The Voice of Sint Maarten

It’s often difficult for a medical student to take time out of their schedule and work on projects in their community. Our free time is often encumbered with the “fire hose” of information that we all need to process and master before we sit for board exams. To be fair, there isn’t any free time per se. It is apparent (in medical school more than any other time I’ve known) that every minute of the time we schedule is, by choice, purposeful or not. With that noted, something exceptional happened this month in a span of three days that I am truly proud of. My “Z-Pack” Zika virus prevention initiative team all came together and tackled three extraordinary events around our Sint Maarten community.

If you’re just joining the Zika-related action, check out the background behind my work as well as some of the major accomplishments, achievements, and noteworthy lessons along the way this past year. My team’s work bridges a gap that exists between public health and the data we laboratorians acquire through diligent research.

The whirlwind of public health outreach events the Z-Pack was able to do were highly productive to the cause:

  • We have bolstered our public health and source reduction message on local radio, television, and print.
  • We have engaged and partnered with innumerable entities within this community and were an integral part of a mainstay annual health fair.
  • We engaged with local community members, not as students, but as public health liaisons fielding in-depth questions and addressing real concerns of the local population.
  • During these episodes, we were able to procure true data which we continue to collect, analyze, and use to formulate new approaches to positive health outcomes.

The first exciting development I listed was the debut into our media campaign. Being invited to the local radio to advertise our work and promote upcoming events was both exciting and reaffirming. In a short interview, I addressed Zika and other virus threats to the island community and discussed epidemiologic data and what it means in the scope of public health. Talking about our work alongside two of my team members and the project manager of the Ministry of Health’s vector control program was a thrill. A fellow team member and I were also fortunate enough to be flagged down by a local cable access television program to promote our work on a short video spot during our presence at the Lion’s Club Annual Health Fair I’ll discuss shortly. These media outlets reminded me of moments back in the laboratory when I had to present data clearly and field questions “on the fly.” Whether it was a staff meeting, educational resource assessment, or CAP inspection response, I couldn’t have been more prepared to handle the translational bridge from data to public view.

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Image 1: “Z-Pack” on the radio!

(Listen to the 16 minute radio spot here from PJD2 102.7FM/1300 AM The Voice of Sint Maarten)

I mentioned the Health Fair the local Lion’s Club sponsors each year, with booths that address a plethora of health education outlets from diet/nutrition, to diabetes, to (of course) mosquito reduction.  Partnering with our colleagues in the Ministry of Health we set up several tables in a tented booth and made available all kinds of educational resources for the public. There was a station designated to secondary interventions for combating mosquito risk reduction such as fogging guns and larvicides for standing water areas. I designed some clear-message flyers to distribute to patrons and others passing by our booth and was able to spark some interesting conversations with local community members and business owners who wanted more information—they wanted to distribute and display the same information in their offices and homes. Gaining popularity with the local community, we decided to record those interested parties and give them the title of “official community partners.” Not only will they feel more involved in the process of empowering and advocating for health for their community, but they will be motivated from within! I will say that my absolute favorite part of this health fair was the station our Ministry partners set up which included all their laboratory equipment they use to speciate, quantify, and analyze the local mosquito threat. This, alongside with our friends in local laboratory medicine who were collecting specimens to screen for Zika serologically, made this a very friendly environment for a laboratory professional like myself. You can bet I was happy to talk to visitors about epidemiology and risk reduction over a few microscopes!

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Figure 1: Clear-message informational flyers for public patrons to our booths at the health fair.
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Image 2: Health fair snapshots, a fogger gun, and some team building with microscopes.
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Figure 2: Preliminary data processing reveals an improvement in perceptions, attitudes, and behaviors toward Zika virus and overall arbovirus risk reduction.

