In preparation for this year’s National Med Lab Week, taking place April 16-22, UHN’s Laboratory Medicine Program and the Canadian Society for Medical Laboratory Science have come together to launch three videos detailing prominent laboratory tests.
The videos bring our audience into the labs at Toronto General Hospital and allow them to follow UHN Medical Laboratory Technologists through the testing process of Complete Blood Counts, Cross Matching and Protein Electrophoresis.
Check out the videos below, and pass the links on to friends, family and colleagues!
Possibly the most common laboratory test ordered. A complete blood count takes an in-depth look at a patient’s blood and counts the number of white blood cells, red blood cells and platelets to monitor a patient’s health and check for abnormalities.
A necessary step in blood transfusion to ensure donor blood is compatible with the receiving patient. Transfusion Medicine MLTs at UHN conduct this test daily to find the perfect match!
Arguably the most complex test we cover in the three part series – protein electophoresis reveals a lot about a patient’s protein levels. Whether there’s too much, too little, or anything in between, UHN MLTs are able to tell physicians a lot about their patients’ health from electrophoresis.
Special thanks to Jaimelyn Rara, Krista Maracle and Megan Spencer for their enthusiasm to show new audiences how things work ‘In the Lab’!
Congratulations to Dr. Eleftherios Diamandis, Chief of Biochemistry, LMP for receiving the 2017 American Association of Clinical Chemistry (AACC) award for Outstanding Contributions to Education.
The award recognizes excellence in education and is given to individuals who have devoted a major portion of their professional life to enhancing the practice and profession of clinical chemistry through education. Award recipients are selected for making significant, innovative, and/or cumulatively outstanding contributions in clinical laboratory science through their teaching, directing, mentoring, writing, and speaking – a feat Dr. Diamandis has achieved in all respects.
With over 20,000 members, the AACC is the largest professional organization of clinical chemists and pathologists, and its annual awards are given to honor those who have advanced laboratory medicine and patient care. This is Dr. Diamandis’ sixth award from the AACC. Winners will be recognized at the 69th AACC Annual Scientific Meeting and Clinical Lab Expo in June.
Full press release available HERE.
In case you missed it on UHN News (02.07.2017):
Dr. Runjan Chetty recalls it as an error of distraction.
It was a number of years ago, before Dr. Chetty became Interim Medical Director of the Laboratory Medicine Program at UHN. He was known for an open door policy in his office, so several colleagues came in seeking his input on a lab initiative as Dr. Chetty was reviewing a patient’s pathology case.
“While we all think we can multi-task, we’re really not very good at it,” Dr. Chetty says now. “We can manage our time to do multiple things throughout a day, but doing even two things simultaneously leaves us unnecessarily susceptible to errors.”
That day, the conversation in his office eventually required some mediation. Dr. Chetty weighed in and offered his opinion while finishing up the pathology report, sending the results to the patient’s treating physician.
Problem was, he left out the most important part of the report – the diagnosis.
And it wasn’t until several weeks later that Dr. Chetty realized his error.
Realizing his mistake
The “cliff-hanger” report revealed itself when a new case came in from the same patient. It was a different biopsy sample this time, and when Dr. Chetty looked at the patient’s previous pathology report, signed out by him, he saw the abrupt conclusion – he left out the diagnosis.
“It was an awful feeling,” he says. “Realizing you made a mistake that causes worry and uncertainty for a patient and their family is difficult to accept as a healthcare provider.”
Fortunately the second biopsy was needed regardless to monitor patient response, but Dr. Chetty says it could have ended much differently – potentially causing an at-risk patient to go through a needless biopsy.
Now, Dr. Chetty has a personal policy where he closes his door whenever a patient case is being reviewed, effectively blocking out all possible distractions. It’s not the open door policy he’d like to be projecting, but with safety on the line LMP staff don’t seem to mind knocking.
Caring Safely in UHN labs
Creating a just culture where mistakes are free from shame and blame is a key component of the Caring Safely initiative underway at UHN. And though Dr. Chetty has spoken out about his “error of distraction” to colleagues before, there is now an added emphasis on safety vigilance – especially for areas already facing significant quality and safety regulation.
Three months ago, LMP underwent one of its most extensive external quality and safety reviews, where staff successfully demonstrated safety practices that complied with hundreds of standards mandated by the province.
