Test Turnover

What’s your lab’s procedure for getting rid of an obsolete test, or bringing in a new one? Any change to the test menu has some level of difficulty associated with it, however my opinion is that replacing a test with a new method that gives different results is the easiest to accomplish, followed by introducing a completely new test, and lastly removing an obsolete test. In that last case I’m specifically talking about removal of a test that is no longer the best way to diagnose a disease or monitor treatment.

In any of these cases, does your lab use the “rip the band aid off” method? For example, do you send a succinct notification that as of the first of the month this test will no longer be available in your lab, or this test will have results 33% higher than the doctors have been previously seeing? Or do you use a more gentle method, such as offering to run the old and new method together for 2-6 months to let the doctors get used to the new values? Or in the case of removing a test, do offer to try to find them an alternative lab which is still running the old test? Or do you simply leave the old test in place and hope it eventually dies a natural death from lack of use? Unfortunately, some tests never seem to die – like CKMB and bleeding time.

A lot of the difficulty, both in getting rid of old tests and in bringing in completely new ones, can probably be laid on the doorstep of human nature. Just like other humans, doctors like what they’re used to and don’t like changing their routine. Even when overwhelming evidence suggested that a new test is better (troponin), they want to use what they have always used to diagnose and treat their patients (CKMB). When the evidence for a test’s utility is not so clear cut, it’s even more difficult to introduce a new test. Examples of this include Cystatin C and fructosamine. Cystatin C is becoming more widely used and will no doubt survive as a test, but fructosamine? Part of the issue with fructosamine may have been the silly name they gave it. Fructosamine? Really? If they had called it glycated proteins/albumin it may have fared better. Fructosamine sounds too much like a fruit drink.

Maintaining a test menu that is appropriate for your population and that doesn’t include unnecessary or obsolete tests is an interesting balancing act. It definitely requires having a good rapport with your clinicians and getting their input along the way.

 

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

A Rare Myeloproliferative Disorder

hypereosinophilic

A 59-year-old male presents with skin lesions, hepatosplenomegaly and cardiomyopathy. A representative field of his blood smear is shown here. Of the following, what is the most likely diagnosis?

  • A. Chronic myeloid leukemia
  • B. Multiple myeloma
  • C. Metastatic prostate carcinoma
  • D. Hypereosinophilic syndrome
  • E. Bacterial sepsis

The diagnosis in this case is hypereosinophilic syndrome, a rare myeloproliferative disorder characterized by a marked and persistent elevation in the eosinophil count. Although this disease is primarily a hematopoietic disorder, it usually affects many other organ systems, such as the cardiovascular, nervous, respiratory, and gastrointestinal systems. Typical presenting symptoms include cardiomyopathy, skin lesions, thromboembolic disease, neuropathy, hepatosplenomegaly, and pulmonary disease. The pathophysiology behind the damage in these organs isn’t well understood, but it probably has something to do with the release of eosinophil granules in those tissues.

You need to have three things in order to make the diagnosis:
1. Persistent eosinophilia (absolute eosinophil count >1500/μL)
2. No other cause for the eosinophilia
3. Signs and symptoms of organ involvement

Other more common causes of eosinophilia, such as drug reactions, allergic reactions and autoimmune disease, must be ruled out before making the diagnosis.

Usually, patients aren’t treated unless or until they have symptoms (because the treatment itself has its risks). These patients are monitored closely with serum troponin levels (to monitor for MI), echocardiograms and pulmonary function tests.

Some patients with hypereosinophilic syndrome have a tiny deletion in 4q12, which ends up producing a fusion transcript called FIP1LI-PDGFRA (which is also present in some cases of systemic mastocytosis). Imatinib works very well in the majority of these patients.

Patients who have symptoms (but not FIP1LI-PDGFRA) are generally treated with steroids first. If those don’t work, interferon alpha and hydroxyurea are used. If those don’t work either, then imatinib is the treatment of choice (it doesn’t work as well as it does in patients withFIP1LI-PDGFRA, but it does seem to work in at least some of these patients).

Here are the reasons the other answers are incorrect.

