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ASCLS Mission/Vision Statement The American Society for Clinical Laboratory Science serves as the voice of all clinical laboratory professionals, creating a vision for the advancement of the clinical laboratory practice field, and advocating the value and role of the profession ensuring safe, effective, efficient, equitable, and patient centered healthcare. ASCLS MEMBER EDITORS Editor-in-Chief Bernadette Rodak MS CLSpH(NCA) Clinical Laboratory Science Program Indiana University Clarian Pathology Laboratory 6002F 350 West 11th Street Indianapolis IN 46202 317-491-6218, fax 317-491-6212 [email protected] Continuing Education Editor George A Fritsma MS MT(ASCP) The Fritsma Factor http://www.fritsmafactor.com 153 Redwood Drive Trussville AL 35173 205-821-5641, fax 205-975-7302 [email protected] Clinical Practice Editor Libby Spence PhD CLS(NCA) University of Mississippi Medical Center School of Graduate Studies in the Health Sciences 2500 North State Street Jackson, MS 39216 601-984-1204, fax 601-815-9440 [email protected] Research and Reports Editor David L McGlasson MS MLS(ASCP) 59th Clinical Research Division/SGRL 2200 Berquist Dr., Bldg. 4430 Lackland AFB TX 78236-9908 210-292-6555, fax 210-292-6053 [email protected] Education Editor Elizabeth Kenimer Leibach, EdD MS MLS SBB Professor Departments of Biomedical and Radiological Technologies and Pathology Medical College of Georgia, EC 2437 Augusta, GA 30912 (706)721-3046, fax (706)721-7631 [email protected] Contributing Editors Eileen Carreiro-Lewandowski/N Dartmouth MA Clinical Laboratory Science (ISSN 0894-959X) is published quarterly by the American Society for Clinical LaboratoryScience, 6701 Democracy Blvd., Suite 300, Bethesda MD 20817; (301) 657-2768; (301) 657-2909 (fax). Annual Subscription Rates: USA Canada Non-USA Individuals $65 $75 $130 Institutions $80 $80 $130 Questions related to subscriptions should be addresssed to: [email protected]. The cost of single copies is $15. Requests to replace missing issues free of charge are honored up to six months after the date of issue. Send requests to ASCLS headquarters. Annual membership dues of ASCLS are $95, $40 of which is allocated to a subscription of CLS. Periodical postage paid at Bethesda, MD and other additional mailing offices.

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ASCLS Core Values Core Values include enhancing quality standards and patient safety; providing professional development oppor-tunities; promoting expanded roles and contributions of clinical laboratory professionals to the healthcare team; increasing the diversity in the profession; and expanding the voice and role of under-represented individuals and groups. Harriette Nadler/King of Prussia PA Joan Prince/Milwaukee WI Margaret Reinhart/Philadelphia PA Perry Scanlan/Clarksville TN Masih Shokrani/Dekalb IL Stephen Sodeke/Tuskegee AL James Vossler/Syracuse NY Kathy Waller/Columbus OH Mara Williams/Santa Clara CA Lori Woeste/Normal IL Michele Wright-Kanuth/Galveston TX

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Diane Kumashiro/Kaneohe HI ASCLS BOARD OF DIRECTORS 2009-2010 Mary Ann McLane, President Marcia Armstrong, President-elect Scott Aikey, Past President Gilma Roncancio-Weemer, Secretary/Treasurer Carol Golyski, Region I Barbara Snyderman, Region II Hassan Aziz, Region III Linda S. Gorman, Region IV Debra Rodahl, Region V Tim Randolph, Region VI Linda Smith, Region VII J.R. Constance, Region VIII Mary Lashinski, Region IX Sheri Gon, Region X Michele Yost, First Year Professional Chair Lisa Martini, Student Forum Chair ASCLS Headquarters Executive Staff Elissa Passiment, Executive Vice President EDITORIAL OFFICE AND PRODUCTION Westminster Publishers 315 Westminster Court Brandon, MS 39047 (601) 214-5028; (202) 315-5843 (fax) [email protected] Executive Editor David Fowler PhD MLS Managing Editor Myra Fowler MT(ASCP) Correspondence related to editorial content should be mailed to: Westminster Publishers, 315 Westminster Court, Brandon, MS 39047; (601) 214-5028; (202) 315-5843 (fax). Email: [email protected] © Copyright 2010 American Society for Clinical

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CLINICAL SUMMER 2010 LABORATORY VOLUME 23/NUMBER 3

SCIENCE

DIALOG AND DISCUSSION 130 Editorial

Kelly A Joyner, Jr

CLINICAL PRACTICE 131 Factor X Deficiency Dorothy M Funk, Dennis Casciato 134 A Tale of Two Biomarkers: The Use of Troponin and CK-MB in Contemporary Practice Amy K Saenger 141 Metastatic Renal Cell Carcinoma with Metabolic Syndrome- A Case Report Kemper Kelly, Carrie Cocklin 146 ASCLS Annual Meeting 2010: Official Abstracts of Submitted Papers, Case Studies and Posters

RESEARCH AND REPORTS

151 Acinetobacter baumannii and MRSA Contamination on Reusable Phlebotomy Tourniquets Donna M Hensley, Kevin J Krauland, David McGlasson 157 CLS to Higher Education Administrator: The Price They Paid Suzanne Campbell, Barbara Y LaCost 166 Graduate Education in Clinical Laboratory Science Is the Glass Half Full or Half Empty? Karen Karni, Joan Polancic, Joann Fenn, Donna J Spannaus-Martin 175 Scholarly Activities of the Most Productive CLS Faculty and Schools in the U.S.A. Kathy V Waller, Karen R Karni

FOCUS: EDUCATIONAL TECHNOLOGY

180 Educational Technology: Online Education and Technology Introduction Vicki Freeman 182 Educational Technology: Using Technology in Resource Limited Countries for Competency

Based Education and Training Wendy Arneson 187 Educational Technology: Moving from Face-to-Face to Online Teaching Muneeza Esani

191 CONTINUING EDUCATION QUESTIONS

130 VOL 23, NO 3 SUMMER 2010 CLINICAL LABORATORY SCIENCE

DIALOG AND DISCUSSION

Editorial

KELLY A JOYNER, JR The recently published article ‘Heparin-Induced Thrombocytopenia (HIT): A Case Study’ contains several issues that I feel need to be addressed. This article does a fine job of describing a very fulminant case of HIT where the patient died following a series of missed diagnoses as well as some questionable therapy practices. This article states in several places that the use of low molecular weight heparins (LMWH) has an effective use in anticoagulation therapy, but also states that these LMWH therapies do not need to be monitored by laboratory methods. Unfractionated heparin (UF) is commonly used in anticoagulant therapy and is monitored by a variety of methods including activated partial thromboplastin time (aPTT), anti-Xa assays, and during surgery or other invasive procedures by the activated clotting time (ACT). The initiation of LMWH therapy is typically used in patients already in higher risk morbidity categories such as those with heparin sensitivity issues, those with described clotting diatheses, in higher risk pregnancies (antiphospholipid antibody patients, pre-eclamptic), and patients with histories of hypercoagulable states. It makes logical sense that drugs with similar uses and effects (UF) heparins should be monitored for better patient outcome. Patients with prolonged baseline aPTT assays, those with complex anticoagulation diagnoses, those with multiple hypercoagulable states, and high risk patients receiving anticoagulant therapy with UF and/or LMWH should be monitored using an applicable and documented assay or assays. The ability to monitor/evaluate possible HIT status is a definite plus for any hospital, but many are limited by resources and technological capabilities. Serotonin release assay (SRA), although a sensitive and specific test, is performed by only a very few laboratories and turn around time for the assay may make this result a moot point. The platelet factor 4 assays, ELISA based, are also very sensitive and somewhat specific assays, but again technological and expense restraints may make

these not profitable or standardized (i.e., heparin reversal of positive results, cost per run if only one or two patients are tested, finding a proper proficiency testing cohort). The use of direct thrombin inhibitors (DTI) such as Lepirudin or Argatroban is becoming more widely accepted as means of anticoagulating HIT and other hypercoagulable patients. There are laboratory and medical restraints with this class of drugs such as there is typically no good or standardized method of testing anticoagulation status, there is no antidote (such as protamine sulfate for the heparins) and renal or liver dysfunction may make these drugs not viable. The author should be commended for preparing a case study for a difficult anticoagulation scenario, but must be careful in suggesting treatment and laboratory testing methods that are not necessarily proven. Respectfully, Kelly A. Joyner, Jr. MS, MT(ASCP)SH, PA-C Analytical Specialist, Clinical Coagulation Laboratory (Retired) Duke University Medical Center Independent Haemostasis Consultant Rougemont, NC

VOL 23, NO 3 SUMMER 2010 CLINICAL LABORATORY SCIENCE 131

CLINICAL PRACTICE

Factor X Deficiency

DOROTHY M FUNK, DENNIS CASCIATO ABBREVIATIONS: PT - prothrombin time, aPTT – activated partial thromboplastin time, INR – inter-national normalized ratio. INDEX TERMS: Factor X Deficiency, amyloidosis, vitamin K deficiency. Clin Lab Sci 2010;23(3):131 Dorothy M (Adcock) Funk, M.D., Esoterix Coagulation, 8490 Upland Drive, Ste.100, Englewood, CO 80112 Dennis Casciato, M.D., David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1732 Address for Correspondence: Dorothy M (Adcock) Funk, M.D., Esoterix Coagulation, 8490 Upland Drive, Ste.100, Englewood, CO 80112, Office: 720 568 4328, Fax: 720 568 4314, [email protected] PATIENT 52-year old Caucasian female who initially presented with lower abdominal discomfort. Evaluation included a urinalysis which was 4+ positive for protein. A 24-hour urine demonstrated 7.7 gm of protein/24 hours. Prior to undergoing a renal biopsy, a prothrombin time (PT) and activated partial thromboplastin time (aPTT) were ordered and the patient was noted to have an elevated PT of 22.4 seconds (normal range 10.0 – 13.0 sec) with an INR of 2.12 and a normal aPTT. CLINICAL HISTORY The clinical history is otherwise not remarkable. She underwent transabdominal hysterectomy and bilateral salpingoophrectomy and cystocele repair 6 years previously without any bleeding complications or report of abnormal laboratory screening assays. She had undergone tooth extractions without bleeding and did not suffer menorrhagia, epistaxis or easy bruisability.