On a more serious note, I want to speak briefly on the amazing opportunity that our community meeting offered for my team and I to learn some real truths about public health here on the island. With the success of partnering with laboratory services, research work in the field, and participating in a growing media campaign, the Z-Pack arranged a community meeting at a local religious center. Our “community meetings” as proposed in part from our earlier work focus on presenting audience and culturally specific information about reducing arbovirus risks and addressing health within the community. A community liaison connected us to a local Islamic center, where we conducted one of these meetings. Our presentation was received well, and a vigorous discussion followed. Having a partner from the Ministry of Health with us that day provided some clout to our discussions. I drew heavily on my interpersonal skills as a laboratorian when I fielded some really challenging questions from the adult crowd. Concerns in this particular community included specific objections to the effectiveness of the Ministry’s work on reducing mosquito populations, frustration over tourist-heavy areas receiving unfair attention, and true worry over improving health outcomes in a constructive and collaborative way. Taking the time to share their personal experiences was greatly appreciated by my team. Really engaging with the community on an individual level really makes it feel as though we are creating positive change. As a part of our work, data was collected on the effectiveness of our message. Still in its early stages, the data (Figure 4) shows qualitative improvements toward answers in post-presentation surveys which reflect new facts learned, potential for social/behavioral change, and establishment of health risk as a community priority.

 

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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.

Hematopathology Case Study: A 54 Year Old Male with Acute Onset of Progressive Neck Swelling

Case History

A 54 year old male with a diagnosis of HIV (last CD4 count was 301 on 11/2016) currently on HAART presented to the Beth Israel Deaconess Medical Center (BIDMC) ED on 2/28/2017 with an acute onset of progressive neck swelling over the course of 4-5 days. Laboratory values on presentation was significant for a LDH of 1061 IU/L. Other laboratory values were stable. Upon CT imaging with contrast of the neck, an extensively necrotic right cervical lymphadenopathy was present and was extending into the supra- and infraclavicular chain. No mediastinal or hilar lymphadenopathy was noted.

On 3/1/2017, the patient underwent an ultrasound guided core needle biopsy of the right cervical mass (see images). By immunohistochemistry, the neoplastic cells are positive for CD138 and MUM1. PAX5 shows dim and heterogeneous staining in a subset of cells while CD79a highlights a minor component of the lymphoid population. CD3 and CD5 are positive in T-cells occupying a small subset of the lymph node. CD20, BCL2, BCL6, BCL1, CD30, CD56 and HHV8 are negative. By Ki-67 immunostaining, the proliferation index approaches 100%. In-situ hybridization for Epstein-Barr virus encoded RNA (EBER ISH) is positive in a major subset of cells.

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CD20 (left) and CD3
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MUM1 (left) and CD138
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EBER ISH (left) and Ki-67

By cytogenetic analysis, only two cells were available for metaphase interpretation and it showed a translocation between the long arms of chromosomes 8 and 14 and by FISH, a t(8;14)(q24.1;q32) was noted, indicating an IGH/MYC rearrangement.

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Overall, the morphologic, immunophenotypic, and cytogenetic findings in conjunction with the clinical features of a HIV positive male and EBV association, the diagnosis is in keeping with a plasmablastic lymphoma.

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Discussion

Plasmablastic lymphoma is a diffuse proliferation in which the cells resemble immunoblasts but share an immunophenotype similar to that of plasma cells. First described in the oral cavity, especially among HIV infected patients, it can present in a variety of extranodal sites, such as skin, soft tissue, and gastrointestinal tract. Although uncommon, plasmablastic lymphoma has its highest incidence among HIV infected individuals. Most patients are at stage III or IV at presentation with an intermediate to high risk IPI score. The tumor cells of plasmablastic lymphoma are invariably infected by Epstein-Barr virus (EBV) and are consistently negative for HHV8. According to Balague et al.2, up to 39% of plasmablastic lymphomas demonstrate a MYC translocation, all of which involved the IGH gene. Generally, plasmablastic lymphoma displays a complex karyotype, although some cases display an isolated MYC rearrangement without a complex karyotype. Taddesse-Heath et al.3 has shown a small cohort that is positive for gains in odd-numbered chromosomes 3, 5, 7, 9, 11, and/or 15, similar to that seen in plasma cell myeloma. The clinical course of plasmablastic lymphoma is quite aggressive with most patients dying within one year after diagnosis. Current first line treatment for plasmablastic lymphoma is dose-adjusted EPOCH with or without bortezomib, intrathecal prophylaxis, and possible autologous stem cell transplantation in first remission candidates. Future directions of therapy include chimeric antigen receptor (CAR) T-cells and small molecular inhibitors against the MYC bromodomain4.

