agar medium for growth and grows tiny colonies on standard media such as Columbia agar. In a patient with urogenital disease, Mycoplasma hominis is diagnosed with a urogenital specimen culture and confirmed by PCR. In a patient with spinal hardware infection, Mycoplasma hominis is diagnosed by a culture of infected tissue with PCR confirmation.

Discussion

Mycoplasma is a bacteria that lacks a cell wall and contains the smallest bacterial genome totally sequenced. Due to its lack of cell wall, Mycoplasma cannot be visualized with a Gram stain, and it is innately resistant to b-lactams.1 Due to its small bacterial genome, 580 kpb, it cannot be detected by light microscopy and requires complex nutrients for growth1.

Mycoplasmas are frequently part of the oropharyngeal and genital tract flora among healthy subjects.1 There are more than 200 Mycoplasma species, of which 13 have been isolated from humans. Only 6 species, among which 5 are pathogens, live in the urogenital tract.2 As one of the Mycoplasma species detected in the genitourinary tract, M. hominis can be either a pathogen or part of the normal flora.1 Colonization with M. hominis is associated with younger age, lower socioeconomic status, multiple sexual partners, African American ethnicity, and hormonal status.1 Infection with M. hominis is more common among pregnant women.1

Mycoplasma hominis is associated with genital infections in females but not in males. Examples of infections include pelvic inflammatory disease and bacterial vaginosis.1 In addition, it is responsible for pregnancy-related infections such as chorioamnionitis and post-partum fever secondary to endometritis.1 Moreover, M. hominis is associated with infections of the newborns, meningitis among premature babies, and low birth weight among neonates.1 Lastly, M. hominis can lead to extragenital infections including spinal hardware infections, septic arthritis, retroperitoneal abscess, hematoma infection, and osteitis.1

Infections by Mycoplasma hominis are infrequent and difficult to confirm prior to the start of empiric therapy.2 Urogenital and systemic infections due to Mycoplasma hominis are treated with oral tetracycline.1 For organisms resistant to tetracycline, fluoroquinolones are recommended.1 For wound infections or abscesses, doxycycline, clindamycin, or fluoroquinolones are recommended for at least 2 weeks.1 Drainage and debridement may be necessary.1

References

  1. Pereyre S. et Mycoplasma hominis, M. genitalium and Ureaplasma spp.  Antimicrobe http://www.antimicrobe.org/m06.asp
  1. Baum S. Mycoplasma hominis and ureaplasma urealyticum infections. (2017, Dec. 7th).  Last retrieved on March 27, 2018 from https://www.uptodate.com/contents/mycoplasma-hominis-and-ureaplasma-urealyticum-infections

 

-Ting Chen, MD 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.