FAMILY HISTORY No family history of bleeding dyscrasias. MEDICATIONS None PHYSICAL EXAMINATION Unremarkable with the exception of 2+ pitting edema of the lower extremities INITIAL WORK-UP Laboratory Data (Initial) Reference Interval PT 22.4 10–13 sec aPTT 31.1 23.7–37.7 sec Factor VII 167% 50–155% Factor II 146% 75–134% Factor V 210% 70–150% Factor X 25% 65–135% PT mixing studies showed evidence of correction into the reference range consistent with a factor deficiency. FX activity repeated on a new plasma sample at another laboratory yielded a result of 32% (reference interval 65–135%).

DIFFERENTIAL DIAGNOSIS 1. Acquired FX deficiency: An acquired factor X

deficiency is the most likely diagnosis as the patient does not have a history of bleeding and was not known to have abnormal APTT and/or PT in the past. Isolated acquired FX deficiency raises the possibility of amyloidosis which is most commonly a complication of an underlying plasma cell dyscrasia. Factor X activity could also be decreased in an acquired fashion due to a factor X inhibitor although normal plasma mixing studies would typically not show evidence of correction.

2. Hereditary FX deficiency: this seems unlikely given that the patient has no previous history of bleeding and there is no family history of such.

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3. Vitamin K deficiency: While factor X may be decreased with vitamin K deficiency, this would not explain an isolated deficiency of factor X. With vitamin K deficiency, all vitamin K-dependent factors; specifically factors II, VII, IX and X decrease. Laboratory evaluation revealed that factors II and VII are normal to slightly elevated.

4. Liver disease: Although factor X may decrease with significant liver disease, this would not explain an isolated factor X deficiency. With liver disease (or vitamin K deficiency/antagonism), factor VII is usually the first factor to decrease as it has the shortest half life of all procoagulant factors produced in the liver. With significant liver disease, factor X is decreased as are all other procoagulant factors, specifically factor XI, IX, VII, V, X and II, except for factor VIII which may be elevated.

ADDITIONAL WORK-UP The most common causes of nephrotic syndrome include underlying diabetes, autoimmune disease (e.g. systemic lupus erythematosus), significant liver disease or pre-existing renal disease, none of which were evident in this case. Due to the isolated low factor X activity, especially in the presence of nephrotic syndrome, a diagnosis of amyloidosis was immediately considered. Serum protein electrophoresis revealed 1.2 gm/dL of a monoclonal protein. Serum immunoelectrophoresis demonstrated an IgG lambda monoclonal protein. Both monoclonal IgG-λ and free lambda light chains were detected in her urine. A bone marrow biopsy demonstrated 30% plasma cells with lambda restricted immunostaining, establishing the diagnosis of myelo-ma. Congo red stains of the bone marrow biopsy and of the aspirate of abdominal wall fat were negative for amyloidosis. Radiographic skeletal survey did not demonstrate either osteolytic lesions or osteoporosis. High dose dexamethasone therapy resulted in a decrease in both proteinuria and serum paraprotein. The patient developed severe epigastric symptoms associated with this therapy. Esophagogastroduodenoscopy revealed no significant mucosal lesions but biopsies demonstrated amyloidosis in the mucosa of both the stomach and duodenum. At this time, she developed severe liver

function test abnormalities, progressive hepatomegaly and ascites, and computerized tomography that suggested cirrhosis of the liver.

DIAGNOSIS Multiple myeloma complicated by systemic amyloidosis (AL) resulting in nephrotic syndrome. MANAGEMENT APPROACH The patient was begun on dexamethasone, melphalan, bortezomib. Two years later the patient was doing exceedingly well and is totally asymptomatic, her PT normalized, serum creatinine decreased from 1.7 to 1.0 mg/dL, total IgG decreased from 1722 mg/dL to 247 mg/dL and monoclonal protein concentration decreased from 1.17 g/dL to 0.21 g/dL. The ascites resolved and liver size returned to normal. Moderate proteinuria persists.

GENERAL DISCUSSION The most common form of amyloidosis is light chain amyloidosis (AL). In this instance, the amyloid fibrils are composed of IgG light chains or light chain fragments produced by a clonal population of plasma cells. Approximately 10 – 15 % of patients with myeloma or Waldenstrom macroglobulinemia develop systemic AL. The diagnosis of AL amyloidosis requires 1) demonstration of amyloid in tissue and 2) demonstration of a plasma cell dyscrasia. Evaluation often includes investigation of serum and urine for monoclonal light chains and a bone marrow biopsy as well as Congo red staining of an involved tissue or random abdominal fat or rectal biopsy. Organs most commonly involved in systemic amyloidosis include the kidney and heart. Renal involvement usually manifests as nephrotic syndrome. Amyloid may also deposit in the gastro-intestinal tract, liver and peripheral nervous system. The majority of patients with AL have 1 or 2 organs involved and about 30% have 3 or more major organ systems involved. Acquired factor X deficiency is the most common coagulation factor deficiency identified in AL amyloidosis and it occurs presumably as a result of adsorption of factor X to amyloid deposits. Decreased factor X levels in AL occurs independent of hepatic parenchymal disease and as in this case, may occur as an

CLINICAL PRACTICE


isolated factor deficiency. Due to the well known correlation of factor X deficiency with AL, it has been recommended that once a diagnosis of AL is made, all patients should be screened for factor X deficiency. A study of 368 new patients with AL revealed an incidence of factor X deficiency in 8.7% or 32 patients. Of these 32 patients, over half had bleeding complications and in two, the hemorrhage proved fatal. Bleeding severity correlated with factor X levels and those with <25 % factor X activity were more likely to bleed. Successful aggressive treatment of the underlying plasma cell dyscrasia is associated with improvement in factor X activity levels and even partial hematologic responses may show improvement of factor X levels. Aggressive therapy employing high dose chemotherapy with stem cell rescue has been used effectively to treat AL. In patients with splenomegaly, splenectomy has been reported to acutely improve factor X levels, presumably due to removal of a large amyloid pool. In the acutely bleeding patient or in a patient requiring surgical intervention, fresh frozen plasma or recombi-nant activated factor VII may be of benefit. Acquired isolated factor X deficiency may also occur secondary to a specific factor X inhibitor. These inhibitors are rare and may arise without provocation or may occur in association with underlying infections, such as leprosy. Laboratory evaluation typically demonstrates an elevated APTT and PT with incomplete correction in plasma mixing studies. Factor X inhibitors can be quantified using the Bethesda assay. Clinically, the majority patients with factor X inhibitors

present with bleeding and factor X levels in the range of 1 to 20%.

Hereditary factor X deficiency is a rare autosomal recessive, hemorrhagic disorder with a reported incidence of about one in one million. Patients with severe deficiencies (<1%) typically present with bleeding early in life, including hemarthroses, gastrointestinal bleeding, hematuria and CNS hemorrhage. Those with less severe deficiencies are often asymptomatic and may bleed only after challenged. The diagnosis of factor X deficiency is based on measurements of factor X activity, typically using a clot-based assay, although a chromogenic factor X activity assay could be used. Typically both the APTT and PT are prolonged in patients with factor X deficiency. With less severe deficiencies, as in this case however, the PT may be prolonged while the APTT falls in the normal range as most PT reagents are more responsive to mild deficiencies of factor X than are APTT reagents. REFERENCES 1. Menegatti M, Peyvandi F. Factor X deficiency. Semin

Thrombos Hemost 2009; 35:407–15. 2. Choufani EB, Sanchorawala V, Ernst T, et al. Acquired factor

X deficiency in patients with amyloid light-chain amyloidosis: incidence, bleeding manifestations, and response to high-dose chemotherapy. Blood 2001; 97:1885–7.