References

  1. Swerdlow, S., et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 4th. ed., IARC press: 2008
  2. Balague, O., et al., “Plasmablastic lymphomas are genetically characterized by frequent MYC translocations [abstract],” Mod Pathol 2009; 22:255A.
  3. Taddesse-Heath, L., et al., “Plasmablastic lymphoma with MYC translocation: evidence for a common pathway in the generation of plasmablastic features,” Mod Pathol 2010; 23:991-999.
  4. Castillo, J., et al., “The biology and treatment of plasmablastic lymphoma,” Blood 2015; 125:2323-2330.

 

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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.

Business and Legal Considerations for Pathology and Laboratory Service Providers

The legal considerations when providing pathology and laboratory services can be daunting. However, help is at hand! ASCP Press recently released a Business/Legal handbook. Also, in this podcast, an attorney gives listeners a basic rundown of some of the legal intricacies involved in running a laboratory.

ASCP Annual Meeting Call for Abstracts Now Open

The 2017 ASCP Annual Meeting is in Chicago, IL September 6-8. If you’d like to present your research at the meeting, the call for abstracts is now open. Summarize your work in 300 words or less and submit it through the online portal by March 20th, 2017.

Spread the word, and good luck!

 

Serotypes and Stereotypes: the Path to Pathology

Hello and welcome back! After a hiatus for the holidays, I’m now back at school and gearing up to write about more Arbovirus-related public health endeavors. But, with projects on hold until now, I’m going to briefly depart the world of mosquito source reduction and epidemiology to discuss something that relates to my experiences in medical school. If you read my Lablogatory bio, you’ll see I spent a number of years studying and working in some of Chicago’s great clinical laboratories. In the past decade, I’ve been very close to the field of pathology and laboratory medicine. As I reach the “half-way” mark in medical school now, I have become increasingly aware of the way people across healthcare professions and specialties view laboratory clinicians. One thing that stands out strikingly is, what I argue, a potential stereotype.

Let me tell you one of my pet peeves. As a medical student, I am fortunate enough to learn and work under the guiding hands of physicians, nurses, and other educators. I work my hardest to learn how to provide the best care possible as I learn the skills needed for my future practice. In debriefing from a simulation, a good performance might spark conversation which culminates to the paramount question: “Have you thought about a specialty?” My heart set on it for a while, I often remark “Pathology” before I correct myself to “Clinical Pathology” since I’ve learned to curtail jokes about autopsies. (Disclosure: autopsies are a very important part of medicine, and the number of autopsies have experienced an unfortunate downward trend.)

As a result of my AP/CP answer, many people are often surprised, citing that I’ve been “great with the patient(s).” So that begs the question: why does my current answer surprise people? And more importantly, what perpetuates the stereotype of an introverted, microscope jockey who doesn’t want to be near patients? Yes, hyperbole, but I’ll come back to this stereotype.

