Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.
All laboratory professionals are aware of the importance of reference intervals (RI). Without appropriate reference intervals, a test result is just a number. A numeric result for any given analyte cannot be used to diagnose or monitor treatment of disease unless there is an accompanying reference interval indicating what amount of that analyte should normally be present. In pediatrics, that’s even more important because as an infant develops through childhood and into adulthood, his or her biochemistry changes, adapts and develops with him or her. Using an adult RI to interpret a test result from an infant or child is likely to result in misinterpretation of the test, including misdiagnosis of disease states. A good example would be using adult alkaline phosphatase RI to interpret the results of a teenage boy’s test during accelerated bone growth in puberty. His result will look pathological if interpreted using adult RI. Pediatric reference intervals (PRI) are age-related and often also gender-related intervals that must be used to interpret testing in the pediatric population.
Establishing reference intervals is problematic at the best of times because of the need to use 120 healthy individuals to establish them. In the pediatric population, especially in infancy, obtaining 120 healthy infants at each necessary time interval can be a daunting task. There are references available that present methods which allow the establishment of RI with smaller sample numbers (1,2). Also the CLSI document (2) allows the “validation” and “transfer” of current or literature RI, rather than complete “establishment” of RI in some cases. Validating a current reference interval can be done with as few as 20 samples in a correlation study. “Transferring” a reference interval also involves using a correlation study and bias evaluation to adapt or adjust a current RI for use with a new assay. Transferring can also be performed with 20 – 60 patient samples.
These techniques especially come in handy with the hardest PRI to establish, the hormones during puberty. During this time, the RI are not really related to the child’s age, but related to the child’s phase of development, or Tanner Stage. To establish a PRI for these hormones, the healthy child donating the blood sample must also have his/her Tanner Stage determined, usually by an Endocrinologist.
Another consideration when dealing with PRI is that although all pediatric institutions use PRI, not all PRI are the same, even when the same instrument is used. An informal poll of 9 pediatric institutions using the same instrument resulted in 9 different PRI for common analytes such as electrolytes. There is a need to harmonize PRI, as we harmonize test results, in order to allow non-pediatric institutions a set of PRI that they can use also.
- Horn PS, Pesce AJ. Reference Intervals: a User’s Guide. AACC Press, Washington DC, 2005
- Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory: Approved Guideline – Third ed. CLSI C28-A3
-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.
And so are STDs.
Well, not the air so much as … other places … but anyway. It’s that time of year again. My personal anecdotal experience is that testing for STDs tends to spike in late winter/early spring (Thanks, Valentine’s Day and Spring Break). Several STDs can make your Valentine’s Day one to remember, though the big three in this country are gonorrhea, Chlamydia, and syphilis. The incidence of these STDs are rising, and the biggest demographic for infections are 15-24 year-olds. (If you want to read the full CDC surveillance report in all its glory, it’s here. Make some popcorn. It’s long.)
What does all of these mean for laboratory professionals? Microbiologists need to be aware that Neisseria gonorrheoeae can grow on blood agar, albeit not as well as it does on chocolate or Thayer-Martin. On blood agar, the colonies are grayish to white and more opaque than those on chocolate agar. The gram stain shows gram-negative diplococci, but as always, a gram stain result should be considered presumptive until confirmed by culture or molecular tests. Laboratories should be aware of their patient demographics; if your lab serves a large population of teenagers and young adults, you might see an influx of specimens.
–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.
“In demographic terms, it seems, the Asian century could be followed by the African century…Whether Africa is able to prepare for its coming population boom may well be one of the most important long-term challenges the world faces right now.” So says Max Fisher in the Washington Post article “The amazing, surprising, Africa-driven demographic future of the Earth, in 9 charts.” I found these charts and Fisher’s commentary incredibly interesting and well-worth exploring (especially with the future of health care resources in mind). As he points out, the next century being the ‘African century’ will have good, bad, and unforeseen consequences. Even if it is does not turn out to be the ‘African century,’ continued population growth seems to becertain and will put increasing burdens on resources in African countries. With more people, there is need for more water, more food, more jobs, more sources for transport, etc. More people also mean the need for more health care and thus, increased capacity for laboratory services. Yet another argument for the importance of expanded and improved laboratory (and all health care) services in the next decade.
Another interesting statistic from Max Fisher’s charts is that life expectancy in Africa in the next 80 years is expected to increase by 50%. However, in 2090, it will still not be equivalent to that in the U.S., Europe, South America or Asia. From a health care perspective this is interesting both in the reasons why it will still be the lowest life expectancy in the world, and, in how health care is affected by a growing aging population (much like challenges we are beginning to see and expecting to see expand in the coming years in the U.S.). However, with this in mind, take a close look at his chart number 9 on dependency ratios (the ratio of the population under age 15 and over age 64 and thus ‘dependent’ on others and the government to provide for them). Africa’s dependency ratio is projected to decrease from 80% today to 60% by 2055, while the dependency ratios in the rest of the world are projected to increase. This could mean a more productive work force, and more people to take care of a population that is living longer. As Mr. Fisher points out, however, a large younger population can result in increased political instability.
While these charts are all projections and any number of factors could completely alter the course of these projections, it is fascinating to think about and study, and certainly worthwhile preparing for.
I originally stumbled across Mr. Fisher’s charts through a different article of his in the Washington Post called “40 more maps that explain the world.” This one is equally fascinating and I could have spent hours absorbed in the various maps.
