A Laboratory Professional’s Perspective on the Opioid Crisis

It was in the 1980s that physicians first explored the use of narcotics/opioids for the treatment of pain associated with non-terminal illnesses, including chronic and “mild to moderate” pain. In 2012, opioid prescriptions for outpatients were common, and some states had as many as 143 opioid prescriptions for every 100 people. Today, more than 6 out of 10 drug overdoses involve an opioid. The CDC states that 91 Americans die every day from an opioid overdose. This situation has been called “the opioid crisis” and the “opioid epidemic.” It is a public health emergency.

The landscape is characterized by new trends in both the drugs involved and drug user demographics. Current data indicates that prescription opioids are not the main problem. In fact, from 2015 to 2016, prescription opioid overdoses decreased from 17,539 to 16,800. The decrease in prescription overdose may indicate that efforts to reduce over-prescribing may be working. Or, drug users may be abandoning high cost prescription opioids for illicit drugs.

While prescription opioid overdoses have been decreasing, the incidence of heroin overdose has tripled. The incidence of fentanyl overdose has increased 196%, and the incidence of overdose due to non-methadone synthetic opioids has increased by 72%. Fentanyl is available both legally by prescription, and illegally from illicit sources. It is frequently combined with or sold as other drugs such as heroin, cocaine, and alprazolam. Fentanyl is 100 times more potent than morphine, and 50-100 times more potent than heroin. Even more dangerous are the fentanyl analogs, carfetanil(yl) sufentanil, acry and acetyl fentanyl, and furanyl fentanyl, to name a few. Sufentanil is 1000 times more potent than morphine, and carfentanil – sometimes called elephant tranquilizer – is 10,000 times more potent than morphine. Opioid abuse now spans nearly all demographics. In fact, NCHS Data Brief in 2017 disclosed that the age group with the most rapid rise in opioid overdose is adults ages 55-64 years. Some of the greatest increases in heroin related deaths have been among women, privately insured, and those with higher incomes – demographic groups that historically have had low rates of heroin abuse.

Laboratory professionals can help fight this crisis by providing relevant testing, and billing for the testing appropriately. Most hospitals are ill equipped to test for the synthetic opioid analogs. For many hospitals, the drug testing capabilities consists of an immunoassay based urine drug screen. These screens can detect many of the “classic” drugs of abuse like morphine (heroin), cocaine, amphetamines, PCP, and benzodiazepines. These screens do not differentiate individual drugs in a drug class, and they can’t detect fentanyl or fentanyl analogs, even with high degrees of cross-reactivity. As our Vice President of Laboratories expressed it to me, “our emergency rooms are full of overdose patients with negative drug screens.” Unfortunately, the culprit drug is not identified until a medical examiner orders forensic toxicology. More comprehensive and confirmatory testing like mass-spectrometry based testing provides more accurate information.

Mass spectrometers are not cheap, and many laboratory professionals are challenged with obtaining funding for them. The challenge is not lessened by the bad taste left in Medicaid’s mouth by code-stacking when billing for drug testing in the pain management patient population. This practice was, unfortunately, exploited by some physicians running office-based drug testing labs. Large multi-drug LCMS based panels were used in routine monitoring of pain management testing but instead of billing per panel, the test was billed by drug (analyte) in the panel. This practice led to CMS scrutinizing the use of mass spec testing alone and recommending the limited immunoassays. Laboratory professionals have the responsibility to advocate for the appropriate use of this powerful testing, and fortunately we are doing that – the Academy of AACC in collaboration with American Academy of Pain Medicine just released guidelines for the use of laboratory tests in monitoring pain management patients. We need to be trusted to do the right test, at the right time, for the right patient.

Forensic pathologists and toxicologists also face big challenges related to the opioid crisis. Forensic toxicologists are challenged to keep up analytically with synthetic and novel drugs entering the market while dealing with the pressure of limited budgets and client frustration with long turnaround times. Forensic pathologists are challenged by the sheer volume of overdose-related deaths. The National Academy of Medical Examiners (NAME) limits the number of autopsies to 325/pathologist/year. There are currently only around 500 board certified forensic pathologists in the US and the future doesn’t look great – only 3% of graduating medical students choose to enter pathology and only 7% of those will enter forensic pathology.

