ASCLS Today Volume 32 Number 3

Joan Polancic, MSEd, MLS(ASCP)^CM; Kyle Riding, PhD, MLS(ASCP)^CM
Entry Level Curriculum Revision Committee Co-Chairs

The Entry Level Curriculum was created to provide guidance as to the knowledge and skills a new graduate at the medical laboratory technologist (MLT) or medical laboratory scientist (MLS) level should possess upon entry into the workforce.

The first Entry Level Curriculum (ELC) was published in 2002 and created by educators and practitioners using the Body of Knowledge (BOK) published by ASCLS. The ELC was revised during the 2015-2016 year by a task force of the Committee for Educational Programs and Initiatives (CEPI), a sub-committee of the Education Scientific Assembly (ESA). 

The two main goals for the 2016 revision were:

• Use the recently updated (2014 version) ASCLS BOK and personal expertise in entry level practice to update the curriculum by removing dated topics and adding new items.
• Ensure differentiation of the MLT and MLS curriculum based on the level of education required for each. 

There were 4 rounds of revisions in 2015-2016 which provided opportunities for ASCLS members – educators and practitioners – to review and provide input:

• 1st revision reviewed by educators at CLEC 2016 
• 2nd revision reviewed by ASCLS members
• 3rd revision to Board of Directors and 2016 House of Delegates
• 4th revision to ASCLS for publication

ELC committee members finalized all documents by applying the Beck/Moon algorithm introduced at CLEC 2016. The algorithm included three basic questions: 

• Is it current practice? 
• Is it entry level? 
• Is it foundational?

In situations where conflicting comments were received, this algorithm provided the criteria for removing information from the documents. 

Uses

The ELC is designed to 

• Help develop the curriculum for a new program
• Assist the new instructor/professor with course development
• Update a current program or course

In addition, the document can provide guidance to other organizations for entry level knowledge and skills of the MLS or MLT graduate. 

ELC Format

The curriculum format is delineated by discipline area within the MLS and MLT levels. Each discipline area is further delineated by major topics using a learning objective format which includes a sequence of concepts, principles/theories, and skills. Taxonomic levels (cognitive, psychomotor, affective) were included to assist new instructors and new programs. 

It is understood that all listed technical items may not be available at each educational institution so that in some programs, only cognitive aspects (state, explain, describe) will be taught and at others the psychomotor may also be taught (perform or observe). The committee also expects that some programs will teach beyond what may be included, based upon regional needs of their graduates and availability of resources.

What’s New/What Changed?

New Additions: Molecular diagnostics is a new addition to the 2016 version of the ELC. Other changes included moving body fluids from the Chemistry section to create a new Urinalysis and Body Fluids section. 

Cross referencing: Where there is overlap in some discipline areas, it is cross-referenced to another section within the ELC disciplines. For example, microscopic analysis in Hematology, Urinalysis and Body Fluids, and Microbiology are all cross-referenced to the more detailed microscope section in the General Practice document.

Differentiation in MLT vs MLS curriculum: Differentiation of the two levels was based on the background knowledge (pre-requisite and/or core courses) required. Different cognitive levels were reflected in the verbs used to elucidate the tasks or knowledge. For example:

MLT version – Identify basic concepts of spectrophotometry 
MLS version - Recognize and explain basic concepts of spectrophotometry

In many instances, the verb levels and expectations were the same, for example in performing tests or identifying abnormal results. 

List of Added and Deleted Topics: To assist educators in knowing which items were deleted from the previous edition of the ELCs and which items were added, a summary list is included at the end of each discipline section. This information could be useful when revising and updating course material. 

Final Product Available

The updated versions of the Entry Level Curriculum for Medical Laboratory Science (MLS) and Entry Level Curriculum for Medical Laboratory Technician (MLT) can purchased in the ASCLS Store at www.ascls.org/store. Each program is available in a variety of formats:

• Institutional Licensed Versions
• Single User Licensed Versions
• Curricula for Individual Disciplines
• Complete Set of MLS and MLT Curricula

The updated version of the ELC would not have been possible without a team of dedicated volunteers. Thank you to everyone who submitted comments. Your participation was tremendous in improving this resource. Thank you especially to the ELC committee members for your time, expertise and efforts. These volunteers enlisted innumerable hours to update, collate and review comments, and create final documents. 

