Clinical pathology selected abstracts

Create PDF

Editor: Deborah Sesok-Pizzini, MD, MBA, chief medical officer, Labcorp Diagnostics, Burlington, NC, and adjunct professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Association of preanalytical error with use of outdoor courier lockboxes in summer

February 2022—Many health care systems are consolidating their laboratory testing to a central core laboratory to save money through volume discounts, increase efficiency, and standardize methodologies and reporting. A challenge of a centralized laboratory approach is the need to have courier services to retrieve patient samples from satellite clinics, where samples are often stored in lockboxes prior to transport. Outdoor lockboxes may be exposed to ambient seasonal temperatures, and delays in transport may result in samples sitting for longer than expected amounts of time. No standards and guidelines exist pertaining to courier lockbox storage time limits, design, placement, or temperature monitoring during any season. The authors conducted a study to determine the impact of short-term exposure (less than four hours) to ambient summer temperatures on lithium heparin samples (uncentrifuged and centrifuged) stored in outdoor lockboxes. They took samples from healthy adult volunteers and placed them in one of two Lab­Locker-KF300 courier lockboxes placed outside in direct sunlight during the summer months. The investigators monitored each courier lockbox every five minutes using a temperature data logger. One lockbox (designated the cold lockbox) contained two cold packs, which was the standard number recommended by the study institution. The other (designated the warm lockbox) did not contain any cold packs. In the authors’ first study, seven samples were collected in lithium heparin BD PST Vacutainer tubes under standard conditions. One sample from each of the volunteers participating in the uncentrifuged study was immediately centrifuged, and plasma was left on the gel barrier. These samples were then placed on the Abbott Architect c16000 analyzer to measure C-reactive protein, comprehensive metabolic panel, lactate dehydrogenase, lipid panel, magnesium, and phosphorous concentrations. These samples served as baseline within-subject controls for the participants. The remaining samples were wrapped in several layers of paper towels and placed in Ziplock bags before being divided equally between the warm and cold lockboxes. One sample from each participant was removed from the cold and warm lockboxes and analyzed at one, two, and four hours. In the second study, all samples were centrifuged and left on the gel barrier before being exposed to the aforementioned lockbox conditions. Otherwise the study design, number of participants, and outdoor temperature for the centrifuged study were comparable to those of the uncentrifuged study. The authors defined acceptable tolerance limits for each analyte using significant change limit (SCL) analysis (P< 0.05) for each analyte. The results showed significant changes in each study condition for the warm and cold lockboxes. Aspartate aminotransferase, glucose, lactate dehydrogenase, and potassium commonly crossed SCLs, which were calculated based on the initial mean value from each participant’s sample and the usual standard deviation of each analyte assay determined from 90 days of quality control performance data. Uncentrifuged samples that were left in an outdoor courier lockbox for four hours before being centrifuged and analyzed showed the greatest difference between the warm and cold conditions. These results indicate that although courier lockboxes are critical components of the sample transport process, even short-term exposure of samples to inappropriate temperatures inside an outdoor lockbox can lead to preanalytical errors. The authors concluded that efforts should be made to standardize conditions to increase quality assurance for external sample transport. They stated that their study provides further evidence of the need to create universal lockbox guidelines and to implement state-of-the-art temperature-controlled transport containers and integrated monitoring systems.

Dibbern ME, Pierre CC, Wiencek JR, et al. Outdoor courier lockboxes in summer are a significant source of preanalytical error. Am J Clin Pathol. 2021;156:866–870.

Correspondence: Dr. Joseph R. Wiencek at joe.wiencek@vumc.org

Enhancing diversity, equity, and inclusion in pathology training programs

Undergraduate and graduate medical education training programs, including pathology training programs, are emphasizing diversity, equity, and inclusion in medical training and the medical field as a whole. The challenges surrounding diversity, equity, and inclusion (DEI) in pathology are due, in part, to the declining interest of U.S. medical students in entering pathology, perhaps because of their limited exposure to pathology in medical school and perceptions about careers in pathology. DEI-related efforts in medical training programs are focused on increasing the representation of people from groups underrepresented in medicine (UIM). These are racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. This group historically includes Blacks/African Americans; Hispanics/Latinx, specifically Mexican Americans and mainland Puerto Ricans; and Native Americans, including American Indians, Alaska natives, and native Hawaiians. The authors conducted a study in which they reviewed the literature to identify the challenges of DEI, how it relates to the pathology trainee pipeline, and what the pathology field may learn from other medical specialties. They specifically conducted a literature review of the PubMed database, a Google search, and a search of the websites of the Association of American Medical Colleges, Electronic Residency Application Service, and National Resident Matching Program. The authors found that descriptions of pathology-specific DEI studies and initiatives are limited in the literature, so pathology training programs often need to extrapolate data from other specialties. The results showed that during the past several decades, medical students’ interest in pathology residency training has declined. Factors contributing to the decline included limited patient interaction, decreased exposure in medical school curricula, a perceived lack of jobs, and a paucity of medical students identifying with practicing pathologists. Consequently, UIM pathology resident representation has increased at an annual rate of only 0.29 percent, and this increase is largely due to an uptick in Hispanic resident applications. Representation of other UIM groups remains largely unchanged in pathology since 1995. The authors recommend numerous strategies to increase DEI in pathology, including increasing clinical exposure to the field, using a holistic application review process, addressing implicit biases, and providing elective and immersive offerings to bolster medical student interest in pathology careers, all of which have helped promote DEI in other medical specialties.