 

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Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.  

Microbiology Case Study: A 51 Year Old Female with New Onset Progressive Weakness

Case History

A 51 year old female with a past medical history for migraines was otherwise healthy up until 6 weeks ago when she began to notice progressive weakness, myalgia and new onset spontaneous lower extremity bleeding. She was evaluated by the internal medicine service and was found to be profoundly thrombocytopenic. A further workup consisting of a bone marrow biopsy revealed findings that were consistent with high-grade (Burkitt’s) lymphoma. She was initiated on chemotherapy. Two days after initiating chemotherapy she became profoundly pancytopenic with recurrent fevers. Additionally, she had worsening erythema and pain in her right buttocks and left thigh. Despite the usage of broad-spectrum antibiotics, her symptoms worsened. Two sets of blood cultures were drawn and the anaerobic bottles of both sets flagged positive after 15 hours.

Lab Identification

Gram stain revealed gram positive rods, some of which did not retain the crystal violet stain but all appeared box car shaped. This organism only grew under anaerobic conditions. On the anaerobic blood plate, the organism swarmed the media.

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Image 1. Gram stain from a positive blood bottle showing gram positive rods (100x oil immersion).
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Image 2. Anaerobic growth on blood agar showing a few colonies with a lawn of growth.

By use of mass spectrometry, the MALDI-TOF positively identified the organism as Clostridium septicum.

Discussion

Clostridium septicum is a gram positive, highly motile, spore-forming organism that grows best under anaerobic conditions. It is found ubiquitously in soil and at a low prevalence rate in the human gastrointestinal tract. C. septicum is best known for its ability to cause neutropenic enterocolitis and “atraumatic” (spontaneous) gas gangrene which is in contrast to “traumatic” gas gangrene caused by C. perfrigens .2 Both neutropenic enterocolitis and atraumatic gas gangrene are commonly seen in association with a malignancy usually hematologic or gastrointestinal in nature. Neutropenic entercolitis is mostly commonly seen in patients that are undergoing chemotherapy treatment. A combination of mucosal injury by the cytotoxic drugs, profound neutropenia, and impaired host defense allows for edema and necrosis of the bowel wall by microorganisms.1 This then allows for hematogenous dissemination of gut flora which includes C. septicum to more distal sites. It is also possible to have weakness in the mucosal lining from mass effect alone without any preceding neutropenia also allowing for hematogenous dissemination. In animal models C. septicum has been shown to be much more virulent than C. perfrigens requiring 300x fewer organisms to have the same lethal effect.2 This lethal infection even with appropriate treatment has a mortality rate of 60%.3

To diagnose C. septicum a gram smear will show gram positive rods with occasional rare sub terminal or terminal spores. They can often appear pleomorphic. They grow under anaerobic conditions and may start out as a single solid colony but usually swarm the plate after 24 hours growth. A more conclusive diagnosis can be made on the MALDI-TOF using mass spectrometry. Effective treatment requires both debridement of infected sites and appropriate antibiotics. The Infectious Diseases Society of America (IDSA) guidelines for skin and soft tissue infections recommend the use of high dose IV penicillin and IV clindamycin.4 Clindamycin is a protein synthesis inhibitor and is believed to aid in preventing toxin synthesis.

 

References:

  1. Urbach DR, & Rotstein, OD. Typhlitis. Cancer J Surg 1999; 42(6):3 415-419.
  2. Srivastava I, Aldape MJ, Bryant AE, Stevens DL, Spontaneous C. septicum gas gangrene: A literature review, Anaerobe (2017).
  3. Larson CM, Bubrick MP, Jacobs DM, West MA. Malignancy, mortality, and medicosurgical management of Clostridium septicum infection. Surgery. 118(4):592–597
  4. Stevens DL, Bisno AL, Chambers HF, et al. Executive Summary: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2014; 59:147–159.

 

-Noman Javed, 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.

Hematopathology Case Study: A 57 Year Old Male with History of Malignant Melanoma

Case History

A 57 year old male with a history of stage IA malignant melanoma presented with a new pink nodule on the right shoulder (see image provided) that has persisted for one month following a tetanus shot. Resultant specimen is a punch biopsy of the lesion.