Going forward, the ELC will be updated every five years using the revised BOK. The newly established BOK Review Committee will guide this process.

James March Mistler, MS, MLS(ASCP)^CM, ASCLS-CNE President, Diversity Advocacy Council Chair

When one thinks of LGBT+ rights, one may automatically think of marriage equality, political movements, employment rights, or even education. But one issue that is often overlooked is healthcare. There are many issues that concern the LGBT+ community in terms of healthcare, as it is not just access to equal, accessible care that is a problem, but also getting the right care at the right time. Before we delve into some of these issues, lets go over some common terms: LGBT+ individuals are those that do not identify as part of heteronormative society. Heteronormativity is the belief that everything is tied to normalizing societal expectations into heterosexual relationships and traditional gender roles. LGBT+ is also sometimes referred to as LGBTQIA (Lesbian, Gay, Bisexual, Transgendered, Queer, Questioning, Intersex, Asexual, Allies). 

The health disparities that affect LGBT+ individuals are caused by discrimination, stigma, and ignorance. Some of these disparities are increased sexually transmitted infections, lower rates of Pap testing and mammographies, and higher rates of substance abuse, smoking, depression, anxiety, and violence victimization.¹ In many parts of the country, providers simply refuse to treat LGBT+ individuals, with 19% of transgendered individuals stating they have been refused care.² Many receive harassment by insurers or providers when applying for care and even receive mistreatment from phlebotomy staff. This, sadly, is not an uncommon issue and isn’t portrayed in the news or media outlets; however, it is something pervasive in our society, even in socially progressive areas of the country such as Massachusetts, where I live. My husband and I often encounter ignorant healthcare professionals when seeking care or simply going for a blood test. And it gets worse when we travel outside of our home state.

When visiting friends in North Carolina a few years ago, my husband had a severe asthma attack and couldn’t breathe, so we ended up at the emergency room. They rushed him right in; however, I wasn’t allowed in with him. Since the U.S. Supreme Court had not ruled marriage equality legal at the time, I was left at the reception area while my husband went in alone. When the shifts changed about 30 minutes later, I told reception that I was his brother so that I could get in to see him. When they finally let me in, I found my husband sitting on a hospital bed, still wheezing and unable to breathe. When I found the physician assistant treating him, he had said that they were extremely busy and that “they had sicker individuals that needed help,” so we could wait. I was stunned. When I was finally able to find his nurse, she took her time finding someone else to order a breathing treatment. About two and half hours after arriving, we finally had the breathing treatment and my husband was feeling better. I was shocked and frustrated. Not only because of how we were treated, but it made me think of how many others are treated this way and how often? It also perpetuated the fear that we would be dealing with this type of ignorance and malice our whole lives. And if this is how we have been treated, how many other LGBT+ individuals experience the same thing, or worse? 

Many LGBT+ individuals do not disclose their sexual orientation or gender identity to providers for fear of harassment or ridicule; however, this reduces the likelihood of receiving proper and adequate care, specifically for those that identify as transgendered. How does a laboratory scientist, the provider, or even the lab information system (LIS) interpret hormone levels for a trans male (female to male)? What are the correct levels for a trans female (male to female)? How about a simple CBC result or liver enzymes that are specific to gender and age? It is even harder if patients do not feel they can be honest with providers. With at least 9 million Americans that openly identify as LGBT, and less than five hours of training in medical schools on LGBT care, we need to be sure we are giving the access to care they deserve but also interpreting the results properly according to their orientation or gender identity.¹

All members of the healthcare team, from physicians to nurses, radiology technicians to laboratory staff, are important providers ensuring patients are getting quality, equitable healthcare. The U.S. Department of Health and Human Services helps fund LGBT+ sensitivity training for healthcare professionals. The Fenway Institute, part of Fenway Health, runs the National LGBT Health Education Center. To learn more about LGBT+ healthcare and to find resources for care, visit their website at www.lgbthealtheducation.org.