While I was stateside visiting family, I coordinated some clinical shadow time with a colleague and alumnus of my medical school in her pathology residency at University of Alabama at Birmingham (UAB). I spent time rounding with their teams in derm-path, watching sign-outs for endless cases, and getting up close and personal with autopsy training with another pathology resident. Each interaction with the faculty and staff were familiar and expected—full of enthusiasm and passion about their respective field of research or clinical work. What struck me as special, however, was that I was neither questioned for my motives in seeking pathology as a specialty, nor did I surprise anyone by being social and amicable. Everyone was quite sociable and proud of their work. My interactions were limited to the anatomic and clinical pathology departments so I suspect there may have been some bias. When I was a medical laboratory science student, I recall working with other disciplines, and, though I may have been in a nascent time in school to notice any stereotypes, they became clearer as I progressed through various jobs across the city. Large trauma centers, small community hospitals, even a shadow stint at the Cook County Medical Examiner’s Office, all taught me valuable lessons on varied scope and different professional perspectives. And all the while, people seemed surprised I would be interested in such a misunderstood specialty.

On Lablogatory, I’ve enjoyed just about every post and one of my favorites is a series by Dr. Lori Racsa, “Lonely Life of a Clinical Pathologist.” Dr. Racsa discussed things about laboratory medicine I had observed in my time as a medical laboratory scientist: the critical role of pathologists on committees, the value of built-in mentorships, the [aforementioned] mystery about the particularities of the job to clinicians and laypeople alike, and the value of technologists like myself! One of the most poignant posts she wrote addressed the potential for a clinical pathologist to round with other “floor” clinicians. That was something I thought I’d dreamed up in my ambition to go to medical school, blazing a trail in Path where I could put some cracks in that stereotype. Dr. Racsa cited a great article from Critical Values by Dr. H. Cliff Sullivan where he recommended pathologists become more actively involved with fellow clinicians to directly improve patient outcomes. Having freshly attended several events at the ASCP National Meeting in Long Beach just prior to his article, I rode a wave of his “rally call” for changing the face and accessibility of pathology as a specialty. I saw myself in both his and Dr. Racsa’s stories of interdisciplinary teams, rounds, and committees and I’ve been excited ever since.

Back to that stereotype. Those articles about pathologists’ roles in medicine reflect a distinct lack of visibility to fellow colleagues. While we all recognize that nearly 100% of cancers are lab-dependent diagnoses and 70% of patient records are tied to diagnostic laboratory data, why are nearly half the residency spots for Pathology in the US National Resident Matching Program unfilled for the past few years? According to recent surveys by the American Medical Association, Pathology has one of the lowest relative rates of physician burn-out compared to other specialties. Pathologists are earning within 15% of the average physician income, with one of the highest relative satisfaction scores to match. So with lifestyle and career quality reporting positive values, I would argue that the seeming lack of interest stems from the possible lack of exposure of pathology as a dynamic field. The stereotype I’ve been talking about might also be one of attrition—“out of sight, out of mind.” Some great pieces of work on Lablogatory focus on promoting the value of laboratory medicine as an integral part of any patient’s care. Just recently, Dr. Sarah Riley discussed CO poisoning and public health, while her bio calls for “bringing the lab out of the basement and into the forefront of global health.” I feel close to that cause myself, hopefully made evident in my previous posts. Stay tuned for next month’s where I’ll be discussing the next steps in our public health project on Sint Maarten. After celebrating a successful 2016 effort presented by the Ministry to the Global Health Securities Agenda, our team has a number of projects lined up to demonstrate effective integration of lab medicine, epidemiology/public health, and social outreach.

A friend and mentor once told me to keep a completely open mind about my medical career and let whatever specialty fits best “find me,” so to speak. I couldn’t have asked for more sound advice. I’ll admit I have my biases and comfort zones, and for now that’s what they’ll remain. In this post, I had hoped to shine some light on the disparities in career reputation between pathology versus other disciplines. Is the stereotype founded in any truths I may have missed? Don’t pathologists have the social tact to work up and down the ladder, working with lab assistants to government health officials? Have you ever been challenged for your career choices in pathology? What reasons do you think contribute to the stereotypes I mentioned? What words can you offer students like me just starting to find a foothold in their newfound careers in medicine?

Leave your comments below! Thanks!

 

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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.