But, its safety accomplishments such as this that have Dr. Chetty cautioning staff to not let the structure of their environment lead to complacency.
“As a clinical laboratory we are tightly regulated through various accreditation bodies, but there will always be potential for error,” says Dr. Chetty. “Safety should be on the forefront of everybody’s mind and we need to encourage open discussion across all areas of the lab to actively prevent errors.”
On the last weekend of January, Laboratory Medicine Program (LMP) Pathologists’ Assistants (PA) held the second annual Surgical Pathology Education Day at UHN, offering students and lab professionals a unique mix of conference style lectures and in-lab presentations.
The event was a major success, with over 100 showing up to participate, and it once again set the bar high for future PA conferences.
Lead organizer and LMP PA, Martin Grealish shares more on why he’s developed the conference and what delegates can expect in the future in this five question Q&A.
- What is Surgical Pathology education day?
Within the PA industry we often find challenges in identifying subject specific continuing education. There are a few PA specific annual conferences put on by the Canadian and Ontario Associations of Pathologists, but with them being spread across the country or province – we saw an opportunity to organize something locally. It’s now our second year hosting the event and we basically bring together local PAs, MLTs (medical laboratory technologist) and really anybody interested in surgical pathology to hear and learn from industry professionals and receive meaningful continuing education credits.
- What does the day entail?
We hold lectures for the first part of the day, and really try to include something for everyone. This year we had:
- “Training, Competency and Continuing Education” – Sarah James, Senior PA, UHN, and Alan Wolff, Supervisor, Pathology, Lakeridge Health
- “Radiation Safety Considerations for Radioactive Specimens in Pathology” – Gina Capone, Senior Radiation Safety Specialist, UHN
- “Gastrointestinal Surgery” – Dr. Fayez Quereshy, GI staff Surgeon, UHN
- “Grossing Gastrointestinal Specimens” – Colin Elliot and Will Tsui, PAs, Mount Sinai Hospital
- “Telepathology and the Importance of the Technologist” – Dr. Andrew Evans, Genitourinary staff Pathologist, UHN
One area that really garnered interest was having a GI (gastrointestinal) surgery presentation followed by a GI grossing presentation. As PAs we receive colon and GI surgical specimens every day, so it was really interesting having Dr. Quereshy share what happens in the peripheral stages of our work. Then having the grossing lecture afterwards just made for a great continuation, and some interesting back and forth discussion.
Another thing we really focus on is fulfilling the continuing education needs of our audience. With a lot of institutions and certification bodies requiring a safety component as part of their annual continuing education requirements, it was important for us to fold in at least one safety lecture, and Gina’s radioactive specimen presentation fit perfectly.
The second part of the day was dedicated to in-lab workshops, which were held concurrently with groups rotating every 30 minutes.
- “Paediatric Gastrointestinal Pathology” – Sue Cromwell, Senior PA, The Hospital for Sick Children
- “Genitourinary Pathology” – Martin Grealish, PA, UHN
- “Sarcoma Pathology” – Colin Elliot, Nadia Saito and Will Tsui, PAs, Mount Sinai Hospital
- “Telepathology” – Zoya Volynskaya, UHN
- “Paediatric Cardiac Pathology” – Konstantin Krutikov, PA, The Hospital for Sick Children
- “Round table scenario and grossing discussion” – Sarah James, Senior PA, UHN, and Alan Wolff, Supervisor, Pathology, Lakeridge Health
This is definitely what differentiates us from other conferences. Getting to come right into the labs and view surgical pathology specimens up close is a rare opportunity for non PAs and is a huge draw for delegates. It also allows the conference to become more personal and get attendees more engaged, as the workshop groups averaged at just 15 people per session.
- What type of feedback have you received?
So we had 103 people attend including delegates, speakers, and volunteers and in our feedback survey we received an 89 per cent in terms of satisfaction. That number’s based on a five point scale of quality and means we were marked with either fours or fives from all attendees that completed the survey.
Overall, I think it was a major success, and our attendees, who came from as far as London to Oshawa and Niagara to Sault Ste. Marie all left satisfied.
- This is the second year you’ve hosted the conference – how did this year compare to the first?
Well, we had more people this time around – which was great. Having only four workshops was a limiting factor for us last year, so by adding two we were immediately able to increase capacity by 50 per cent. We also had more volunteers and higher satisfaction in our feedback survey.