In terms of gender identity and transgendered individuals, there is a lot of work that needs to be done for accurate healthcare, and the laboratory is one place where it can start. Laboratories should work with administration, patient advocates, medical staff (ID, pharmacy, radiology, gastro, etc.), and information technology, among others, to find the best way to interpret laboratory results for these individuals. It is also important to ensure that those interpretations move correctly from instrument, to LIS, to electronic health record, to provider, to patient for proper diagnosis, management, and treatment. Even though we in the laboratory may not always see patients, we have a profound effect on them and their healthcare. 

REFERENCES
1. Ard, Kevin. Understanding the Health Needs of LGBT People. Fenway Institute. March 2016. Available from: http://www.lgbthealtheducation.org/wp-content/uploads/LGBTHealthDisparitiesMar2016.pdf
2. Grant J, Mottet L, Tanis J, et al. National Transgender Discrimination Survey Report on health and health care. October 2010. Available from: http://www.thetaskforce.org/static_html/downloads/resources_and_tools/ntds_report_on_health.pdf

Lindsey Keill, MLS(ASCP)^CMSBB; Stacie Lansink, MS, MT(ASCP); April Nelson, MLS(ASCP)^CM; Tiffany Montalvo, MLS(ASCP)^CM

A 22-year-old female presented to the blood bank to donate blood. A type and screen were performed. The donor typed as B-positive with a positive antibody screen. The autocontrol was negative, which assisted in ruling out the possibility of a warm autoantibody. The technologist noted the strength of the reactions to be like that of a patient with multiple antibodies. Usually these individuals have varying strengths of reactivity on a panel or antibody screen, whereas high frequency antibodies tend to have more of a uniform pattern of reactivity.

The technologist tested additional panel cells to determine if any clinically-significant antibodies could be ruled out. The reactions were still positive. The technologist performed an enzyme panel; those results were all positive. The technologist then checked the donor ethnicity to determine if a high incidence antibody was a possibility. Certain high-frequency antibodies are more common in certain ethnic groups, such as Anti-Fy3, Anti-Hrb, Anti-Jsb, and Anti-U in African Americans, and Anti-VEL and anti-Kpb in Caucasians. The donor was registered as being of Asian descent. 

There was no indication on the donor questionnaire of being recently transfused. The technologist phenotyped the patient and received the following results: 

Based on the negative results for Jka and Jkb, the technologist believed the donor may have developed Anti-Jk3. The blood bank had an inventory of rare frozen red cell droplets that can be thawed in cases like this to either assist in ruling out or confirming a high-frequency antibody. The technologist removed two Jk3 negative cells from frozen inventory and tested those cells with the patient’s plasma. Both cells were negative. This confirmed the Anti-JK3. The technologist still needed to rule out any underlying clinically significant antibodies, so rather than deplete the inventory of rare frozen red cells, the technologist chose to adsorb out the JK3 and test the adsorbed serum against fresh panel cells to rule out any other antibodies. Since 99.9% of people are JK3 positive, it was an easy procedure to incubate the serum with another donor’s red cells and pull the Anti-JK3 out of the donor’s serum. The technologist performed the adsorption and the antibody screen was negative; thus, ruling out any other clinically significant antibodies. 

Anti-Jk3 is a high-frequency antibody in the Kidd system. It commonly forms in patients that phenotype as Jk(ab)-. There are two ways this can occur. One is that the donor is homozygous JkJk and genotypes Jk(ab)-, making them a true null phenotype. The other possible mechanism is a silencing mutation that can occur. The donor may have inherited any combination of Kidd alleles but there is a genetic mutation that prevents the alleles from being expressed giving the appearance of Jk(ab)- phenotype but genotyping as having functioning Kidd alleles. It is like the GATA box mutation in the Duffy system that causes many people of African descent to phenotype at Fy(ab)-. If the donor/patient types negative for the Jka and Jkb antigens, they can form what is known as an Anti-JK3. It will react with all cells that are not Jka- and Jkb-. This rare phenotype is found in >99.9% of the population. However, there are certain ethnic groups in which the JK(ab)- phenotype is more common. It is seen mostly in Asian populations, particular those of Polynesian or Hawaiian descent. 