  1. Myeloma is a monoclonal disease of plasma cells which manifests mainly in the bone marrow. In the blood, the main thing you see is rouleaux (red cells stacking up on top of each other). This blood smear just has a lot of eosinophils – so it’s not consistent at all with myeloma. The clinical history also doesn’t fit. In myeloma, patients usually have bone pain, signs of anemia (fatigue, palpitations), and maybe signs of renal failure. Hepatosplenomegaly, skin lesions, and cardiomyopathy aren’t generally seen in myeloma.
  2. In CML, you see a massive leukocytosis which is composed of neutrophils and precursors. There is a big left shift and a basophilia. This smear just has a ton of eosinophils, which is not consistent with CML. The patient’s hepatosplenomegaly would be consistent with CML (especially the splenomegaly part) – but the skin lesions and cardiomyopathy don’t go along with that diagnosis.
  3. In metastatic prostate cancer, it’s possible that you might see a rare tumor cell in the blood; you might also see a monocytosis (you occasionally can see that with solid tumors). Eosinophilia, however, is not consistent with prostate cancer. The history is also unsupportive. Patients with advanced prostate cancer may have urinary symptoms (trouble urinating, blood in the urine), abdominal or pelvic pain, or signs of metastasis (bone pain, particularly in the spine).
  4. The characteristic blood finding in bacterial sepsis is a neutrophilia, with or without a left shift. You may also see toxic changes in the neutrophils: toxic granulation, Döhle bodies, and/or cytoplasmic vacuolization. Bacterial infections generally don’t produce an eosinophilia – but some parasitic infections can.

Krafts

-Kristine Krafts, MD, is an Assistant Professor of Pathology at the University of Minnesota School of Medicine and School of Dentistry and the founder of the educational website Pathology Student.

Season of Greetings

It’s amazing the year is nearly over, the halls are decked, candles lit, celebrations scheduled. Friends and families gather, eat too much, hug and kiss, pass around gifts and graciousness…and microbes.

Laboratory professionals know all too well that “Seasons Greetings” are just the thing for passing along your favorite virus or enteric pathogen. This year, we are especially conscious of the contagious nature in the world of unseen assailants. Global health has faced the disastrous affects of improper hand washing and challenging sanitation conditions; and not just with the Ebola crisis, but in refugee camps and among those facing the strife of war.

Laboratories don’t close for holiday celebrations…and laboratory professionals don’t always get the days and times off that would make them happy around the holidays. But this year I challenge us with two things:

  • Remember to offer “Seasons Greetings” with best practices and don’t take any of your laboratory favorites along to the parties and gatherings!
  • If you’re working that extra shift, or one that is encroaching on your family and personal time—remind yourself that there are so many in the world who would rejoice in the opportunity to be working, to be healthy enough to be working and free of disease, strife and conflict, and could watch their children and families smile, eat too much, hug and kiss and pass along “Seasons Greetings”.

My best to you for this holiday season, whatever ways you celebrate, and ‘tis the season to remember our colleagues globally and do something to make the world a little better place locally! Happy Holidays!

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Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Selective Pathology Fellowships

So, what are selective pathology fellowships? They are 12 month fellowships that originally provided advanced competency training in subspecialty areas but would not result in ABP certification at their completion (eg – surgical pathology subspecialties). There are 3 tracks of these types of fellowships encompassing 80 currently ACGME accredited programs with 155 available positions as of the writing of this blog post (12/17/14): A) selective pathology-surgical pathology, B) selective pathology-focused AP, and C) selective pathology-focused CP. These programs can either be non-accredited programs (NAPs) or ACGME-accredited programs (AAPs) and the ACGME requirements for such fellowships can be found here.

These fellowships can be a stand-alone 12 months, as many of the surgical pathology selective pathology fellowships tend to be, or can include an extra year. Examples of extra year selective pathology fellowships include the New York City’s Office of the Medical Examiner and University of New Mexico’s forensic neuropathology/cardiovascular pathology fellowships and the Houston Methodist Hospital’s hematopathology fellowship (http://www.houstonmethodist.org/SelectivePathologyHematopathology), both of which require a second year beyond the traditional fellowship in these subspecialty areas. Methodist’s hematopathology selective pathology fellowship can be completed alone but will not lead to eligibility for ABP board certification in hematology, so it is preferable to combine it with the traditional hematopathology fellowship.

These fellowships either provide additional focused diagnostic training in areas important for these fields and/or opportunities for research. If there is a second year, funding is provided by the institution and not the Centers for Medicare and Medicaid Services (CMS) like it is for residency, and so this limits the numbers of these types of fellowships. Traditional AAPs are eligible for funding from CMS while NAPs are not. Some institutions instead of selective fellowships provide a second “junior faculty” or “clinical instructor” year.