The structure of the day was a similar format to last year which I think works well and is well received. Also like the first year, we had great involvement from other institutions, including Lakeridge Health, Michener, Mount Sinai and SickKids. And though we’re not official partners with each organization, on the greater scale of healthcare and Toronto hospitals – we’re all colleagues and need to support each other. There is lots of skill and talent at each of our organizations and this works as a great platform to show that off.
- What would you say to people thinking of attending next year’s conference?
I would say, please join us for our next event. The topics are interesting. The speakers are engaging. Attendees are consistently satisfied. Our format is unique and there are very few opportunities to attend the kind of specimen workshops we provide. It is a fun way to get continuing education hours and a great way to network within the local Laboratory Medicine and Surgical Pathology community.
The second annual Surgical Pathology Education Day was sponsored by:
ESBE Scientific and Huron Digital Pathology
For the first time ever, UHN’s Laboratory Medicine Program (LMP) is collaborating with The Michener Institute of Education at UHN to familiarize internationally trained medical laboratory technologists (MLT) with Canadian Standards of Practice.
The collaboration is part of Michener’s 16 week Medical Laboratory Science Bridging Program, and is designed to enhance student experience and better transition students from Michener’s simulated laboratory training to real, high volume clinical work.
“The new observership component of the program is set to provide students with insights to how a Canadian clinical laboratory operates,” says Carolyn Menezes, Manager, International Education and Bridging Programs, Michener. “It will also build upon the theory and simulated clinical experience already part of the bridging program, giving students greater confidence when it’s time to write their CSMLS (Canadian Society for Medical Laboratory Science) exam and enter the workforce.”
Students will visit five disciplines within LMP, spending a day in each observing safety guidelines, workflow, quality control protocol, and specialty techniques used for different tests and procedures. Rotating between departments, students will familiarize themselves with Chemistry, Hematology and Coagulation, Histotechnology, Microbiology and Transfusion Science.
Christine Cursio, Manager, Point of Care Testing and Clinical Coordinator, MLT/MLA Student Training Program, LMP says, “After working closely with Michener and the UHN International Centre for Education, LMP is proud to open its doors to internationally trained MLTs through the observership program.”
“There is a sure benefit to students as they’ll see how LMP staff work in what are very busy, high volume laboratories. But, the collaboration will also benefit our laboratory and others that look to hire competent, experienced lab professionals and what we hope to be future leaders.”
The observership program will begin Monday, February 13, and will take place over four weeks with five students participating each week. Student will rotate daily until all five lab areas are visited.
Observership rotations are planned as follows:
Rotation #1: February 13-17, 2017 Rotation #2: February 27-March 3, 2017
Rotation #3: March 6 – March 10, 2017 Rotation #4: March 20 – March 24, 2017
“We expect to learn a lot over the course of this first observership rotation,” says Christine. “And with potential labour gaps in the future we hope this opens the door for internationally trained MLTs to join the workforce more easily and more experienced. “
To learn more about Michener’s Medical Laboratory Science Bridging Program – click HERE.
New digital pathology book, co-authored by Dr. Andrew Evans, Genitourinary Pathologist and Director of Telepathology, Laboratory Medicine Program (LMP), University Health Network (UHN) provides a balanced overview of whole-slide imaging (WSI) digital pathology for those interested in implementing the technology. The various chapters in this book highlight specific clinical and non-clinical uses for WSI as well as the exciting possibilities for WSI in the future. The book also gives readers a realistic presentation of current barriers to adoption.
Read Dr. Evans’ Q&A below to learn more about digital pathology and the newly released book which is available HERE.
What is digital pathology and telepathology?
Digital pathology refers to viewing glass microscope slides as high-resolution digital images as opposed to using a light microscope. There are a number of different digital pathology modalities that can be used including WSI and robotic microscopy (which we use or have used in LMP) as well real-time video microscopy and hybrid real-time video-WSI devices. Telepathology is then using digital pathology over some kind of distance, where you use the internet to connect a digital slide in one location to a pathologist in another. The technology can be used for clinical diagnoses as well as quality assurance.
Why have you and fellow experts in the field come together to create this book?
