ASCLS Today Volume 32 Number 6

New Professional Leadership Award nominees

The Student Forum Leadership Award recognizes a student member who has demonstrated outstanding leadership and who has contributed to the growth and development of the Student Forum. Nominees for the Student Forum Leadership Award were: Samantha Buck, Colorado; Brittany Campion, Minnesota; John Mark Frederick, New Jersey; Ivan Sanchez, California; and Wendy Wang, Kansas.

The 2018 Student Forum Leadership Award winner is Ivan Sanchez.

This excerpt is from Ivan’s nomination letter: “His sincere commitment to the profession and organization has been such a wonderful benefit to our state society. We are truly fortunate to have such a dedicated, intelligent, and wonderful person represent our organization’s values and integrity. I know he will continue to be an asset for our profession and organization.”

The New Professional Leadership Award recognizes a member of ASCLS who has contributed significantly to the field of clinical laboratory science and the society within the first five years in the profession and who has made a significant contribution and shown a talent for leadership. Nominees for the New Professional Leadership Award were: James Gardner, Louisiana; Nathan Howell, New York; Kathryn Norton, Idaho; William Jonathan Windsor, Colorado; and Nicholas Yu, Kansas.

The 2018 New Professional Leadership Award winner is James Gardner.

This excerpt is from James’ nomination letter: “He has a passion and love for the profession. He sees the importance of the medical laboratory profession and it is evident in the work he does both at his place of employment and in the organization. He has participated in many local, state, regional, and national events, serving in numerous leadership roles. He is currently serving as our society’s president elect and continually reaches out to members of the profession and encourages them to renew their membership or encourages them to join. He is a role model for those entering the profession and those thinking of joining the profession.”

Congratulations to Ivan and James for their leadership, their support for the clinical laboratory profession, and their passion for ASCLS. Visit Awards and Scholarships for details about the 2019 awards.

Stephanie K. Rink, MS, MLS(ASCP)^CMSC^CM, ASCLS PAC Chair

Members of ASCLS-MI meet with Michigan Senator Debbie Stabenow.

For me and many ASCLS members, the Legislative Symposium in Washington, D.C., each March is the most anticipated event of the year. The venue steeped in history, the camaraderie with fellow laboratorians from across the country, and the opportunity to advocate for our profession and the patients we serve are all things to look forward to each year.

While the event is advertised each year as a two-day conference, many members make the trek to Washington, D.C., early to participate in an ASCLS Board Meeting, Government Affairs Committee Meeting, or Political Action Committee Meeting. These meetings are generally open to all members and are a great way to learn about a number of issues surrounding the medical laboratory science profession and how ASCLS plans to address those issues. It is always enlightening to hear about the behind-the-scenes activities of the organization.

The conference officially begins on Monday morning. The day is filled with updates on the political environment in Washington, D.C.; information on the legislative topics to be discussed with our congresspeople; and role-playing exercises to prepare for our trips up to Capitol Hill.

This year, the two primary issues discussed were the negative impact Protecting Access to Medicare Act (PAMA) implementation will have on patient access to effective, timely, and quality laboratory testing, and strategies to address the critical medical laboratory workforce shortage. Other topics briefly touched upon were the Centers for Medicare & Medicaid Services (CMS) Personnel Regulation Request for Action, the Diagnostic Accuracy and Innovation Act, and the importance of donating to the ASCLS Political Action Committee. The day closed out with another anticipated feature of the event—a wine and hors d’oeuvre reception.

Finally, the culmination of the event is the trip up to Capitol Hill to meet with our senators and representatives to explain our concerns and present them with solutions to the issues. The Legislative Symposium is a collaborative event including members of the Clinical Laboratory Management Association (CLMA), American Society for Clinical Pathology (ASCP), Association of Genetic Technologists (AGT), American Medical Technologists (AMT), and the National Society for Histotechnology (NSH). It is interesting to network with members from these organizations and learn their viewpoints on the issues surrounding the profession.

We all left in groups Tuesday morning, out into the cold and the sleet, and headed straight to our senators’ offices. Both senators from Michigan host coffee hours, where we get to meet personally with staffers and the senators to discuss our concerns and solutions. We told them how new payment rates for the Clinical Laboratory Fee Schedule under the implementation of PAMA are based on flawed data and thus do not represent a true market-based payment system. We followed up with a request that they support a statutory adjustment to these rates to provide temporary relief, while also providing time for a proper data collection process to occur so appropriate long-term rates can be set.

We also discussed the serious shortage of medical laboratory professionals and requested that they enhance recruitment within the Veterans Affairs system, as well as authorize the Government Accountability Office to perform a study of the shortage and its impact on healthcare.