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Diagnosis

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H&E, 10x
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H&E, 20x
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H&E, 50x

 

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CD20
calccd3
CD3
calccd4
CD4
calccd8
CD8
calccd30low
CD30, low power
calccd30high
CD30, high power
calclgranzyme
Granzyme
calclperforin
Perforin

Sections show a punch biopsy of skin with a superficial as well as deep dermal infiltration of small and large lymphocytes. No epidermotropism is noted. An admixed background of inflammatory cells including eosinophils, neutrophils, and histiocytes is present.

By immunohistochemistry, CD2, CD4, and CD5 highlight the abundance of lymphocytes indicating a dominant T-cell population. CD30 highlights a major subset of larger lymphocytes that co-express perforin. Granzyme is positive only in a small subset of cells. CD3 is present in a subset of CD30 positive cells indicating downregulation of CD3 in neoplastic cells. By Ki-67, the proliferation index is focally high (70%). CD20 highlights rare B-cells. CD8 is positive in a small fraction of T-cells. EMA is negative.

Overall, the diagnosis is that of a primary cutaneous CD30 positive T-cell lymphoproliferative disorder. The differential diagnosis includes lymphomatoid papulosis, type C and primary cutaneous anaplastic large cell lymphoma.

Discussion 

Primary cutaneous CD30 positive T-cell lymphoproliferative disorders are the second most common cutaneous T-cell lymphoma (30% of cases). The primary groups within this entity include lymphomatoid papulosis (LyP) and cutaneous anaplastic large cell lymphoma.

Primary cutaneous anaplastic large cell lymphoma (C-ALCL) is composed of larger cells that are anaplastic, pleomorphic, or immunoblastic morphology that express CD30 in over 75% of the tumor cells. C-ALCL most commonly affects the trunk, face, extremities, and buttocks and often present as a solitary or localized nodules or tumors with ulceration. Clinically, the lesions may show partial or complete remission similar to LyP but often relapse in the skin. Interestingly enough, approximately 10% of cases may disseminate to local lymph nodes.

The histologic pattern of C-ALCL demonstrates a non-epidermotropic pattern with cohesive sheets of large CD30 positive T-cells. Ulcerating lesions may show a morphologic pattern similar to LyP with abundant inflammatory cells such as histiocytes, eosinophils, neutrophils with few CD30 positive tumor cells. By immunophenotyping, the tumor cells are CD4 positive with variable loss of CD2, CD5 or CD3 and express cytotoxic markers such as granzyme B, TIA1, and perforin. Unlike systemic anaplastic large cell lymphoma, C-ALCL does not express EMA or ALK.

The 10 year disease related survival of C-ALCL is 90%. Lymph node status or multifocal lesions does not alter prognosis significantly.

The differential diagnosis also include LyP, type C. These lesions often present on the trunk and extremities and are characterized by popular, papulonecrotic and/or nodular skin lesions. After 3-12 weeks, the skin findings may disappear. Up to 20% of LyP may be preceded by, have concurrent, or followed by another type of lymphoma such as mycosis fungoides (MF), C-ALCL, or Hodgkin lymphoma.1

Briefly, there are up to 5 types of LyP (types A-E).2,3 The more recently described LyP type D and E are determined by either simulating an epidermotropic aggressive CD8 positive CTCL and angiocentric and angioinvasive CD8 positive CTCL, respectively.

LyP has an excellent prognosis but since these patients may have other lymphomas, long term follow up is advised.

Overall, C-ALCL and LyP type C show considerable overlap both morphologically and clinically so close clinical follow up is recommended, however both demonstrate an excellent prognosis.

References

  1. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2008.
  2. Cardosa J, Duhra P, Thway Y, and Calonie E, “Lymphomatoid papulosis type D: a newly described variant easily confused with cutaneous aggressive CD8-positive cytotoxic T-cell lymphoma.” Am J Dermatopathol 2012 Oct; 34 (7): 762-765.
  3. Kempf W, Kazakov DV, Scharer L, et al. “Angioinvasive lymphomatoid papulosis: a new variant simulating aggressive lymphomas.” Am J Surg Pathol 2013 Jan; 37(1): 1-13.

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.