3. Comenzo RL. How I treat amyloidosis. Blood 2009; 114:3147–57.

4. Sanchorawala V. Light-chain (AL) amyloidosis: diagnosis and treatment. Clin J Soc Nephrol 2006; 1:1331-41.


CLINICAL PRACTICE

A Tale of Two Biomarkers: The Use of Troponin and CK-MB in Contemporary Practice

AMY K SAENGER

In its Fall, 2009 issue, Clinical Laboratory Science featured a Focus Series on Cardiovascular Risk Assess-ment. This series contained articles on B-type natriuretic peptide and genetic markers of cardiov-ascular disease and explored the links between decreased serum vitamin-D levels and cardiovascular disease. Traditionally, cardiovascular risk assessment has referred to markers that help predict long-term mortality and morbidity for heart disease. Markers like LDL, HDL, triglycerides, total cholesterol, hsCRP, BNP and many others make up this group. Acutely however, in cases of suspected myocardial infarction, cardiovascular assessment relies on a very different class of serum markers. Measurement of CK-MB and troponin proteins allows us to confirm or rule out damage to the myocardium. These markers are in obvious contrast to risk markers that are used as tools to assess a person’s future risk for cardiovascular events. When considering markers for myocardial infarct, laboratorians know that CK-MB and troponin are both used to give diagnostic and sometimes even prognostic information. In this article, which is an extension of the Fall 2009 Focus series, we review the progress of these two myocardial markers while contemplating the question, ‘is it time to phase-out CK-MB testing given the advances and advantages of troponin testing?’ Clin Lab Sci 2010;23(3):134 Amy K. Saenger, PhD, DABCC, Laboratory Medicine and Pathology Mayo Clinic 200 First Street SW Rochester, MN 55905 Address for Correspondence: Amy K. Saenger, PhD, DABCC, Director, Central Clinical Laboratory/Central Processing, Assistant Professor, Laboratory Medicine and

Pathology Mayo Clinic 200 First Street SW Rochester, MN 55905 507-266-6494 [email protected] Modern diagnosis of myocardial infarction includes the use of blood biomarkers, which can also be used for risk assessment and for guiding interventional and non-interventional therapies. An ideal marker of cardiac necrosis should exhibit the following characteristics: cardiac specificity, tissue sensitivity, early and stable release after necrosis, predictable clearance, and the ability to be quantitatively and rapidly measured by cost effective methodologies available in the majority of clinical laboratories. In addition, the biomarkers should provide additional novel information pertinent to clinical care of the patient. This review provides an overview of the use of creatine kinase MB (CK-MB) and cardiac troponin (cTn) in contemporary clinical practice. Clinical Efficacy of Creatine Kinase MB The first cardiac biomarker to fit many of the above criteria was CK-MB. CK-MB is one of three isoenzymes arising from total creatine kinase (CK). Total CK is a dimeric enzyme composed of two subunits, termed “M” to denote muscle origin or “B” to designate brain origin. There are three major CK isoenzymes; the two homodimers CK-MM and CK-BB and the heterodimer CK-MB.1 Myocardium is the only tissue that has a high proportion and concentration of CK-MB (Table 1). Release of CK-MB only occurs upon death of myocardial cells and it is not released in the setting of ischemia.2 However, CK-MB is also present in skeletal muscle and interpretation of the CK-MB activity assay may therefore be confounded with false positives in the setting of suspected cardiac disease with concomitant skeletal muscle disease.3-6

CLINICAL PRACTICE


Table 1: Tissue Distribution of CK Isoenzymes

CK-1 CK-2 CK-3 (BB) (MB) (MM) Skeletal 0 1 99 Cardiac 1 20 79 Brain 97 3 0

In the 1970s and 1980s, CK-MB transformed the diagnosis and treatment of patients with acute cardiac events.7 CK-MB proved more specific than an accurate clinical history, which is often unattainable in the critically ill or is atypical in the elderly and diabetics. CK-MB was more reliable than ECG pattern recognition which can be blind to disease depending on the location of the ischemia. CK-MB also improved specificity over myoglobin (90% vs 70% specificity, respectively) and consequently became the gold standard for identification of cardiac injury. Myocardial infarction was rarely diagnosed in the absence of CK-MB elevation8,9 and utilization allowed earlier diagnoses, permitted an uncomplicated mechanism for detection of reinfarction, encouraged the concept of serial measurements, and proved to be one of the first accurate ways to measure infarct volume. The initial CK-MB assays quantitated activity, but were analytically imprecise and required a significant amount of manual technical intervention. Development of CK-MB immunoassays led to increased analytical precision, improved clinical sensitivity (approximately 90%, dependent upon the assay utilized), and allowed for earlier detection of elevated CK-MB concentrations following an acute myocardial infarction (AMI). How-ever, use of immunoassays raised the frequency of CK-MB interference by acute and chronic skeletal muscle injuries because the dilutions required for activity assays were eliminated.10-12 Application of the percent relative index (RI), as defined below, aided in the interpretation of CK-MB values when only cardiac injury or skeletal muscle injury occurred but generated inaccurate diagnoses in patients presenting with concurrent cardiac and skeletal muscle injuries.

Relative Index = CK-MB (mass) x 100 CK (activity)

Macrokinases, broadly defined as either an immune-globulin complex with CK-BB or mitochondrial CK, were also discovered to interfere with immunoassays and led to further attempts at CK-MB assay stand-ardization.13,14 Although partially successful, poor standardization still exists and results cannot be easily compared over time between manufacturers or plat-forms. In the absence of myocardial infarction, CK-MB may be elevated due to poor specificity in patients who present with multiple co-morbidities or conditions including renal failure, non-cardiac surgery, chest trauma, asthma, pulmonary embolism, chronic and acute muscle disease, head trauma, hyperventilation, and hypothyroidism.13,15,16 Any elevation in CK-MB becomes confounded with questionable analytical and biological interferences and restricts the use of CK-MB as a stand alone diagnostic cardiac marker. In addition, reporting CK-MB properly requires the use of gender-specific reference ranges, which many laboratories fail to do.17 By mid-1990 it was evident that better biomarkers were needed to improve patient care and quality outcomes. The Advent of Troponin Development of cardiac troponin I (cTnI) and troponin T (cTnT) assays in the 1990s revolutionized the use of biomarkers for diagnosis and risk stratification of cardiac injury. Troponin consists of three subunits: T, I, and C (Figure 1). Troponin T is a protein that binds tropomyosin; troponin I enhances the interaction of actin and myosin in the myocardium, and troponin C is responsible for calcium binding within the complex and results in muscle contraction. Troponin C is present in both the myocardium and skeletal muscle whereas troponin T and I are highly specific for cardiac muscle. There is a cytosolic pool of unbound cardiac troponin which is released acutely after myocardial infarction, and mimics the release of other cytosolic proteins like CK. The smaller cytosolic pool represents about 6% of cTnT and 3% of cTnI, and a similar percentage of the cytosolic pool exists for CK-MB. The increased sensitivity of cardiac troponin over CK-MB is primarily due to the fact that the percentage of troponin released into the blood after an acute cardiac event is greater for troponin than CK-MB.4,18 There is a 13-15 fold

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increase in troponin per gram of myocardium that is primarily complexed and this complexed form is responsible for the late and not early release of troponin.19-22 Troponin elevations persist in the blood due to the slow release and degradation of the structural pool, and the half-life of complexed troponin is approximately 2 hours.

Figure 1: Structure of Troponin In 2000 the European Society of Cardiology (ESC) and American College of Cardiology (ACC) task force concluded that diagnosis of AMI required biochemical evidence of necrosis and indicated the marker of choice was troponin.23 Recommendations were also put forth to utilize troponin for risk stratification and CK-MB was advocated at that time to be measured in conjunction with troponin to distinguish acute MI from an older injury due to troponin persistence. In 2000, there were problems with the analytical aspects of troponin assays which included poor precision, poor standardization, and an overall lack of harmonization, all of which prevented troponin from being recommended as a stand-alone biomarker. There is only one manufacturer of the troponin T assay (Roche Diagnostics), but there are numerous companies that market troponin I. The antibodies for each troponin I assay are directed towards different epitopes and each manufacturer has a different calibration standard. These dissimilarities result in troponin I assays that have different recommended cutoffs, precision profiles, and positive predictive values. Lack of standardization among troponin I assays remains a

source of confusion and potential misclassification of patients by clinicians who utilize troponin I results from different laboratories, a common example being an emergency room point-of-care method versus an automated core laboratory result. Analytical issues remain an unsolved problem for many laboratories, and the majority of assays still suffer from overall imprecision at very low concentrations, including most point-of-care assays. Troponin guidelines were updated in 2007 by both clinical (ACC/ESC/AHA) and biochemical (NACB) expert groups to recommend use of a troponin concentration greater than the 99th percentile for diagnosis of acute myocardial infarction.24,25 The International Federation of Clinical Chemistry and Laboratory Medicine recognized the definition of the 99th percentile as the upper limit of normal for troponin. Accepted by the ESC and ACC, the 99th percentile reference interval for any troponin assay is the 99th percentile generated from a presumably normal reference population (mean ± 3 standard deviations) and should be used as the cutoff for determining abnormal values. Analytical guidelines recommend an optimal coefficient of variation for troponin of <10% at the 99th percentile. In 2009, only three assays meet these precision criteria. The formal definition from the 2007 guidelines specifies evidence of a changing (delta) pattern of cardiac markers (preferably troponin) with at least one value above the 99th percentile reference range. However there has been substantial confusion about use of the 99th percentile and a lack of understanding that a single elevated troponin above the 99th percentile does not diagnose AMI; instead, a pattern of troponin rise and fall is required. There are trends toward use of ultrasensitive troponin assays, which may be achieved by longer sample incubation times or enhanced signal amplification techniques. Use of ultrasensitive troponin assays may result in a 10-fold lower reportable concentration and allows for the potential to identify AMI patients at earlier time points.24 As assays have progressively increased in sensitivity, it is clear that even the most minor elevations are indicative of cardiac damage (acute or chronic) and thus are

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significant and predictive for patients. This can make the differential diagnosis difficult in some patients who may not have a clear etiology for a chronically increased troponin. Nonetheless, it is clear from several studies that any troponin concentration greater than the 99th percentile defines subsequent risk.26-30 While an elevation of cTnT or cTnI is specific for cardiac injury, there are rare exceptions of analytical false positives most often due to fibrin interference or cross reacting antibodies.31 These interferences are less frequent with current generation assays as technologies have substantially improved over the last decade. The majority of interferences are eliminated by re-centrifuging specimens, performing dilution studies, or using heterophile antibody blocking tubes. Troponin assays have substantially improved analytically in terms of precision, accuracy, and detection limits, which have enhanced the clinical utility for earlier diagnosis of AMI, reinfarction, and risk prediction for future cardiac events. The use of troponin has gradually superseded CK-MB in the majority of indications and patients. Troponin versus CK-MB It has been observed and well-documented that troponin concentrations rise quickly after the onset of chest discomfort. Thus, in upwards of 80% of patients, a definitive diagnosis can be made in a 2-3 hours using only troponin.32 The previously touted “rapidly rising” markers which lack specificity such as myoglobin, CK-MB, and fatty acid binding protein are no longer needed.33-35 Values of both CK-MB and troponin generally peak within 24 hours or even earlier when reperfusion therapies are effective. For these reasons, CK-MB is not used definitively for diagnosis without troponin. When troponin is below the 99th percentile but the CK-MB is elevated, the patient prognosis is excellent.36 However, the opposite statement does not hold any validity. Individuals with an elevated troponin but not CK-MB still have a marked increased risk for development of future coronary events, morbidity, and mortality.28,32 A rising or falling pattern of cardiac troponin provides all the pertinent information needed to time, diagnose, and treat acute events and CK-MB does not provide any supplemental knowledge to the physician.