After meeting with both senators as a group, we split into smaller groups to meet with our individual representatives. We also stopped by each office from Michigan that did not have a constituent in attendance to drop off information about these issues along with contact information for our state Government Affairs Committee.

Overall, this year’s Legislative Symposium was highly productive and enjoyable. While I’m already looking forward to next March, advocacy is not a once-a-year event that can be accomplished by a few members from each state.

I encourage every member to take a few minutes to look up the information about the Advocacy-Issues on the ASCLS website and send an email or leave a phone message with your senators and representative. Stay informed about the issues and in touch with your legislators. Follow up with them, meet with them at a local coffee hour, or even consider attending the Legislative Symposium next March. I can promise you won’t be disappointed.

Diane Davis, PhD, MLS(ASCP)^CMSC^CM, SLS^CM

In 1948 an ambitious, long-term prospective study started in the small town of Framingham, Massachusetts¹. The goal was to follow a large group of adults over many years to study the evolution of hypertension and cardiovascular disease and in so doing, identify risk factors and prognostic markers in subjects who went on to develop either of these conditions.

The subjects had several annual tests performed, but by the 1960s the correlation of total serum cholesterol with cardiovascular disease was evident. Soon the roles of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) were discovered.

More than 50 years later, virtually all adults in the United States have heard of “good cholesterol” (HDL) and “bad cholesterol” (LDL), and many know their own levels of each. Clinicians rely heavily on the values reported by the laboratory to guide recommended lifestyle changes versus more aggressive therapy. Lipoprotein analysis is a high-volume, commonly performed test, yet for a majority of specimens, laboratories still use a formula first published in Clinical Chemistry in 1972².

Early analysis of lipoprotein fractions was performed by electrophoresis or ultracentrifugation. The terms LDL and HDL come from their relative density in the ultracentrifuge. Performing this type of analysis on the limited number of specimens from the Framingham study was possible, but neither electrophoresis nor ultracentrifugation was suitable for mass screening.

Enzymatic analysis of serum total cholesterol, triglyceride and HDL were comparatively easy, so the team of Friedewald, Levy, and Fredrickson developed a simple formula to estimate LDL using this data. The three lipid particles that carry virtually all the cholesterol in blood are LDL, HDL, and VLDL, so subtracting HDL and VLDL cholesterol from total cholesterol should yield LDL cholesterol. VLDL is decently estimated as 1/5 of triglyceride in mg/dL, so the Friedewald equation was born (LDL = Total cholesterol – HDL cholesterol – Triglyceride/5).

The Friedewald equation has been a cost-effective and valuable tool over many decades to estimate LDL. That said, it is an estimate and not a direct measurement, so there are many situations in which the estimation is inaccurate. Of particular importance is inaccuracy due to extremes in triglyceride measurement. For example, the higher the triglyceride, the more likely that LDL will be underestimated.

It has long been the consensus that the LDL estimate is inaccurate when triglyceride exceeds 400 mg/dL, but the underestimation of LDL begins at triglyceride levels as low as 150 mg/dL³. Thus, the Friedewald equation works best in relatively normolipidemic patients, not hyperlipidemic patients who are most likely to need therapy monitoring.

Why does an estimate that worked well in 1972 and for many years thereafter need to be replaced? The short answer is statin and PCSK-9 inhibitor therapies for hypercholesterolemia. These drugs are extremely effective at lowering LDL cholesterol, and clinicians are heavily influenced by LDL measurements when initiating and adjusting drug therapy. Since the drugs have undesirable side effects, inappropriate use of them is to be avoided, and the need for the extremely accurate LDL measurement is acute. Direct LDL measurements offer better accuracy but are costlier than a “free” calculation.

Enter the Martin-Hopkins formula.⁴ Dr. Seth Martin, based at Johns Hopkins, is first author on a paper detailing analysis of lipid specimens from 2,129 children; 8,165 adolescents; and 1,340,614 adults. Cholesterol content of lipid fractions was determined after ultracentrifugation, and triglycerides were directly measured. These values were considered “true,” and the team subsequently developed a modification of the Friedewald equation that provides a more accurate estimate of LDL.

The Martin team found that the level of VLDL cholesterol varies primarily with triglyceride and non-HDL levels. Although Friedewald’s original VLDL estimate of Triglyceride/5 is still valid when the total population is considered, the estimate is better if the denominator is customized for each patient’s levels.

The team constructed a matrix that allows the user to select a denominator which more accurately calculates LDL. Instead of dividing all triglyceride values by 5, one of 180 different options is selected based on total triglyceride and non-HDL levels. Online you can access the matrix and a free LDL Calculator.