Microbiology Case Study: 6 Year Old Male with Meningitis

Case History

A 6 year old male presented to the emergency department with a concern for ventriculo-peritoneal shunt (VP) malfunction. His past medical history is significant for myelomeningocele and hydrocephalus since birth. On arrival, symptoms included high fever (102.7°F), headaches and swelling at the VP shunt catheter site in the neck. Over the past week, his mother also noted nausea, vomiting and diarrhea. CT scan of the head revealed increased size of the 3rd and lateral ventricles which was concerning for either a VP shunt malfunction or infection. Lab work showed a white count of 13.5 TH/cm2 and elevated CRP values suggestive of an infection/inflammatory process. He was taken to surgery for VP shunt removal and placement of an external ventricular drain (EVD). Intra-operatively, purulent yellow material was noted at both the proximal and distal ends of the catheter. Cerebrospinal fluid (CSF) was sent for Gram stain and bacterial culture. He was started on vancomycin and ceftriaxone.

 Laboratory Identification

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Image 1. CSF Gram stain prepared from the cytospin showed many white blood cells and Gram positive bacilli (100x oil immersion).
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Image 2. Gram stain from the liquid media culture showing gram positive bacilli (100x oil immersion).
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Image 3. Small, grayish colonies with a narrow zone of beta hemolysis grew on blood agar after 48 hours incubation in a 35°C incubator with 5% CO2.

Bacterial cultures collected from a shunt tap and intra-operatively both showed short gram positive bacilli on Gram stain (Image 1&2). The organism grew on blood and chocolate agars as small, gray colonies with a narrow zone of beta-hemolysis when observed closely (Image 3) after incubation at 35°C in CO2. The isolate was positive for catalase and showed a “tumbling motility.” MALDI-TOF MS identified the isolate as Listeria monocytogenes.

 Discussion

Listeria species are gram positive bacilli that grow as facultative anaerobes and do not produce endospores. The major human pathogen in the Listeria genus is L. monocytogenes and it is found in soil, stream water, sewage & vegetable matter and may colonize the gastrointestinal tract of humans and animals.

The most common mode of transmission is ingestion of contaminated foods, in particular, raw milk, soft cheeses, deli meats and ice cream. L. monocytogenes’ ability to grow at cold temperatures (4°C) permits multiplication in refrigerated foods. In a healthy adult, it causes an influenza like illness and gastroenteritis. Pregnant women are especially susceptible to disease and neonates infected in utero can develop granulomatosis infantiseptica which can lead to miscarriage, stillbirth or premature delivery. Elderly or immunocompromised can present with a febrile illness, bacteremia and meningitis (20-50% mortality).

In the microbiology laboratory, L. monocytogenes is usually identified via blood, CSF or placental bacterial cultures. It grows well on standard agars and after overnight incubation, the small, gray colonies show a narrow zone of beta hemolysis on blood agar. L. monocytogenes is positive for catalase & esculin and the CAMP test demonstrates block like accentuated hemolysis. It has characteristic tumbling motility at room temperature and an umbrella shaped motility pattern in semi-solid agar.  Automated methods of identification provide reliable species level differentiation on the majority of current platforms.

Susceptibility testing should be performed on isolates from normally sterile sites. Ampicillin, penicillin, or amoxicillin are given for L. monocytogenes, and gentamicin is often added for its synergistic effect in invasive infections. Trimethoprim-sulfamethoxazole and vancomycin can be used in cases of allergy to penicillin. Cephalosporins are not effective for treatment of listeriosis.

In the case of our patient, after L. moncytogenes was identified, his antibiotic therapy was changed to ampicillin and gentamicin. Antibiotics were administered for 3 weeks before the placement of a new VP shunt. On further questioning, his mother revealed his diet consisted heavily of hot dogs and soft cheeses. She was educated on how to prevent subsequent infections prior to discharge.

 

JKO

-Jaspreet Kaur Oberoi, MD, is a Pathology resident at the University of Mississippi Medical Center. 

 

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 the Microbiology and Serology Laboratories. Her interests include infectious disease histology, process and quality improvement and resident education.

A Primer on HIV, Hepatitis, and Clinicals: A Bronx Tale

Hello again everyone! Last time on Lablogatory, I discussed the importance of patient advocacy and how it was especially poignant around the recent holiday season. We all have families, and sometimes those families and our medical professions intersect. Since then, I hope you’re all having a good start to the new year!