In summary, this donor presented with a positive antibody screen. The technologist was unable to rule out clinically significant antibodies. Based on the donor’s history and antibody identification panel, the technologist performed an adsorption to rule out other clinically significant antibodies, while ruling in Anti-JK3. This was a typical presentation of a patient with Anti-JK3.

Monica Bustos, MSHS, SM(ASCP)^CM

A 74-year-old man with a history of atrial fibrillation, chronic renal impairment, diabetes mellitus II, essential hypertension, gout, and hyperlipidemia presented to the emergency room with hypotension, some shortness of breath, and dizziness. The patient had a sudden onset of shortness of breath with acute decompensation and hypotension the morning of presenting. Vital signs showed a temperature of 98.2^oF, blood pressure of 157/89, and pulse ox of 94% on room air with an observation of being weak with trouble ambulating. The patient was also found to be in atrial fibrillation with rapid ventricular response, with a heartrate above 170 beats per minute at presentation. The patient was started on a diltiazem drip for the atrial fibrillation followed by amiodarone and digoxin was started for hypotension. Intravenous (IV) fluids were pushed due to leukocytosis and lactic acidosis. 

Once the heartrate had improved, the patient was started on IV Piperacillin/Tazobactam for pneumonia and admitted as an inpatient for observation. The pneumonia responded successfully to the antibiotics by the second day. The patient was then weaned from oxygen with no further incidence of acute respiratory failure. The anaerobic bottle of the one set of blood cultures (TREK Diagnostic Systems, Cleveland, OH) drawn in the emergency room became positive with gram-negative spirillum at 27.5 hours of incubation. Broth was subcultured onto Trypticase soy agar with 5% sheep blood, MacConkey, chocolate, and Campylobacter blood agar plates (BBL prepared plated media; Becton, Dickinson Inc., Franklin Lakes, NJ). Repeat blood cultures were collected after the initial collection was reported as positive for bacterial growth, but antibiotics had already been consistently administered for over 24 hours. Patient was discharged after 4 days of IV therapy with no hypoxia at room air. The antibiotics were changed at time of discharge to levofloxacin for 11 days to complete a two-week antibiotic therapy. Follow up care was to be given by the primary provider the following week. Laboratory results at the time of patient discharge were a white blood cell (WBC) count of 7.5 x 103/μl, hemoglobin of 11.2 g/dl, hematocrit of 32.8 g/dl, and a platelet count of 115,000 x10³/μL.

The blood agar plates were incubated anaerobically yielded small, translucent, spreading, nonhemolytic colonies that were oxidase and catalase negative at 72 hours. The organism could not be identified biochemically (bioMérieux Inc., Durham, NC). Consequently, the organism was send out to a Mayo Clinic reference laboratory (Rochester, Minnesota) for further testing. The Mayo Clinic identified the organism as Anaerobiospirillum succiniciproducens by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) using the FDA-approved Vitek MS version MS-CE CLI 2.0.0 on intact cells without extraction (bioMérieux Inc., Durham, NC). Although the species did not have identification by MALDI-tof validated, the confidence value was 99.9%. The identification was confirmed by 16S rRNA gene sequencing performed at the Mayo Clinic. The patient was switched from levofloxacin to Augmentin and due to the continual decline in health after hospital discharge and proper organism identification, was admitted into a rehabilitation facility for continued antibiotic therapy. After two weeks of appropriate therapy, the patient noted full recovery and was sent home.