Prognosis after acute myocardial infarction is closely related to the extent of myocardial damage. Calculations based on analysis of serial levels of CK or CK-MB have provided estimate of the infarct size for many years since the pioneering work of Sobel and Roberts.37-40 For clinicians, peak concentrations provide a reasonable clinical estimate if a sufficient number of data points are collected and if an accurate assessment of whether reperfusion (which changes the kinetics and magnitude of CK-MB release) has occurred. Although peak concentrations may relate to overall subsequent cardiovascular risk, there are major limitations in using these measurements to quantify infarct size. Recent data suggest that troponin concentrations provide better estimates of infarct size. Ingkanisorn et al41 published the first work investigating the association between early troponin concentrations and infarct size in patients with acute coronary syndromes. They reported that the peak troponin I correlated with acute infarct mass in patients undergoing acute primary percutaneous coronary intervention (PCI) (r = 0.83, p <0.001, n = 23). These data were confirmed in a study by Younger et al42 where there was a significant relationship between infarct size and cTnI in both thrombolyzed and non-thrombolyzed patients. Troponin provides better information than CK-MB on infarct size and thus CK-MB should not be ordered for this purpose. Recent data on utilization of cardiac biomarkers for diagnosis of reinfarction are sparse, largely because modern day contemporary intervention for AMI and suspected AMI is rapid, aggressive, and predicated on the use of troponin. Some argue that CK-MB should still be used to diagnose reinfarction but supportive data for troponin demonstrates equivalency. The 2007 ACC/ESC/AHA guidelines still suggest that serial samples for CK-MB may be helpful, yet advocacy for the use of CK-MB for reinfarction diagnosis likely represents a widespread level of comfort with CK-MB rather than evidence based data. The studies which originally validated CK-MB for diagnosis of reinfarction were conducted at a time prior to the extensive use of interventional strategies for AMI. Patients were often hospitalized for several days and recurrent chest discomfort rarely triggered coronary angiography and/or

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intervention. Reinfarction criteria still required a rise from the prior baseline; this information was readily accessible from commonly obtained surveillance CK-MB values. The criteria proposed for use of CK-MB in reinfarction43 and modified by many clinical trial groups have never been validated. Literature comparing CK-MB and troponin simultaneously in reinfarction is minimal, with the most comprehensive paper stemming from Apple et al.44 Troponin provides equivalent, if not superior, information to CK-MB in patients who delay acute intervention and a 20% change in troponin is required for diagnosis. Awareness surrounding the occasional patient who will have a secondary rise in troponin (especially cTnT) after an ST-segment eleva-tion myocardial infarction, most often in the absence of symptoms, is essential. CK-MB has also been promoted as providing crucial information in patients undergoing interventional pro-cedures, such as percutaneous coronary intervention (PCI). While it is true that biomarker monitoring is of importance in interventional patients, cardiac intervene-tional experts now advocate changing from CK-MB to a troponin standard.45 However, elevation in CK-MB or troponin retains no prognostic importance in patients who undergo PCI when the baseline CK-MB/troponin is used for risk stratification,46,47 suggesting neither marker is specifically prognostic. An elevated troponin can be used to direct specific anticoagulant, anti-platelet and invasive therapies predicated on results from multiple large randomized clinical trials, an important caveat to its use in interventional procedures.25, 48 Troponin concentrations can be elevated in many situations but observed commonly in renal failure patients, the critically ill, and with strenuous exercise (Table 2). These chronic elevations are not “false positives” but instead provide prognostic significance. CK-MB testing is not useful in these populations, as CK-MB will likely also be elevated and should not be retained for this purpose.16,49 In contrast to chronic troponin elevations, chronic CK-MB elevations have not been reported to help distinguish risk for further adverse outcomes. Therefore, although renal patients can have a chronically elevated troponin, measurement of troponin should still supersede CK-MB testing to predict risk of cardiovascular events. Ultimately, it is

evident that a rising or falling pattern of troponin can be used to differentiate those with acute disease from those with chronic troponin elevations.

Table 2: Troponin Elevations in Patients Without Overt Ischemic Heart Disease

Acute rheumatic fever Hypotension, often with Amyloidosis arrhythmias Cardiac trauma (including Hypothyroidism

contusion, surgery, ablation) Inflammatory disease Cardiotoxicity from (including myocarditis,

chemotherapy bacterial endocarditis, Chronic renal failure Kawasaki disease) Heart failure Acute neurological diseases Critically illness Post-operative non-cardiac Diabetes surgery Drug toxicity Pulmonary embolism, Hypertension severe pulmonary hypertension Sepsis

Summary With the advent of sensitive cardiac troponin assays, CK-MB no longer provides additional information to the diagnostic algorithm for acute myocardial infarction. The ordering patters of CK-MB often represent a clinical level of comfort which may be difficult to supersede. Contemporary troponin testing essentially renders the use of CK-MB as obsolete and frequent ordering of CK-MB yields unnecessary costs for the patient and the laboratory. In situations where little, if any, incremental information is provided with duplicate testing laboratories should focus efforts to-wards educating clinicians and/or implement strategies to restrict CK-MB orders. Troponin assays in 2009 are continually improving in precision, accuracy, sensitivity, and specificity. REFERENCES 1. Christenson RH, Azzazy HM. Biochemical markers of the

acute coronary syndrome. Clin Chem 1998;44:1855–64. 2. Ishikawa Y, Saffitz JE, Mealman TL, et al. Reversible

myocardial ischemic injury is not associated with increased creatine kinase activity in plasma. Clin Chem 1997;43:467–75.

3. Wu AH, Wang XM, Gornet TG, Ordonez-Llanos J. Creatine kinase MB isoforms in patients with skeletal muscle injury: ramifications for early detection of acute myocardial infarction. Clin Chem 1992;38:2396–400.

4. Adams 3rd JE, Bodor GS, Davila-Roman VG, et al. Cardiac troponin I. A marker with high specificity for cardiac injury. Circulation 1993;88:101–6.

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5. Adams 3rd JE, , Schechtman KB, Landt Y, Ladenson JH, Jaffe AS. Comparable detection of acute myocardial infarction by creatine kinase MB isoenzyme and cardiac troponin I. Clin Chem 1994;40:1291–5.

6. Tsung JS, Tsung SS. Creatine kinase isoenzymes in extracts of various human skeletal muscles. Clin Chem 1986;32:1568–70.

7. Jaffe AS. Biochemical detection of acute myocardial infarction. In: Gersh B, Rahimtoola S, eds. Acute Myocardial Infarction, Elsevier, 1991:110–27.

8. Roberts R. The two out of the three criteria for the diagnosis of infarction: Is it passe? Chest 1984;86:511–3.

9. Lee TH, Goldman L. Serum enzyme assays in the diagnosis of acute myocardial infarction. Recommendations based on a quantitative analysis. Ann Intern Med 1986;105:221–33.

10. Mair J, Artner-Dworzak E, Dienstl A, et al. Early detection of acute myocardial infarction by measurement of mass concentration of creatine kinase-MB. Am J Cardiol 1991;68:1545–50.

11. Collinson P, Rosalki S, Kuwana T, et al. Early diagnosis of acute myocardial infarction by CK-MB mass measurements. Ann Clin Biochem 1992;29:43–7.

12. Bakker A, Gorgels J, van Vlies B, et al. The mass concentrations of serum troponin T and creatine kinase-MB are elevated before creatine kinase and creatine kinase-MB activities in acute myocardial infarction. Eur J Clin Chem and Clin Biochem 1993;31:715–24.

13. Jaffe AS. Biochemical detection of acute myocardial infarction. In: Gersh B, Rahimtoola S, eds. Acute Myocardial Infarction, Vol. 2nd ed: Elsevier, 1997:136–62.

14. Christenson RH, Vaidya H, Landt Y, et al. Standardization of creatine kinase-MB (CK-MB) mass assays: the use of recombinant CK-MB as a reference material. Clin Chem 1999;45:1414–23.

15. Robbins M, Epstein E, Shah S. Creatine kinase subform analysis in hemodialysis patients without acute coronary syndromes. Nephron 1997;76:296–9.

16. Jaffe AS, Ritter C, Meltzer V, et al. Unmasking artifactual increases in creatine kinase isoenzymes in patients with renal failure. J Clin Lab Med 1984;104:193–202.

17. Apple F, Quist H, Doyle P, et al. Plasma 99th percentile reference limits for cardiac troponin and creatine kinase MB mass for use with European Society of Cardiology/American College of Cardiology consensus recommendations. Clin Chem 2003;49:1331–6.