The new formula is also more reliable in non-fasting patients because it adjusts for triglyceride level, mitigating effects from patient non-compliance. Implementing the new formula on a large scale will initially be costly for the re-programming of laboratory information systems. After this initial expense, however, the LDL cost will again be “free,” minimizing the need for direct LDL measurements.

The time has come to modernize the “free” LDL estimate and improve prevention and care for cardiovascular and cerebrovascular diseases, the leading cause of death in the United States.

References

1. www.framinghamheartstudy.org, accessed 22 November 2017.
2. Friedewald, W.T., Levy, R.I., and Frederickson, D.S. 1972. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clinical Chemistry 18: 499-502.
3. Martin, S.S., et al. 2013. Friedewald-estimated versus directly measured low-density lipoprotein cholesterol and treatment implication. Journal of the American College of Cardiology 62:8 732-739.
4. Martin, S.S., et al. 2013. Comparison of a Novel Method vs the Friedewald Equation for Estimating Low-Density Lipoprotein Cholesterol Levels From the Standard Lipid Profile. Journal of the American Medical Association. 310(19): 2061–2068.

Susan Stalewski, MBA, MLS(ASCP)^CM, ASCLS-Wisconsin Past President

You know you’re from Wisconsin when: green and gold make up the bulk of your wardrobe; “bubbler” is part of your vocabulary; you know the difference between frozen custard and ice cream; 40 degrees is shorts and t-shirt weather in March; you always know what you’re having to eat on Friday night (fish fry); you can pronounce Waukesha, Kaukauna, Sheyboygan, and Oconomowoc; you make an Old Fashioned with brandy; you head “up north” for vacation; you use your hand as a map to tell someone where you’re from; AND, as a laboratory professional, you know that ASCLS-WI supports your professional practice and connection to like-minded peers.

ASCLS-Wisconsin has long-standing traditions and activities that support our professional society. In 2017-18, the ASCLS-WI Board of Directors initiated a strategic planning process targeted to support the ASCLS Strategic Map and priority pillars of Organizational Efficiency, Internal Communication, Advocacy, and Professional Promotion. In September 2017, the ASCLS-WI Board approved the following plan.

Strategic goals:

1. Streamline processes and facilitate effective and sustainable initiatives.
2. Raise the profile of ASCLS as the organization for laboratory professionals in Wisconsin through recognition of member leadership, service, and expertise.
3. Expand opportunities for interested volunteers by following orderly committee leadership and member processes.
4. Strengthen/support branch societies where needed.
5. Facilitate volunteer satisfaction through clear communication, defined expectations, and recognition.
6. Be open, inclusive, and welcoming.

We think these are worthy goals, and we can follow and revise the framework to facilitate a vibrant and sustainable constituent society.

We believe communication and recognition of leader and member expertise is essential to the satisfaction of our members. ASCLS-WI has made a focused effort to utilize the ASCLS CONNECT community as a means for providing information and as a document repository for our members. Once organized, it should assist in providing consistency of communication for leadership and others (Strategic Goal #1).

ASCLS-WI supports member participation at Annual Meetings, Legislative Symposia, Leadership Academies, and other national or regional events. We are pleased we had a delegation of 10 members at the 2018 ASCLS Annual Meeting; five of them were first-time attendees.

To facilitate wider participation, we established communication via the member community and provided clear guidelines for participation and financial support. Although these are small changes, previous feedback indicated members were confused about applying for participation and requesting reimbursement. Interest in participating as delegates supports the positive nature of this change and supports our strategic goal of being open, inclusive, and welcoming (Strategic Goal #6). 

Membership is key for all of us. ASCLS-WI benefits from five MLS and 10 MLT programs, where program directors are active in mentoring students into our profession and professional society. Six of the education programs established institutional membership packages in 2017, and we hope we can move that to all 16!

How do we encourage student participation in ASCLS? Each year, at the ASCLS-WI Annual Convention, more than 150 students attend and participate in Student Bowl, student posters, and Student Forum activities. The April 2018 convention in Milwaukee included 22 Student Bowl teams and 89 poster entries representing 100 student participants.

In 2016, we established an electronic discount code, streamlining the process of converting student members (Developing Professionals) to First Year Professionals (Ascending Professionals). Ascending Professional members in Wisconsin are strong, but efforts to recruit new Professional members this year tell us we should refine our messaging and communications (Strategic Action #9). And we need to be more proactive in encouraging Ascending Professionals to renew their membership (Strategic Goals #1 and #3).

What is next for ASCLS-WI? We will continue to work on our strategic planning; continue to use the member community and other avenues of communication to demonstrate the relevancy and activity of our society; and systematically analyze the outcomes of supporting students, new professionals, and others in terms of member retention and leadership progression. Every improvement is a step forward.