For me, the new year means a new start in medical school with clinical clerkships in New York City. Building off the theme I started last year, I hope to continue a message of patient advocacy through a laboratorian’s lens as I learn and navigate the clinical side of our field. My first such rotation is in a clinic serving a population with very significant statistics, both from the standpoint of laboratory data and epidemiology: HIV, hepatitis, and chronic infectious disease. As such, let me use this as a primer and explore what that really means for the patients in that community.

Now it’s no surprise that laboratory professionals like ourselves are deeply involved with public health efforts aimed at mitigating chronic/infectious diseases through screening, collaborating, and advancing technology. Last year I was fortunate enough to be part of the 2017 ASCP Annual Meeting in Chicago. Participating in sessions, and roundtable discussions, I was also able to listen to US Global AIDS Coordinator, Deborah L. Birx, MD had to say regarding ASCP’s global contributions to HIV/AIDS research and public health efforts. She spoke about resource limited laboratories and how ASCP has been an active and longstanding partner to the President’s Emergency Plan for AIDS Relief (PEPFAR), a global health initiative to address HIV/AIDS.

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Image 1. My wife Kathryn C. Booth, RN, MSN, CNL, and I, take part in a roundtable discussion at ASCP Chicago 2017. From Critical Values: 2017;11(1):34-39. doi:10.1093/crival/vax040
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Image 2. US Global AIDS Coordinator Deborah Birx, MD, delivers the scientific general session at ASCP 2017 in Chicago. From Critical Values: 2017;11(1):34-39. doi:10.1093/crival/vax040

The relationship between laboratory data and epidemiology is evident, as results from screening and routine testing demonstrates both snapshots of evolving health statistics as well as progress in public health initiatives like PEPFAR. ASCP’s global initiatives reach all the way to Africa as those resource-limited laboratories gain support from telecommunications and shared materials. From rapid HIV tests with Western Blots, to Zika seroprevalence research, laboratory data and public health are dependent on each other. So how does this manifest in a place like New York, specifically the Bronx where my clinical rotations are located?

First, let me illustrate a snap shot of the scene in this New York borough. Something that demonstrates important data are a region’s social determinants of health—something I have found in my research and experience to be invaluable pieces of information when trying to address health concerns and influence outcomes with particular patient populations.

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Figure 1. A clear layout of New York’s Boroughs. I currently live in Manhattan and go to clinical sites in the Bronx for my clerkship rotations. (Alamy stock photo. Photo credit: http://www.alamy.com/stock-photo-new-york-city-5-boroughs-map-96927034.html)

HIVfig2HIVfig3HIVfig4

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Figures 2-5. 2015 NYC Rates of Persons Living with Diagnosed HIV compared against variable social determinants of health including poverty, high school education, median income, and income inequality. Accessed through AIDSVu.org interactive map, visit it here: https://tinyurl.com/y8u9op8v

It’s clear to see here that the Bronx area has the most significant epidemiologic presence of active and new HIV cases. Parallel to this, the data demonstrates that the social determinants of health illustrated in Figures 2-5 are clearly correlative. More so, in the most recent report by the New York City Department of Health and Mental Hygiene (DOHMH) and the office of HIV Epidemiology and Field Services Program (HEFSP), data collected since 1981 from reported clinical encounters, viral loads, CD4 counts, and HIV genotypes reveal significant social health statistics. According to their 2016 NYC HIV/AIDS Annual Surveillance Statistics, the Bronx remains plighted with high numbers for HIV. It would appear as well, that regardless of HIV status, an overwhelming majority of the population (>71%) live in very high poverty—defined as >30% of the federal poverty line. According to data from Community Board 6, the local representation for the Bronx and specifically the zip code around my clinical site, the median household income is $24,537. A majority of this population is comprised of minorities as well, >40% Black and >40% Latino. The data differs slightly between men and women (including transgendered men and transgendered women) with regard to transmission risk. For men the highest risk factor continues to be sexual transmission between homosexual men, or men who have sex with men (MSM). For women, the risk stratifies to a high majority of heterosexual transmission (>70%). Read the full 2016 NYC DOHMH report here: https://tinyurl.com/ycf82xld. According to AIDSVu.org nearly 3,000 people out of 100,000 residing in the Bronx are living with active diagnosis of HIV/AIDS. The same source reports that between 2011 and 2015, the number of new cases approaches 200 annually.