18. Katus HA, Remppis A, Neumann FJ, et al. Diagnostic efficiency of troponin T measurements in acute myocardial infarction. Circulation 1991;83:902–12.

19. Adams 3rd JE, Sicard GA, Allen BT, et al. Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med 1994;330:670–4.

20. Apple FS, Falahati A, Paulsen PR, et al. Improved detection of minor ischemic myocardial injury with measurement of serum cardiac troponin I. Clin Chem 1997;43:2047–51.

21. Katus HA, Remppis A, Scheffold T, et al. Intracellular compartmentation of cardiac troponin T and its release kinetics in patients with reperfused and nonreperfused myocardial infarction. Am J Cardiol 1991;67:1360–7.

22. Tanaka H, Abe S, Yamashita T, et al. Serum levels of cardiac troponin I and troponin T in estimating myocardial infarct size soon after reperfusion. Coron Artery Dis 1997;8:433–9.

23. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000;36:959–69.

24. Apple F, Jesse R, Newby L, et al. National Academy of Clinical Biochemistry and IFCC Committee for Standardization of Markers of Cardiac Damage Laboratory Medicine Practice Guidelines: analytical issues for biochemical markers of acute coronary syndromes. Clin Chem 2007;53:547–51.

25. Morrow D, Cannon C, Jesse R, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Clin Chem 2007;53:552–74.

26. Antman E, Tanasijevic M, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335:1342–9.

27. Hamm CW, Ravkilde J, Gerhardt W, et al. The prognostic value of serum troponin T in unstable angina. N Engl J Med 1992;327:146–50.

28. Babuin L, Vasile V, Rio Perez J, et al. Elevated cardiac troponin is an independent risk factor for short and long term mortality in medical intensive care unit patients. Crit Care Med 2008;36:759–65.

29. Kavsak P, MacRae A, Palomaki G, et al. Health outcomes categorized by current and previous definitions of acute myocardial infarction in an unselected cohort of troponin-naïve emergency department patients. Clin Chem 2006;52:2028–35.

30. Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 2003;42:1547–54.

31. Jaffe AS. Elevations in cardiac troponin measurements: false false–positives: the real truth. Cardiovasc Toxicol 2001;119: 87–92.

32. MacRae A, Kavsak P, Lustig V, et al. Assessing the requirement for the 6-hour interval between specimens in the American Heart Association Classification of Myocardial Infarction in Epidemiology and Clinical Research Studies. Clin Chem 2006;52:812–8.

33. Eggers K, Oldgren J, Nordenskjold A, Lindahl B. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148:574–81.

34. Ilva T, Eriksson S, Lund J, et al. Improved early risk stratification and diagnosis of myocardial infarction, using a novel troponin I assay concept. Eur J Clin Invest 2005;35:112–6.

35. Kavsak P, MacRae A, Lustig V, et al. Effects of contemporary troponin assay sensitivity on the utility of the early markers myoglobin and CKMB isoforms in evaluating patients with

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possible acute myocardial infarction. Clin Chem Acta 2007;380:213–6.

36. Goodman S, Steg P, Eagle K, et al. The diagnostic and prognostic impact of the redefinition of acute myocardial infarction: lessons from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 2006;151:654–60.

37. Geltman E, Ehsani A, Campbell M, et al. The influence of location and extent of myocardial infarction on long–term ventricular dysrhythmia and mortality. Circulation 1979;60:805–14.

38. Roberts R, Sobel B, Parker C. Radioimmunoassay for creatine kinase isoenzymes. Science 1976;194:855–7.

39. Roberts R, Henry PD, Sobel B. An improved basis for enzymatic estimation of infarct size. Circulation 1975;52:743–54.

40. Smith J, Ambos H, Gold H, et al. Enzymatic estimation of myocardial infarct size when early creatine kinase values are not available. Am J Cardiol 1983;51:1294–300.

41. Ingkanisorn W, Rhoads K, Aletras A, et al. Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction. J Am Coll Cardiol 2004;43:2253–9.

42. Younger J, Plein S, Barth J, et al. Troponin–I concentration 72 h after myocardial infarction correlates with infarct size and

presence of microvascular obstruction. Heart 2007;93:1547–51.

43. Muller J, Rude R, Braunwald E, et al. Myocardial infarct extension: occurrence, outcome, and risk factors in the Multicenter Investigation of Limitation of Infarct Size. Ann Intern Med 1988;108:1–6.

44. Apple FS, Murakami MM. Cardiac troponin and creatine kinase MB monitoring during in–hospital myocardial reinfarction. Clin Chem 2005;51:460–3.

45. Kleiman NS. Measuring troponin elevation after percutaneous coronary intervention: ready for prime time. J Am Coll Cardiol 2006;48:1771–3.

46. Miller WL, Garratt KN, Burritt M, et al. Baseline troponin level: key to understanding the importance of post–PCI troponin elevations. Eur Heart J 2006;27:1061–9.

47. Prasad A, Rihal C, Lennon R, et al. Significance of periprocedural myonecrosis on outcomes following percutaneous coronary intervention: an analysis of pre and post intervention troponin T levels in 5487 patients. Circulation: Cardiovascular Intervention 2008: in press.

48. Thygesen K, Alpert J, White H, et al. Universal definition of myocardial infarction. Circulation 2007;116:2634–53.

49. Jaffe AS, Garfinkel B, Ritter C, Sobel B. Plasma MB creatine kinase after vigorous exercise in professional athletes. Am J Cardiol 1984;53:856–8.

The peer-reviewed Clinical Practice Section seeks to publish case studies, reports, and articles that are immediately useful, are of a practical nature, or contain information that could lead to improvement in the quality of the clinical laboratory’s contribution to patient care, including brief reviews of books, computer programs, audiovisual materials, or other materials of interest to readers. Direct all inquiries to Libby Spence, PhD, CLS(NCA), Clin Lab Sci Clinical Practice Editor, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, [email protected]. Clinical Laboratory Science encourages readers to respond with thoughts, questions, or comments regarding these articles. Email responses to [email protected]. In the subject line, please type the journal issue and lead author such as “CLIN LAB SCI 23(3) RE SAENGER”. Selected responses may appear in the Dialogue and Discussion section in a future issue. Responses may be edited for length and clarity. We look forward to hearing from you.


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Metastatic Renal Cell Carcinoma with Metabolic Syndrome- A Case Report

KEMPER KELLY, CARRIE COCKLIN

ABSTRACT Renal cell carcinoma (RCC) affects patients by proliferating in the renal tubules, resulting in renal failure and concomitant urinalysis findings of blood, protein, casts, and abnormal cells in the urine. If untreated, it can spread to the lymph nodes, liver, and lungs. There is currently no proven tumor marker for RCC. The clinical case reported here describes the clinical laboratory findings in a patient with 2 common co-morbidities (metabolic syndrome and alcoholism), who was found to have metastatic renal cell carcinoma at autopsy. Understanding the clinical chemistry of metastatic carcinoma in the presence of common co-morbidities is important for earlier diagnosis and treatment of patients who are most likely to develop these conditions. INDEX TERMS: RCC, renal cancer, CAIX, carbonic anhydrase ABBREVIATIONS: ALP= Alkaline phosphatase, Hct= Hematocrit, AST= Aspartate aminotransferase, MCV= Mean corpuscular volume, ALT= Alanine transaminase, MCHC= Mean corpuscular hemo-globin concentration, BUN= Blood urea nitrogen, RDW= Red blood cell distribution width, GFR= Glomerular filtration rate, PLT= Platelet, WBC= White Blood Cells, INR= International normalized ratio, aPTT= activated Partial thromboplastin time, GGT= Gamma-glutamyl transferase. Clin Lab Sci 2010;23(3):141 Kemper Kelly, MT(ASCP), 88th DTS/SGQC, Wright-Patterson AFB, OH 45433. Carrie Cocklin, M.D., Institution: Indiana University, Purdue University at Indianapolis, IN 46202

Address for Correspondence: Kemper Kelly, MT(ASCP), 88th DTS/SGQC, 4881 Sugar Maple Dr, Wright-Patterson AFB, OH 45433, kemper.kelly@ wpafb.af.mil, 937-257-9375, (fax)937-257-9342. Patient History An obese 66-year-old male presented to an outpatient center with generalized weakness, fatigue, thirty-five pound weight loss, shortness of breath, lower extremity edema, and oliguria. The patient had a medical history of coronary artery disease (status post coronary artery bypass graft), hypertension, hyper-lipidemia, obesity, malnutrition, alcoholism, chronic renal disease and RCC. Two weeks later, the patient was transferred to a large medical center presenting with acute and chronic renal failure, lethargy, edema in both legs, and elevated liver function tests. While in the hospital, the patient experienced respiratory failure, right lower extremity cellulitis, sepsis, multi-organ failure, disseminated intravascular coagulation, and several hypotensive and tachycardic episodes. One week later, the patient was not responding to treatment. His family stopped supportive therapy, and he died later that day. An autopsy revealed a tumor in the right kidney, which extended into the perinephric fat with metastases to the liver and lungs. The heart revealed fibrosis from an earlier myocardial infarction. Overview on Renal Cell Carcinoma Renal cell carcinoma is responsible for 3% of all cancers in adults and 85% of all malignant kidney tumors.1 It will initially grow in the tubules of the nephrons.1,2 Males are at a higher risk for developing RCC.2 Other risk factors include smoking, obesity, high blood pressure, family history of RCC, or genetic problems such as von Hippel-Lindau Disease.1,2,3 Typical symptoms of RCC are hema-

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turia, abdominal or flank pain, anemia, a lump in the abdominal area, reduction in appetite, and rapid weight loss.1,2