On an unrelated note, a quick update to my post from last month: President Obama nominated Dr. Deborah Birx to become the next Global AIDS Coordinator. Dr. Birx has spent her career focusing on immunology, vaccine research, and global health. From the laboratory-strengthening perspective she is an exciting choice for this role. Her nomination still needs to be approved by the Senate. Her bio on the CDC website.
-Marie Levy spent over five years working at American Society for Clinical Pathology in the Global Outreach department.
Fellow residents, do you sometimes feel burned out, especially with the dismal winter weather than many of us have been experiencing lately? There have been many, predominantly small sample size, cross-sectional studies over the years on this topic. Methodological deficiencies in many of these studies may bring into question some of the generalized conclusions that they assert but does not discredit the truth that resident burnout exists and should be taken seriously by training programs.
In 2004, an article in JAMA on this topic defined “burnout” as a “pathological syndrome in which emotional depletion and maladaptive detachment develop in response to prolonged occupational stress.”1 Multiple studies have identified factors such as time demands, variability in faculty expectations, work overload that inhibits learning, systemic program issues, inadequate elective time, and lack of communication and support from faculty and peers as potent contributors to resident burnout.1,3 Furthermore,a subsequent study identified that burnout was associated with absenteeism, low job satisfaction, and medical errors.2
So, first, how can we identify if we are experiencing burnout? As with everything in life, know thyself. Conduct an honest self-assessment of your strengths and weaknesses as well as your absolute needs, both at work and outside of it. If you are not good at honestly evaluating yourself, then ask a trusted person who has your best interests at heart their opinion and truly listen. Then set aside designated time to recharge your batteries. For some this means exercise, for others, it may mean spiritual or community volunteer experiences, or even, just doing “nothing.” The key is to not do any residency work during this time. This is often easier said than done but the first step is to make a commitment to try to do so.
Next, be proactive to bring out the change you want to see. Often when we feel that a situation is out of our control or that we have no choice but to submit to a situation that makes us unhappy, fatigued, or emotionally drained, these negative feelings we internalize may manifest as burnout. So, find a way to take back some control. Frequently, part of this does mean cutting out those aspects of your life that have become toxic, whether it be negative situations or negative people. Of course, this is also easier said than done. If I had the cure for this, I’d bottle it and sell it.
Finally, find support. This statement can mean interacting with a mentor who will both personally and professionally “be in your corner” and help guide you through acquiring the necessary skills you need to be a good doctor. It also means to turn to those positive people in your life, whether it is a family member or a good friend, who will listen to you without judgment, let you vent, encourage you in healthy pursuits, but most importantly, remain honest with you and not just be your cheerleader.
Interestingly, a small survey study in 2013 by Medscape of pathologists showed that only 32% of respondents stated that they were burned out.4 Even though the methodology for this study is not stated to be able to determine the legitimacy of this study, it at least gives me hope that if I survive residency, there is hope at the end of the tunnel for a reprieve from those often seemingly, hydra-like tentacles of burnout that threaten to bring us down.
- NK Thomas. Resident Burnout. JAMA, 2004;292(23):2880-2889.
- LW McCray, PF Cronholm, RA Neill. Resident Physician Burnout: Is There Hope? Fam Med, Oct 2008; 40(9): 626-632.
- L Joseph, PF Shaw, BR Smoller. Perceptions of Stress Among Pathology Residents. Am J ClinPathol 2007; 128:911-919.
- Pathologist Lifestyles – Linking to Burnout: Medscape Survey. Last updated on 3/28/13. Accessed on 2/11/14 at http://www.medscape.com/features/slideshow/lifestyle/2013/pathology#1
–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.
My struggle in the community hospital setting is having the appropriate inventory for the patient population I need to serve. When I stocked the refrigerator during my golf club days the oldest inventory went up front and the new product went to the back. Later in graduate school I learned that was the FIFO method of inventory management. Blood Bankers have a unique twist thrown our way in that as blood sits on our shelves certain things happen that make an older unit less desirable than one collected a few days prior. The life span of a red cell is around 100-120 days depending on which literature you cite. Our job as blood bankers is to get the freshest blood to each patient we serve, so inventory management becomes more of an art than science.
Let’s take first the type specific debate. Some will say always transfuse type specific blood; if the patient is type A then the patient receives type A blood. Some will say to give whatever is most fresh; if we have fresh O cells an A person will get O. What I found when I first came to be the supervisor in my blood bank is that we were outdating a lot of type A blood. So instead of just decreasing the amount of type A, I also increased the number of type O I had on my shelf. This allowed me to be more flexible; I would give out more O when my inventory of A was low. Also, the blood I was giving out was always fresher than before I changed the inventory.
Let’s take this another direction. My policy states that any patient with an antibody has to have two red cell units set up so there is no delay if a transfusion is necessary. I would rather have two type O units typed for some antigens, because if the patient with the antibody doesn’t need it, the units are readily available to anyone else. I use the flexibility of type O blood to be more versatile and to make sure that my patients are getting the freshest possible unit. I have searched for literature that says giving type specific blood is better for patient outcomes but I haven’t found it. If anyone has literature on the topic please send it my way.
This really comes down to what type of setting your blood bank serves. If you are in a medium size community hospital you will need to make these type of decisions to be flexible with your inventory. If you are a large medical center and are going through blood as soon as it gets delivered then you may not have to worry as much. The majority of us do not work for large centers, however, so we must look and analyze how we can best use this precious resource.
–Tommy Transfusion is the pseudonym of a blood bank supervisor in the midwest.