Another valuable function of the AIDSVu.org website is their HepVu.org companion site which provides incidence and infographic data about Hepatitis infections. The Hepatitis B and C Annual Report for 2014 published by the NYC DOHMH in 2016 also provides information about this chronic condition and how it affects the population. The maps below demonstrate that chronic Hepatitis is a serious and prevalent problem, and at a slight majority directly affects patients proportional to age.

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Figures 6-8. Maps from the DOHMH NYC Hepatitis B and C Annual Report for 2014 published in 2016. (Source: https://www1.nyc.gov/assets/doh/downloads/pdf/cd/hepatitis-b-and-c-annual-report.pdf)
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Figure 9. Mortality rates of HepB, HepC, and HIV in New York City at large. Note the decrease in HIV and slight increase in HepC. (Source: https://www1.nyc.gov/assets/doh/downloads/pdf/cd/hepatitis-b-and-c-annual-report.pdf)

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Figures 10-11. Maps that demonstrate that even though New York State has a lower-than-average HepC prevalence rate, it has a relatively higher rate of mortality. Source: https://hepvu.org/resources/

But what does all this data mean? First and foremost it means progress. Progress for our patient populations because we’re busy tracking and keeping ahead of health statistics as they happen, and progress in our innovative ways to test earlier, screen better, and use the data wisely. None of this would be possible without the lab. From every hepatitis viral load, antigen immunoassay, and serology, lab data becomes translated to health data. And, all the while, clinical encounters with real patients experiencing real chronic illnesses are reported into epidemiologic data. Together we use those two sets of data to improve patient outcomes—I talked about that a lot with Zika in Sint Maarten.

I am honored to be at that bridge between the lab and the patient. Translating data back and forth from bedside to primary source is something that brings me a real sense of purpose. As part of this clinical rotation I will have to be involved in patient education, delivering presentations and conducting follow-up with those in the community who these public health messages are targeted to. So, instead of boring you some more with facts about lab science, testing/screening opportunities, and a promising future for those with chronic illness, I’ll go ahead and get a presentation ready for them!

Talk to you soon with some more in-depth clinical case-based blogging! Thanks for reading!

 

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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.

New Year. New Skills.

I do not recall if it was an email or if I saw it on the ASCP website, but the byline caught my attention: New Year. New Skills. My mind quickly started racing. January marks a fresh beginning, the time to make new resolutions, the time to feel the excitement of new possibilities. 

The Issue

We are more than halfway through the month and I have yet to identify the skill I would next like to acquire. So many questions! So much to learn, so little time! How do you choose what to focus on? Where do you start? What can you manage? Is there anyone who can help or teach you? And if you are like me, you might also ask yourself, “Why do I always pile more on my plate?” Maybe this is the year you choose to learn to say no? Nah. So what’s it going to be?

The Solution

Since our lives are all different and there are millions of possible distinct scenarios, I will share what I decided to do. First, I evaluated my work-life balance and determined if I wanted to acquire a skill that would benefit my work (career and ambition) or lifestyle (health, pleasure, leisure, family) (1). I also took into consideration how much more I could fit onto my already overflowing plate.

I decided to work on something that would help me with both work and lifestyle (because who doesn’t like to maximize their return on investment?). I chose something I do not like to do, something that scares me, something I have difficulty with, something I avoid like the plague, but most importantly it’s something that I wish I could do better; a skill that I envy: having difficult conversations.

Communication is a vital component of our lives. We all communicate, but how many of us have mastered the skill of communicating? Also, there are many aspects of communication (2). Poor communication can make or break a situation or relationship. Being able to communicate well is a great skill to possess (3). Reference two provides a long list of skills that I highly recommend you also take a look at (https://www.thebalance.com/communication-skills-list-2063737). I went down the list and individually assessed which skills I feel that I do well with and which ones I do not (2). This little exercise served as a reality check as to where I stand in regard with my aptitude to communicate. I invite you to do the same. You may be surprised at what you find!