Prognosis for patients with RCC is good if the tumor is localized in the kidney, but spreading to the lymph nodes carries a poor prognosis.2 If the RCC is completely untreated and becomes metastatic, one year survival is only 12%.4 Although the spread of RCC to the lymph nodes and liver is associated with a lower survival rate, RCC metastasis to the lungs have little, if any affect, on survival.4 Other factors associated with a much lower survival rate are a Hgb <11g/dL, neutrophil count >6500/uL, and LDH >220.4 This patient had a history of obesity, hypertension, and malnutrition, and alcoholism. He presented with symptoms of anemia and a thirty-five pound weight loss. The patient had hematuria and decreased hemoglobin. The post-mortem examination revealed RCC extending into the perinephric fat and metastases to lymph nodes, liver, and lungs. RCC effects on the kidney The GFR is a measure of the kidney’s ability to filter substances from the blood and is also a rough estimate of the amount of functioning nephrons.6

RCC is initially formed in the tubules (nephrons) of a kidney.1 Therefore, over time, the tumor’s growth will crowd out and damage more nephrons. During renal failure, the serum BUN and creatinine will increase as the GFR decreases. The removal of BUN and creatinine from the blood is slowed down as the GFR decreases, leaving these waste products to accumulate in the blood.6 Increased nitrogen in the blood (uremia) can present with symptoms of nausea, lethargy, and vomiting.6 Hematuria is often seen in conditions causing renal injury and is a common symptom of renal tumors.1,2,7 Many rapid urine screening tests measure the amount of albumin in the urine as a way to determine if there is protein present.7 A normal blood albumin level is necessary to maintain the correct oncotic pressure and prevent edema. 6 In addition to carcinoma damaging nearby nephrons, proteinuria also damages the glomeruli.6 Renal casts and glycoproteins can damage the kidneys

if many are present in the urine.6,7 These casts are composed of uromodulin (Tamm-Horsfall protein) and are produced in the ascending loop of Henle and the distal convoluted tubules by renal tubular epithelial cells.6,7 Casts can take the shape of the tubules as they get excreted in the urine.7 Healthy people have few, if any, casts present.7 Increased numbers of hyaline casts are seen in patients with renal problems or congestive heart failure.7 Cast formation is enhanced by an acidic pH, which the patient had as shown in Table 1.7

Table 1: Urinalysis (Hospital Day 1)

Patient Reference Color Yellow Clarity Slt. Cloudy Sp Gravity 1.013 1.003-1.030 pH 5.00 5.00-8.00 Protein 30.00 Negative Glucose Normal Negative Ketones Negative Negative Bilirubin Negative Negative Nitrate Negative Negative Urobilinogen 2.0 mg/dL <1.0 mg/dL Leukocyte Esterase Negative Negative RBC 7 RBCs/μL 0-2 RBCs/μL Hgb 20 mg/dL Negative Bacteria Occasional Negative Mucus Rare Negative Casts 10-20 Hyaline/lpf 0-2/lpf RBC= Red Blood Cells Hgb= Hemoglobin

The patient’s renal panel, shown in Table 2, indicates that his GFR was below normal. His abnormal GFR led to reduced urine output (oliguria) when he was admitted.6 The edema in his lower extremities was due to decreased albumin in the blood and increased excretion through the urine. The patient was described as lethargic (a symptom of severe anemia) when he was transferred to the larger medical facility. Table 2 shows that his serum BUN was increased and that the creatinine was twice the upper limit of normal. Blood and protein were present in the urine (Table 1) and that many hyaline casts were seen per low power field. This patient had a clinical history of coronary artery disease and chronic renal failure,

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which can explain the presence of increased hyaline casts.

Table 2: Complete Metabolic Panel, Complete Blood Count and Coagulation (Hospital Day 5)

Patient Reference Albumin 2.2 g/dL 3.5-5.0 g/dL Total Protein 5.3 g/dL 6.7-8.6 g/dL Direct Bilirubin 3.2 mg/dL 0-0.5 mg/dL Total Bilirubin 5.9 mg/dL 0-1.0 mg/dL ALP 205 IU/L 25-125 IU/L AST 471 IU/L 15-41 IU/L ALT 137 IU/L 0-45 IU/L Serum Total CO2 21 mmol/L 22-29 mmol/L Serum BUN 26 mg/dL 5-20 mg/dL Serum Creatinine 2.4 mg/dL 0.8-1.4 g/dL GFR 29 mL/min/1.73m2 30-59 mL/min/1.73m2 Serum Glucose 109 mg/dL 70-109 mg/dL Serum Ca2+ 9.0 mg/dL 8.5-10.5 mg/dL Serum PO43- 4.3 mg/dL 2.5-4.9 mg/dL Serum Albumin 2.4 g/L 3.5-5 g/L WBC 11500/uL 4500-11500/μL RBC 4.41 million/uL 4.6-60 million/μL Hgb 9.8g/dL 14-18 g/dL Hct 30.8% 40-54% MCV 70 μ3 80-94 μ3 MCHC 31.8 g/dL 32-36 g/dL RDW 30% 11.5-14.5 % PLT 73 K/uL 150K-450K/μL Fibrinogen 415 mg/dL 192-389 mg/dL INR 2.99 0.9-1.1 aPTT 132 sec 22-36 sec

RCC effects on the liver Liver function tests were assessed as shown in Table 2. The ALP, AST, and ALT were all increased, (Table 2) and the serum albumin and protein levels were reduced. The liver is responsible for protein metabolism; less protein will be made if its function is impaired.8 Table 2 also shows that his total and direct serum bilirubin were both elevated. Albumin transports unconjugated bilirubin to the liver where it is metabolized using glucuronic acid into direct bilirubin. A portion of bilirubin is converted to urobilinogen in the intestine and eventually gets excreted into the urine and feces.9 However, the reduction of albumin in the serum, as shown in Tables 2 and 3, explains why the total bilirubin is increased. The liver, despite the effects of alcohol and

tumors, was still able to produce glucuronic acid, since the direct bilirubin was also increased as well as the urinary urobilinogen (shown on Table 1).7,9

However, if another complete urinalysis was done, the urine would have probably been positive for bilirubin since the serum direct bilirubin was increased. The AST:ALT ratio was greater than two, which is consistent with alcoholic liver disease.8 Finally, the patient’s autopsy showed that the “liver was almost completely replaced by metastatic nodules and associated necrosis.”

Table 3: Blood Gas and Liver Transplant Panel (Hospital Day 5)

Patient Reference HCO3- 17.3 mmol/L 22-29 mmol/L pH 7.35 7.35-7.45 pO2 67 mmHg 80-110 mmHg O2 Saturated 92% 95-98% Base Excess -7 mmol/L -2 to 2 mmol/L Lactate Assay 8.7 mmol/L 0.5-1.6 mmol/L CO2 Total 18 mmol/L 22-29 mmol/L BUN 47 mg/dL 5-20 mg/dL Creatinine 3.4 mg/dL 0.8-1.4 mg/dL GFR 19 mL/min/1.73m2 30-59 mL/min/1.73m2 GGT 174 IU/L 15-73 IU/L PO43- 6.3 mg/dL 2.5-4.9 mg/dL

Table 2 also shows the results of the patient’s complete blood count. The “Rule of Three” is not followed regarding the Hgb’s relation to the RBC count. The MCV and MCHC were reduced, indicating microcytic/hypochromic anemia.10 The patient’s renal function was impaired by the renal carcinoma and chronic renal failure, hence there was impaired renal production of erythropoietin, which is needed to produce red blood cells. The RDW was above the normal level, indicating that the patient’s red blood cell size varied widely, (anisocytosis).10 The patient’s symptoms of generalized weakness, fatigue, and shortness of breath were all typical symptoms of a severely anemic patient.10,11 While being treated, the patient had an episode of DIC. During DIC, the PT and APTT will increase, while the platelets and fibrinogen will decrease.12 The patient’s PT, APTT, and platelets match the findings of typical DIC, as shown on Table 2. The increased PT and APTT, as well as the thrombocytopenia, are

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secondary to liver disease which was partially secondary to the spreading renal carcinoma.1,12

Thrombocytopenia is also secondary to chronic renal failture.12 However, in DIC, the fibrinogen level should be decreased. The patient’s fibrinogen assay was increased which is another indicator of liver damage.12 RCC effects on the lungs and acid/base state The patient’s autopsy report stated that the lungs contained small white nodules, as a result of the RCC spreading through the lymphatics. It is possible the patient’s saturated oxygen percentage and pO2 was reduced, due to an impaired ability to take in air. This would also explain the patient’s episodes of respiratory failure. However, the patient did not appear to have any problems exhaling carbon dioxide. The renal tumor was impairing the kidney’s ability to produce bicarbonate, a blood buffer.13 Table 3 showed the reduced bicarbonate and reduced base excess, which contributed to his reduction in blood pH, causing a metabolic acidosis.13 The patient tried to compensate for this reduction in pH by lowering the pCO2 in an attempt to increase the pH to a safe normal level; this can be done by breathing more rapidly.13 The patient had several tachycardic episodes while admitted. The patient had an increased lactate assay that was almost four times the upper limit of normal. This is explained by the impaired oxygen intake, due to the renal tumors spreading to the lungs, as well as his anemia.13 In the absence of oxygen, the body metabolizes glucose into lactic acid as a waste product which can cause the patient to go into a lactic acidosis.13 Lactic acidosis and renal failure can cause the serum phosphate to increase as seen in Table 3.14 Treatment for Renal Cell Carcinoma There are several available treatments for renal cell carcinoma. Radiation therapy can be used as long as the tumor has not metastasized to other parts of the body.1 Metastatic tumors are resistant to radiation therapy.1,2 Nephrectomy can also be used if the patient is in good health for surgery and if the other kidney is free of tumors.1,2 Chemotherapy can also be used to treat localized and metastatic RCC.2 Current treatments, such as interferon alpha and interleukin-2