Lonely Life of a Clinical Pathologist: Thank You

I wanted to say thank you to everyone who has left comments on my past posts and shown encouragement to the topics discussed. I will be taking a break from blogging but wanted to encourage everyone in the clinical pathology field to keep up the hard work of patient care behind the scenes. I hope you can be ambassadors of laboratory services and help influence the care of patients in positive ways throughout the hospital systems you work in.

In lieu of a holiday card, I wanted to sign off blogging with a meme for all clinical pathologists out there:

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-Lori Racsa, DO, is the director of microbiology, immunology, and chemistry at Unity Point Health Methodist, and a Clinical Assistant Professor at the University Of Illinois College Of Medicine at Peoria. While microbiology is her passion, has a keen interest in getting the laboratory involved as a key component of an interdisciplinary patient care team.

The Lonely Life of a Clinical Pathologist: Finding a Mentor

Over the last few blog posts I have spoken about my involvement in the laboratory and hospital to find other people interested in clinical pathology. While this has helped fuel my passion for laboratory medicine, one of the issues that made me feel the loneliest was the responsibility I felt as a new pathologist and not having someone to help share that burden.

As a pathology trainee I saw several new pathologists start their positions in microbiology, hematology, and even anatomic pathology. They always seemed to be cool, calm, and collected (unless they were running around trying to get their research published).  What I did not focus on was that they also had a built-in mentor (the experienced pathologist) who was there to discuss a tough case or help them make a difficult decision.

When I took a community practice based job I was immediately entrenched in a decision making role. The sense of responsibility I felt to our patients, and making sure those decisions affected care in a positive way, was more overwhelming than I expected. The decisions included items such as which instruments to bring into the lab, when to report certain isolates, and even how to handle irate clinicians about the way we report our results. Every time I encountered a new situation I had not experienced first-hand in residency, I wanted to run my approach by someone to make sure it was the right way of doing things. I had one mentor I am pretty sure I texted every day the first two weeks of my job (thanks Dr. Lars Westblade!) for every single technical question that came up in microbiology. While it may seem excessive, it was the only thing that gave my decision making confidence at that time.

As the year went on, other mentors from training were also there for me, but I realized I needed a mentor on site that I could run major decisions by, as they understood the environment I was in more than my training mentors could. I was hesitant to seek advice from my bosses, as I was hired for my clinical pathology expertise, but as I reached out for guidance, I came to find the senior pathologist could guide me in the politics of my current situation while I could make decisions on the technical background. I can now see that having a senior pathologist with a wealth of information on how to handle situations and clinicians has been invaluable to the start of my career. The wisdom imparted has given me direction and experience in making decisions that residency could not fully prepare me for, such as handling physicians not happy with aspects of the lab or employees who did not want to perform tasks I asked of them.

Beyond individual mentors, another area that helped me with technical aspects of my job has been belonging to clinical pathology societies. American Society for Microbiology has several different list-serves you can post questions and get answers back from experts all over the country and world. The American Association for Clinical Chemistry has a board called “The Artery” that you can also post questions to and experts will answer. These formats have been priceless when seeking advice on certain topics literature does not seem to cover and are examples of why belonging to professional societies really bolsters your career.

As the year has progressed and I have made one decision after the next, my confidence has been built up so that I don’t have to discuss every decision with my mentors; that being said, I still have them on speed dial. While I think that responsibility is one area that residency was not able to fully prepare me for, I can see that it is a work in progress and one aspect of my job that will continue to motivate me to be the best I can be and make the best decisions for our patients.

Now to hear from you: did responsibility overwhelm you your first year of practice? How do you utilize mentors and professional societies to help approach unique and new situations?

 

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-Lori Racsa, DO, is the director of microbiology, immunology, and chemistry at Unity Point Health Methodist, and a Clinical Assistant Professor at the University Of Illinois College Of Medicine at Peoria. While microbiology is her passion, has a keen interest in getting the laboratory involved as a key component of an interdisciplinary patient care team.