The Importance of Good Communication

As a laboratory director, many facets of my job depend on my ability to communicate well. I must communicate with clinicians, technologists, administrators, other coworkers, vendors, students, etc. Not only do I communicate with a variety of groups of people, in a multitude of different platforms (individually, small groups and meetings, or large groups; such as national conferences), but it is also important that my written, verbal, and non-verbal communication skills are clear and easily understood.

As laboratory professionals, one very important aspect of our job is to communicate critical results. It is essential that we not only relay the data, but it is equally important for us to communicate it well so that the clinician completely understands the information so that they can properly care for the patient. Moreover, we must not forget the golden rule: garbage in, garbage out. What I mean by this is that good communication should begin in the pre-analytical phase. We want the clinician to provide the laboratory with the best possible specimen so that in turn, we can provide them with the most accurate result. So how do we ensure that we obtain the best possible specimen? We communicate.

The laboratory communicates our needs to the provider in order to properly do our job. For example, we provide detailed information on how to properly collect specimens, which container type to use, how to handle the specimen, how much (volume) specimen to submit, which temperature to submit the specimen, etc. Properly communicating these details is essential.

The Difficult Conversation

As laboratory professionals, we are just one part of a larger healthcare team. If you stop to think about it, we all have to participate in difficult conversations as part of our jobs. Doctors have to tell patients that they are going to die, laboratory professionals have to tell clinicians we lost their specimen, executive administrators have to tell downstream leadership that the budget has been cut again, managers and supervisors have to tell employees they are being written up or worse. Being able to successfully have a difficult conversation would serve us all well. As such, most institutions provide classes or webinars to help employees develop this skill.

The definition of difficult is: not easily or readily done; requiring much labor, skill, or planning to be performed successfully; hard (4). Carrying out a difficult conversation with grace is an extraordinary skill that encompasses a variety of communication attributes. Regardless of the scenario, the communicator must be clear, articulate, and courteous. However, depending on the scenario, being concise, confident, strategic, diplomatic, convincing, empathetic, motivating, open-minded, and/or quick thinking may also be useful skills to possess during a difficult conversation. Other valuable skills are conflict management, being able to explain, and/or listening. 

The Conclusion

For many, the New Year marks the time to set new goals, to accept new challenges, and welcome new beginnings. Why not use this opportunity to learn a new skill? The good news is that no matter what your new skill will be, it will also benefit your health. In order to acquire a new ability, you must work to actively learn to become proficient in that ability; therefore learning a new skill will also benefit your brain function. There are many studies that demonstrate that active learning keeps the mind sharp (5). Challenging your mind improves brain function and active learning slows cognitive decline (6). If you want to be brave, then don’t only choose a skill that will be fun or helpful, but choose to learn something that also challenges you to face one of your fears. For me, I hope to learn how to master the art of having difficult conversations….successfully. In the words of Marie Curie, “Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.”

Happy learning! Happy New Year!

 

The References

  1. Work-life Balance. https://en.wikipedia.org/wiki/Work–life_balance. Accessed January 16, 2018.
  2. The balance. List of Communication Skills for Resumes. https://www.thebalance.com/communication-skills-list-2063737. Accessed January 16, 2018.
  3. The balance. Communication Skills for Workplace Success. https://www.thebalance.com/communication-skills-list-2063779. Accessed January, 16, 2018.
  4. com. Difficult. http://www.dictionary.com/browse/difficult. Accessed January 16, 2018.
  5. Stenger, M. 2013. New Study Shows How Active Learning Improve Cognitive Function. https://www.opencolleges.edu.au/informed/other/new-study-highlights-activities-to-improve-cognitive-function-6008/. Accessed January 17, 2018.
  6. Park, D.C., Bischof, G.N. 2013. The aging mind: neuroplasticity in response to cognitive training. Dialogues Clin Neurosci. 15(1): 109-119. PMC23576894. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622463/. Accessed January 17, 2018.

 

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-Raquel Martinez, PhD, D(ABMM), was named an ASCP 40 Under Forty TOP FIVE honoree for 2017. She is one of two System Directors of Clinical and Molecular Microbiology at Geisinger Health System in Danville, Pennsylvania. Her research interests focus on infectious disease diagnostics, specifically rapid molecular technologies for the detection of bloodstream and respiratory virus infections, and antimicrobial resistance, with the overall goal to improve patient outcomes.