work by blocking blood supply to the tumors.2,15 Side effects of interferon alpha are fever, chills, and similar flu-like symptoms.16 A newer drug, Sunitinib, acts by inhibiting blood supply to the tumors by blocking blood vessel growth.16 This experimental drug, now in Phase III trials, may halt the progression of RCC metastasis in patients, longer than interferon alpha.16 However, Sunitinib is more likely to cause severe episodes of leukopenia and thrombocytopenia.16 Several tumor markers are being studies to achieve earlier diagnosis of RCC. A potential tumor marker for RCC is a screen for serum carbonic anhydrase IX (CAIX).5 One study suggests that a low amount of CAIX in the serum of a RCC patient is not only associated with a poor prognosis, but that these patients will not respond well to cytokine therapy such as Interleukin 2.5 Since CAIX is a cell surface molecule, it may be possible to make an antibody against it or develop drugs that have fewer side effects than current treatments.5 Summary The clinical chemistry of renal cell carcinoma in the presence of the common co-morbidities afflicting the patient population most at risk is reported here. Renal cell carcinoma (RCC) initially starts in the renal tubules of the nephrons. It will cause renal failure evidenced on a urinalysis by the presence of blood, protein, and casts in the urine. It may be difficult to diagnose because the patient may only complain of feeling weak and tired. It is critical that RCC is diagnosed before it spreads to other body sites, since the mortality then becomes much higher. Several tumor markers for RCC are being studied. Carbonic anhydrase IX is a potential tumor marker that shows some promise for earlier detection of RCC. Current treatments include radiation therapy, nephrectomy, and chemotherapy using interleukin 2 and interferon alpha. Newer drugs might be more effective in treatment but the side effects may be unsuitable for use.

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REFERENCES 1. National Cancer Institute. “Renal cell cancer treatment,”

Available at: http://www.cancer.gov/cancertopics/pdq/treat-ment/renalcell/patient. Accessed April 20, 2008.

2. MedlinePlus Medical Encyclopedia. “Renal cell carcinoma,” Available at: http://www.nlm.nih.gov/medlineplus/ency/ article/000516.htm Accessed April 11, 2008.

3. Linehan WM, Zbar B. Focus on kidney cancer. Cancer Cell 2004;6(3):223–8

4. Atzpodien J , Royston P, Wandert T, Reitz M, DGCIN - German Cooperative Renal Carcinoma Chemo-Immunotherapy Trials Group. Metastatic renal carcinoma comprehensive prognostic system. British Journal of Cancer 2003;88:348–53

5. Bui MHT, Seligson D, Han K, Pantuck AJ, Dorey FJ, et al. Carbonic anhydrase IX is an independent predictor of survival in advanced renal clear cell carcinoma: implications for prognosis and therapy. Clinical Cancer Research 2003;9: 802–11

6. Newman DJ, Price CP: Renal function. IN Brutis CA, Ashwood ER, Border BG, editors: Tietz fundamentals of clinical chemistry. Saunders; 5th ed(January 15, 2001): 698-722

7. Brunzel NA. Fundamentals of urine and body fluid analysis, 2nd ed. Philadelphia: W.B. Saunders, 2004: 133, 99

8. Tolman KG, Rej R: Liver function. IN Brutis CA, Ashwood ER, Border BG, editors: Tietz fundamentals of clinical chemistry. Saunders; 5 edition (January 15, 2001): 747-70

9. Nuttall KL, Klee GG: Analytes of hemoglobin metabolism-porphyrins, iron, and bilirubin. IN Brutis CA, Ashwood ER,

Border BG, editors: Tietz fundamentals of clinical chemistry. Saunders; 5 edition (January 15, 2001): 584-607

10. Bell A: Anemias: RBC morphology and approach to diagnosis. IN Rodak BF: Hematology clinical principles and applications. Philadelphia: Saunders 2nd ed 2002: 199-210

11. National Heart Lung and Blood Institute. “Anemia, Signs and Symptoms,” Available at: http://www.nhlbi.nih.gov/ health/dci/Diseases/anemia/anemia_signsandsymptoms.html. Accessed 19 April, 2008.

12. Fritsma GA: Hemorrhagic coagulation disorders & Thrombosis Risk Testing. IN Rodak BF: Hematology clinical principles and applications. Philadelphia: Saunders 2nd ed 2002: 627-644, 69

13. Heusel JW, Siggard-Andersen O, Scott MG: Physiology and disorders of water, electrolyte, and acid-base metabolism. IN Brutis CA, Ashwood ER, Border BG, editors: Tietz fundamentals of clinical chemistry. Saunders; 5 edition (January 15, 2001): 723-46

14. Endres DB, Rude RK: Mineral and bone metabolism. IN Brutis CA, Ashwood ER, Border BG, editors: Tietz fundamentals of clinical chemistry. Saunders; 5 edition (January 15, 2001): 795-821

15. McDermitt DF, Regan MM, Clark JI, Flaherty LE, Weiss GR, et al. Randomized phase III trial of high-dose interleukin-2 versus subcutaneous interleukin-2 and interferon in patients with metastatic renal cell carcinoma. Journal of Clinical Oncology. 2005;23(1)

16. Motzer RJ, Hutson TE, Tomczak P, Michaelson MD, Bukowski RM, et al. Sunitinib versus Interferon Alfa in Metastatic Renal-Cell Carcinoma. The New England Journal of Medicine 2007;356(2)

2011 CLEC Abstract Deadline

The deadline for abstracts for oral presentation at the 2011 ASCLS Clinical Laboratory Educators’ Conference (CLEC) is October 1, 2010. Submission instructions and the proposal form may be found at www.ascls.org/conferences. The completed proposal form and abstract must be submitted electronically by the deadline. There will be no poster presentations or technology demonstrations at CLEC 2011. Presentations acceptable for submission include research studies, teaching tools or education/curriculum projects. The 2011 CLEC will be held February 17-21 in Fort Lauderdale, FL. Additional meeting information will be available at the ASCLS Conferences website.


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ASCLS Annual Meeting 2010: Official Abstracts of Submitted Papers, Case Studies and Posters

Anaheim, CA

The following abstracts have been accepted for presentation at the 2010 American Society for Clinical Laboratory Science (ASCLS) Annual Meeting and Clinical Laboratory Exposition to be held July 27 through July 31 in Anaheim, CA. Abstracts are reviewed by appropriate representatives of the ASCLS Abstract Review Committee. They are the final authority in selecting or rejecting an abstract. Papers, case studies and posters will be presented during the following times at the annual meeting. Room assignments will be listed in the final program. ORAL RESEARCH PRESENTATIONS Thursday, July 29, 11:30am-12:30pm at the Anaheim Convention Center Friday, July 30, 2:30-3:30pm at the Hyatt Regency POSTER PRESENTATIONS Tuesday and Wednesday, July 27 and 28, 10:00am-4:30pm; Thursday, July 29, 9:30am-Noon at the Anaheim Convention Center; Authors will be present on Wednesday, July 28, 2010 from 10:30am to Noon to discuss their work and answer questions. Oral Research Abstracts Antimicrobial Combination Therapy for Pseudomonas aeruginosa: Which is Best? Nicholas M. Moore, MS, MT(ASCP), Christopher Crank, PharmD, Maribeth Flaws, PhD, SM(ASCP)SI, Jane Stevens, MS, MT(ASCP), SM(ASCP), Rush University Medical Center, Chicago, IL Pseudomonas aeruginosa has been implicated in serious infections resulting in significant morbidity and mortality. Empiric therapy regimens are initiated before susceptibility testing of the suspected pathogen(s) is complete. There is much debate whether physicians

should utilize an antibiotic combination when treating infections. The purpose of this retrospective, cross-sectional study was to examine antimicrobial susceptibilities of P. aeruginosa and to see if the combination of a beta-lactam with an aminoglycoside offered a higher probability of coverage against P. aeruginosa than a beta-lactam plus a quinolone or monotherapy with a beta-lactam alone. Five hundred and one clinical isolates identified as P. aeruginosa from February 2008 through January 2009 were examined from inpatients and outpatients at Rush University Medical Center, a tertiary care academic medical center in Chicago, Illinois. Overall, antibiotic susceptibilities for each drug tested decreased in 2008 as compared to 2007 with the exception of piperacillin/tazobactam (up to 90% susceptible from 68% in 2007). All combinations of beta-lactams tested with levofloxacin, gentamicin, tobramycin or amikacin were statistically significant (p<0.05) with the exception of piperacillin/ tazobactam plus levofloxacin (p=0.136), indicating that P. aeruginosa would be susceptible to these antimicrobial combinations. Overall, empiric combination therapy that included a beta-lactam plus levofloxacin or an aminoglycoside increased the probability that P. aeruginosa would be susceptible to at least one of the antimicrobial agents. Comparing phenotype and PLD1 activity during biofilm production in clinical isolates of Candida albicans April L Harkins, PhD, MT(ASCP), Bridget Nelson, Rezvaneh Ghasemzadeh, Marquette University, Milwaukee, WI Candida albicans biofilm formation has been shown to consist of multiple phenotypes (hyphae, pseudohyphae and yeast cell) and reports have shown the strain of C. albicans can influence the physical heterogeneity of the