We’re at the point now where validation studies from numerous pathology groups around the world have demonstrated this technology can be used safely for patient care purposes. Enough studies have been done comparing the review of cases using both digital platforms and light microscopy to dispel the notion that “digital pathology is an unproven technology”. This will be underscored by the granting of regulatory approval for this technology from the U.S. Food and Drug Administration in mid-late 2017, which is expected to generate appreciable interest in digital pathology in the United States. As such, the editors of the book, Drs. Liron Pantanowitz and Anil Parwani, were asked by the American Society of Clinical Pathology to create a comprehensive resource allowing those interested to learn about the technology – especially if they are considering implementing it in their own practice.
How might it change someone’s opinion of digital pathology?
I think people will see two things. The first being that the technology can be used safely for patient care, but the other is that it requires a fair amount of work in order to implement an admittedly disruptive technology. It’s not a simple plug and play solution – there is a lot of development work and it requires a multidisciplinary approach, including pathologists, histotechnologists, lab managers, information technology and business development staff, and financial planners. It’s a major undertaking, but it also generates significant opportunities that would not be exist if pathology remains in the glass slide-light microscope paradigm of the last 100 or so years.
How were you selected as an author?
Like any technologies that are still on the early part of the adoption curve, the community of people championing the technology is fairly small. So having been involved in digital pathology guideline committees with the College of American Pathologists and the American Telemedicine Association I’ve worked closely with the book editors over the last several years and they simply asked if I would like to participate.
How much of your content is based on personal experiences and studies with digital pathology at UHN/LMP?
Well, I was selected specifically for the chapter covering clinical applications of whole slide imaging because of UHN/LMP’s experience in validating and implementing the technology for clinical service. Our primary diagnosis validation study, which was one of the first large scale studies comparing digital whole slide imaging to light microscopy included over 1500 cases, from 11 different specialties with input from 29 different pathologists. The study involved LMP pathologists prospectively reviewing cases first digitally and then using a microscope. Our results showed that over 98 per cent of the cases could be reported by digital review without a perceived need to review glass slides. This study greatly informed our implementation of digital pathology for primary diagnosis at one of our partner hospitals, Lakeridge Health.
Where do you feel UHN/LMP stands as a digital pathology centre?
I think UHN is recognized as one of the leaders in the adoption of digital pathology for patient care in a number of niche applications, particularly in the area of frozen section coverage where we have been using telepathology at Toronto Western since 2004. However, we’re still essentially a glass slide and light microscope department. I think in the immediate future we’re poised to build on what we’ve done in digital pathology and leverage the experience we’ve gained over the last 13 years. The challenge now is to move forward in a way that demonstrates real value-added, and not just simply digitizing everything for the sake of being one of the first pathology departments to move to high-volume digital reporting. There is opportunity for meaningful and relevant adoption of the technology in a way that improves efficiency and quality over the traditional glass slide-light microscope paradigm. This is where image analysis and computer-aided diagnostics comes in as part of the next iteration of digital pathology.
What’s next for digital pathology at UHN/LMP?
We are attempting to move forward with the development and implementation of image analysis and various other measures that would allow us to really leverage the power of digital pathology over and above simply looking at scanned slides on a computer monitor and making visual diagnoses – but it’s the type of thing that costs time and money to develop. In the current fiscal environment these can be significant obstacles to innovation. Now we need to look outside, to create opportunity through partnerships between UHN and industry to move this initiative forward. Our department with its considerable subspecialty expertise and experience in digital pathology is currently attractive for such partnerships. However our window of opportunity is not boundless, so we are actively exploring the best way to get moving before others in the digital pathology space seize the day.
Dr. Evans has been a major factor in UHN/LMP’s early adoption of digital pathology and has helped implement the technology as a primary diagnosis tool for several LMP partner hospitals. But, he’s also quick to point out that constructive skepticism plays an important role in the evolution of any emerging technology, saying, “Those reluctant to adopt it can provide sound reasons as to why. This ultimately assists in implementing the technology in a safe and prudent manner.”
Dr. Evans serves as Chair for the College of American Pathologists’ Digital Pathology Committee, and the book, Digital Pathology (available here) is published by the American Society for Clinical Pathology.
Collaborative research efforts between Canada and Australia have led to a better pathological understanding of aggressive prostate cancers, which could serve as an indicator for the genetic mutation, BRCA2.
The findings are part of a larger study published online this week in Nature Communications, showing that BRCA2- associated prostate tumours are pre-set to be resistant to standard therapies due to abnormalities in genes responsible for regulating cell growth and division.