Discussion:

Anaerobiospirillum succiniciproducens is an anaerobic, gram-negative spirillium that has been isolated from the stool of household pets, such as dogs and cats, as well as humans.³ Previous studies have linked A. succiniciproducens bacteremia to infections with an origin in the host’s gastrointestinal tract.⁵ In recent decades, A. succiniciproducens has been identified as a rare causative agent of diarrheal illness and bacteremia in humans.⁷ All reported cases of septicemia and diarrheal illness had a host with a clinical history of underlying immunocompromising conditions, such as diabetes mellitus, heart conditions, cancer, or AIDS.² 

The disease progression of A. succiniciproducens in an immunocompromised host as well as the successful treatment is not well understood in the medical community. Most hypotheses state that A. succiniciproducens is significantly underreported due to similarities with Campylobacter spp., despite both organisms having different growth requirements. Having 56 documented cases from the United States, Europe, Asia, and Africa suggests this organism has a global distribution. All reported cases have occurred in immunocompromised patients with conditions such as diabetes mellitus, cancer, atherosclerosis, and liver disease.⁴ The global distribution, the zoonotic nature and its propensity to cause infection in immunocompromised hosts as well as the fact that it is difficult to biochemically identify contribute to the likelihood that this organism goes undetected in the clinical laboratory. Most resources also indicate that the 31% mortality rate² is a high number especially considering the vast clinical improvements in the microbiology and diagnostic fields. The standard treatment profile for A. succiniciproducens remains inconclusive, with documented cases of mortality even though the treatment used showed in vitro susceptibility.⁴ Some patients have even been documented as recovering without any specific medical intervention.¹ 

Most studies indicate the gastrointestinal tract as being the most likely portal of entry for cases that progress to bacteremia. However, in this presentation the patient had no history of gastrointestinal discomfort or diarrhea. Large animal farming produces a wide spectrum of respiratory disease due to the complex diversity of inhalants. A. succiniciproducens is frequently utilized commercially during feed-control development for succinic acid production⁶; this making the organism an occupational risk factor that is likely under-identified. This study suggests that the advanced immunocompromised state of the patient along with the aerosolized feed, produced bacterial pneumonia which turned to bacteremia. During the epidemiology follow-up performed by the Scottsbluff County Public Health Department (Scottsbluff, Nebraska), cattle feed utilizing A. succiniciproducens as the primary fermenter was found. However, due to the complexity of testing required, genome sequencing was unable to be performed.

REFERENCES

1. Tee W, Korman TM, Waters MJ, et al. Three cases of Anaerobiospirillum succiniciproducens bacteremia confirmed by 16S rRNA gene sequencing. J Clin Microbiol 1998;36:1209–1213. 
2. Kelesidis, Theodoros. Bloodstream Infection with Anaerobiospirillum Succiniciproducens: A Potentially Lethal Infection. Southern Medical Journal104.3 (2011): 205-14. Web.
3. Malnick H, Williams K, Phil-Ebosie J, et al. Description of a medium for isolating Anaerobiospirillum spp., a possible cause of zoonotic disease, from diarrheal feces and blood of humans and use of the medium in a survey of human, canine, and feline feces. J Clin Microbiol 1990;28:1380–1384. 
4. McNeil MM, Martone WJ, Dowell VR Jr. Bacteremia with Anaerobiospirillum succiniciproducens. Rev Infect Dis1987;9:737–742. 
5. Malnick, H. (1997). Anaerobiospirillum thomasii sp. nov., an anaerobic spiral bacterium isolated from the feces of cats and dogs and from diarrheal feces of humans, and emendation of the genus Anaerobiospirillum. Int J Syst Bacteriol 47, 381–384.
6. Bretz, K., & Kabasci, S. (2011, December 12). Feed-control development for succinic acid production with Anaerobiospirillum succiniciproducens. Biotechnology and Bioengineering, 109(5), 1187-1192. doi:10.1002/bit.24387
7. Papasian C J, Kragel P J, Enna-Kifer S, Kemmis R, Webb K. Anaerobiospirillum succiniciproducenssepsis. Clin Microbiol Newsl. 1995;17:14–15.