Reference:

  1. JC Iezzone, A Ewton, P Chévez-Barrios, S Moore, LA Thorsen. Selective Pathology Fellowships: Diverse, Innovative, and Valuable Subspecialty Training. Arch Pathol Lab Med, April 2014; 138: 518-525. http://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2013-0454-SA

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Future Cost of Antimicrobial Resistance

Over on Superbug, Maryn McKenna (are you following her yet? No? If you’re into infectious disease, you should) discusses a recent report on the global ramifications of antimicrobial resistance. In it, the authors project by 2050, 10 million deaths a year will be attributed to infections caused by six resistant organisms. (Those are: Klebsiella pneumoniae, E. coli, MRSA; HIV, TB and malaria.) These deaths will cause an estimated loss of 100 trillion dollars of lost gross national product.

So what can laboratory professionals and pathologists do to help stop these predictions from coming true? For starters:

  • Advocate for and implement antibiotic stewardship programs.
  • Educate the public about proper antibiotic use.
  • Practice good laboratory safety practices.

What else can labs, microbiologists, and pathologists do to stem the tide of antibiotic resistance?

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Next Generation Sequencing and Personalized Genomic Patient Care

I’m sure that everyone has heard about next generation sequencing (NGS). But why exactly is it a big deal? Even though I have spent a significant amount of time at the bench performing “wet lab” basic science research and was acquainted with the term, I did not have practical hands-on experience with NGS prior to residency. It was not a readily accessible technology during my biomedical research days prior to medical school and so I did not entirely grasp the full power of this then disruptive technology until I was a pathology resident, and even more so, as an applicant for molecular genetic pathology (MGP) fellowships.

All of us should have previously learned about the “gold standard,” Sanger sequencing. This method combined irreversible dideoxynucleotide chain termination with a detection method such as gel electrophoresis, or on a larger, automated level, capillary electrophoresis. It was powerful because it allowed us to read the genomic map that directs cellular life, albeit only one sequence at a time. It served as the mainstay for more than a quarter of a century and still is employed for smaller scale sequencing or for long (>500 bp) stretches of DNA.

In the 1990’s, initial methods of massively parallel signature sequencing (MPSS) and pyrosequencing began to appear which would lay the groundwork for today’s massively parallel sequencing (MPS), also known as second generation sequencing, or more popularly as NGS. The two most commonly utilized NGS platforms to date are based on semi-conductor technology for the Ion Torrent (now Life Technologies) and reversible dye-terminator, sequencing based synthesis (SBS) technology for the Illumina platforms.

The power of NGS comes from its ability to simultaneously sequence 1 million to 43 billion short reads (400-500 bp each). The Human Genome Project took over a decade to complete and cost nearly $3 billion whereas NGS can sequence the same genome for a cost on the order of $1000’s, a cost that is further decreasing as the technology is refined. When I was working in research (eons ago), we had nitrocellulose based dot arrays where each “dot” represented multiple copies of a specific cDNA sequence and which helped us to build expression profiles for our particular area of study. This would be analogous to analog technology and NGS would now be considered a digital version.

With conventional PCR, we could only amplify one target sequence per sample reaction. The results were also only qualitative. The results only measurable after multiple cycles of denaturation, annealing, and extension as amplified product of the expected size or no amplified product. Then came along real-time or quantitative PCR (qPCR) which some people refer to also as RT-PCR (although this is a confusing term for people like me who were around before qPCR and think of RT-PCR as meaning reverse transcription PCR). The power of qPCR was that within the linear range of detection, we could now quantitate the amount of product present in real time. NGS also provides the resolution of qPCR in terms of quantitation.

So, as a technology, NGS nicely combines and refines some (but not all) characteristics of multiple technologies with large scale profiling. But for a non-molecular person, what is the relevance? Obviously, it has taken us some time to get to this point, even though the Human Genome Project was completed in 2003 (it started in 1990). We needed time for biomedical and translational research to provide us with clinical significance to the mutations and genetic aberrations NGS could identify. We also needed to develop tools to distinguish true mutations with clinical significance from benign polymorphisms present in our population and to build our bioinformatics support.

But here we are, stepping into the new frontier of personalized genomic medicine. Sure, there is a lot of hype surrounding it and these promises will take time to keep. But these are exciting times for someone like me who fell in love with the molecular dance that plays out within our cells. One of the reasons that I want to complete an MGP fellowship is to get more hands-on practical knowledge of the nuances of NGS from a technical standpoint but also to collaborate with other physicians in directing patients to the correct clinical trials and targeted treatment – and therein, is where the power of NGS really lies. For someone who may never get to meet the patient, at least for me, there’s probably no greater satisfaction than knowing you had a pivotal part in helping a patient more effectively combat their disease. Personalized genomic medicine is another step in that direction.

[12/12/2014: edited to fix a few inaccuracies. We apologize for the error.]

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.