Dr. Theodorus Van der Kwast, genitourinary pathologist, Laboratory Medicine Program, University Health Network and lead pathologist of the Canadian Prostate Cancer Genome Network (CPC-GENE) study, co-authored the publication and has since helped outline the role of pathology, sharing important characteristics of BRCA2 associated prostate cancer.
“Linking pathological properties of prostate cancer with genetic findings is a necessary step to developing therapies,” says Dr. Van der Kwast. “And the genetic findings of this study will likely affect clinicians’ decisions when patients show possible indicators of BRCA2.”
Intraductal and invasive carcinomas
A key pathologic component of the study is the distinction between intraductal carcinoma and invasive carcinoma, two cancerous cell structures that may be seen in prostate cancer. Because each is not mutually exclusive of each other there has been significant questioning regarding their development.
To investigate the properties of each, pathologists microdissected the prostate samples containing intraductal carcinoma, separating the two carcinoma components from each other and preserving each for individual genetic testing.
Through this, the research team discovered new information about the carcinomas’ development and proved two commonly held hypotheses wrong.
The first, being that the intraductal carcinoma spreads beyond the prostate ducts into surrounding tissue and becomes invasive carcinoma. The other, suggesting the opposite – that the invasive carcinoma pushes its way into the prostate ducts becoming intraductal carcinoma.
“What we found was that both carcinoma components by essence were distinctly different from each other,” say Dr. Van der Kwast. “The study showed that a common precursor cancer cell diverges into both intraductal and invasive carcinoma. This would mean that prostate cancers with intraducal carcinoma are entirely separate entities from those without.”
The role of pathology – step by step
- The first step for Dr. Van der Kwast and fellow pathology staff was finding, diagnosing and grading prostate cancer samples to ensure a high level of cellularity and consistency among all samples used in the study.
- Pathologists then identified which tissue samples have intraductal carcinoma present and ensured they were assigned for microdissection.
- Using laser microdissection equipment, the tissue sample, about the size of a dime, is dissected, allowing the intraductal carcinoma to be separated from the invasive carcinoma. The dissection process is precise down to the micrometer and uses a laser so thin target cells are left undamaged.
- Once the tissue sample has been micro dissected, both the intraductal carcinoma and the invasive carcinoma for each patient is sent to the genetics team for DNA, RNA and epigenetic testing.
How clinical decisions could be affected
Though inherited BRCA2 affects less than 2 per cent of men with prostate cancer, findings from the study may lead to earlier diagnoses, particularly for younger patients due to intraductal carcinoma being a potential indicator of the mutation.
Of the 14 prostate cancer samples from patients with BRCA2, approximately 57 per cent had intraductal carcinoma present, and of the 500 non-BRCA2 cases studied, just 27 per cent had intraductal carcinoma present.
“For pathologists this means that when a younger patient, below the age of 50 has prostate cancer containing intraductal carcinoma, there is reason to believe they could have the inherited BRCA2 mutation and genetic testing may be a consideration,” says Dr. Van der Kwast.
The genetic findings of the study will likely lead to new treatment options for patients with BRCA2 as well.
Co-principal investigator Dr. Robert Bristow, clinician-scientist at Princess Margaret Cancer Centre, University Health Network says, “We now know we need to explore the use of novel therapies to offset the BRCA2-associated aggressiveness earlier on in the treatment of these men and improve survival in an otherwise lethal tumour. This might include different types of chemotherapy or the use of molecular-targeted drugs that specifically target the changes associated with BRCA2 mutation.”
A team effort
The study required the collaboration of researchers from Toronto, Quebec City and Melbourne, Australia to collect the necessary amount of frozen tissue samples needed for the study.
“Due to the characteristics of prostate cancer, it can be very challenging to locate the cancerous area of the prostate in surgical specimens,” says Dr. Van der Kwast. He says because of this, pathology staff reviewed over 1,000 different frozen tissue samples in order to collect the 514 samples used in the study.
“It takes immense collaboration to produce a study of this magnitude,” says Dr. Van der Kwast, “and everybody plays an important role.”
“As a pathologist, this type of investigation provides the opportunity to ask fundamental questions from a pathology perspective that can go on to affect future studies.”
Additionally, he says because the study is part of the CPC-GENE Sequencing Project, the genomic and pathologic data collected from every sample will be made available to fellow researchers from around the world.