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biofilm. The purpose of this study was to evaluate the various biofilm architectures produced by C. albicans clinical isolates and to measure the phospholipase D1 (PLD1) activity during formation. PLD1 hydrolyzes phosphatidylcholine (PC) to phosphatidic acid (PA), a potent second messenger molecule in many cellular signaling processes, and a free choline. C. albicans PLD1 is involved in hyphal development in vitro and PLD1 deficient yeast are avirulent compared to wildtype in mouse models of candidiasis. Currently, there are no studies of PLD1 during biofilm formation. Studying lipid modifying enzymes (PLD1) in biofilms may elucidate signaling molecules as potential antifungal targets. This is especially important for medically-significant infections with high mortality rates. In this study, C. albicans biofilms were grown on silicone squares for 65 hours and cells were imaged and harvested for PLD1 activity assays. The PLD1 activity increased during biofilm formation compared to planktonic cells, with differences seen depending on the phenotype present in the biofilm. In conclusion, PLD1 activity plays a role in the development of C. albicans biofilms. In most cases, C. albicans isolates from “sterile” sites (i.e. blood or tissue) form more hyphae and more complex biofilms and had a higher amount of PLD1 activity than those isolates taken from “non-sterile” sites (i.e. sputum and genital tract). Correlation of Student Assignment Submission with Examination Scores Michelle S. Kanuth, PhD, MLS(ASCP)CMSBB, Jose H. Salazar, MS, MLS(ASCP)CM, University of Texas Medical Branch, Galveston, TX Most students submit their assignments on or before the due date routinely. However, a few students get into the habit of frequently being late with assignments. These habitual procrastinators appear to be more likely to perform poorly on examinations. There are many studies on procrastination in studying and test scores, but nothing regarding other types of assignments. One class of thirty (30) Clinical Laboratory Science students was tracked through three (3) courses, CLLS 4417 Hematology and Coagulation II, CLLS 3326, Methodology Development and Assessment, and CLLS 4415 Immunology and Immunohematology. Submission of assignments for each student in each

course was assessed to be either on time or late. On-time was defined as an average submission of the course assignments by 11:59 PM on the due date. Late submission was defined as an average submission of the course assignments at any time after 12:01 AM on the day after the due date. Each student’s examination average in each course was also determined. Late submissions were correlated with the examination score average using Fisher’s exact t-test. Preliminary results for CLLS 3326: 11 students averaged <75% on examinations. There were 12 students who met the criteria for late submissions; 9 of these averaged <75% on examinations. For these data, Fisher’s p=0.0533, suggesting a positive association between these events. Detection of P2Y12-receptor Blockade (Clopidogrel) in Patients with Cardiovascular Disease by Accumetrics VerifyNow® P2Y12 and INNOVANCE® PFA P2Y* David L. McGlasson, MS, MLS (ASCP)CM, Anand D. Shah, MD, Wilford Hall Medical Center, Lackland AFB, TX This investigation compared results of clopidogrel-induced platelet inhibition (P2Y12-receptor blockade) as measured by INNOVANCE® PFA P2Y* (P2Y*), a novel test for the Platelet Functional Analyzer-100 (PFA-100 system), and an FDA-cleared device, the Accumetrics VerifyNow® P2Y12 (VNP). Patients (n = 101) undergoing cardiac catheterization were tested either following administration of 300-600 mg clopidogrel (6-24 hours) or 75 mg clopidogrel for at least 7 days. Blood samples were collected in 3.2% and 3.8% buffered sodium citrate for P2Y, while only in 3.2% buffered sodium citrate for VNP. Pre-defined cut-offs for clopidogrel-induced P2Y12 receptor blockade were: P2Y >106sec and VNP >20% inhibition. Detection rates of P2Y12-receptor blockade for each method are shown in the table below. Method: P2Y

3.2% P2Y 3.8%

VNP

Sensitivity(%) 66 86 60 Sensitivity is determined by dividing the number of true positives (TP) by the TP plus the false positives (FP) x 100%. Concordance is the agreement between two

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methods cut-offs usually expressed in percent. The concordance (%) between P2Y and VNP was 75% for results generated in 3.2% citrate. In conclusion, the INNOVANCE® PFA P2Y method agrees with the VerifyNow® P2Y12 method for detection of P2Y12-receptor blockade induced by clopidogrel therapy. Inhibition of platelet function by anti-platelet medications such as clopidogrel, a P2Y12 receptor blockade drug, is one of the main line of defenses in protecting patients against cardiovascular disease involvement. Plant-Derived Antifungal Activities Marcia Lee, DVM, CLS (NCA), Richard L. Bretz, PhD, Gloria A. Wada, MS, Alison M. Herrick, Christine R. Barrett, Miami University, Oxford, OH This study’s purpose was to characterize antifungal effects of the inner gel portion of tropical Aloe species’ leaves upon virulence factors of the opportunistic fungal pathogen Candida albicans. Although Aloe species have an abundance of anecdotal medicinal and cosmetic applications, few studies have scientifically investigated their antifungal effects. Three species of Aloe, e.g, A. barbadensis, A. cameronii and A. arborescens, were acclimated for approximately 2 years in an environmentally controlled, fungicide-free greenhouse. Inner gel from these plants was extracted and homogenized. Next, antifungal activities of their 0.2 micron filtrates were determined using established germination frequency assays and microscopic detection of morphologic aberrations against 10 strains of Candida albicans, including clinical isolates and quality control strains obtained from the American Type Culture Collection (Manassas, VA USA). Both clinical isolates and quality control strains of C. albicans exposed to each Aloe species demonstrated significant (p<0.1) inhibition of germination. Aberrations in germ tube morphology were qualitatively and quantitatively assessed. Antifungal activities of gel components from A. arborescens obtained through ethanol extraction and C18 reversed phase chromatography were investigated. Thus, the conclusion was that the data strongly supported the hypothesis that plant-derived filtrates obtained from the inner gel of Aloe leaves inhibit germination of Candida albicans. This work was significant because it elucidated Aloe-derived antifungal

activities that may have diverse beneficial applications against opportunistic fungi. Poster Presentation Abstracts Assessment of Exposure to PACs in Asphalt Workers: Measurement of Urinary PACs and their Metabolites with an ELISA Kit Barbara A. MacKenzie, Jerome P. Smith, Raymond E. Biagini, Belinda C. Johnson, Larry D. Olsen, Shirley A. Robertson, Deborah L. Sammons, Cynthia A.F. Striley, Cynthia V. Walker and John E. Snawder, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, OH Asphalt pavers are exposed to polycyclic aromatic compounds (PACs), several of which are carcinogens, by inhalation and dermal contact. However, data linking exposure to asphalt with specific health effects are limited. Measurement of PACs and PAC metabolites as biomarkers of exposure provide a useful tool in assessing health effects. An enzyme-linked immunosorbent assay (ELISA) kit developed for the determination of PACs in water was adapted for measuring PACs and their metabolites in urine and then applied to a pilot asphalt worker PAC exposure study. Currently, liquid-liquid extraction with gas chromatography/isotope dilution high-resolution mass spectrometry (GC/HRMS) is the preferred method to determine urinary PAC metabolites. Although sensitive and specific, GC/HRMS is time consuming and costly. PAC ELISA is promising as a more rapid and less costly routine method for determining worker exposure to PACs in asphalt emissions. The ELISA method measured from 14-720 ng/ml 1-hydroxypyrene equivalents with a lower limit of detection of 14 ng/ml urine. Measurements of PAC metabolite equivalents in urine from asphalt exposed and control concrete workers using the ELISA had a good correlation (R=0.89), using Excel, to the sum of select GC/HRMS PAC urine metabolites (naphthalene, fluoranthene, phenanthrene, and pyrene) and the PAC ELISA results were indicative of potential asphalt exposure. The Effectiveness of Digital Microscopy as a Teaching Tool in the Clinical Laboratory Science Curriculum.

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Demetra C. Castillo, MAdEd, MT (ASCP), Rush University, Chicago, IL As the technology of medicine advances, the need for innovative techniques also grows. An essential component of the practice of Clinical Laboratory Science (CLS) is the microscope. While the microscope is the instrument of choice in many CLS related procedures, it is not without its drawbacks. The high cost of maintenance associated with the microscope has led to an increased demand for more cost effective methods. One such method is digital microscopy. It has converted all of the features of the traditional microscope to a computer driven software. It has been speculated that the implementation of digital microscopy facilitates understanding of morphology in the areas of pathology and histology. The aim of this study is to investigate the effectiveness of digital microscopy as a teaching tool in didactic coursework within the field of Clinical Laboratory Science. The implementation of digital microscopy will facilitate students’ understanding of morphology and lead to improved assessment scores. Students enrolled in the hematology course reviewed known study slides using both traditional and digital microscopy methods and were assessed with unknown slides using both methods. A paired t-test was performed and it was determined that the implementation of digital microscopy produced statistically significant exam score improvement (Mean (digital) = 85.67% +/-6.84%); Mean (traditional) = 82.93% +/- 9.21%) (p<0.05). Exam score improvement was directly related to the ability of the student in accurately identifying key elements of the unknown peripheral blood smears. It appears that digital microscopy may be an effective learning tool. Extracorporeal Membrane Oxygenation Support for Pediatric Acute Respiratory Distress Syndrome Erin Meister, University of Massachusetts Dartmouth, N. Dartmouth, MA and Massachusetts General Hospital, Boston, MA; Eileen Carreiro-Lewandowski, MS, CLS, University of Massachusetts Dartmouth, N. Dartmouth, MA Extracorporeal Membrane Oxygenation (ECMO) use in neonatal patients is well documented. Its use in adult and pediatric populations, however, is less clearly

defined. In this case study, a 17 year-old male motor vehicle accident victim suffered severe trauma including bilateral lung contusions with pneumatoceles, several fractures to his femur, forearm, ribs, and thoracic vertebrae, plus splenic and liver lacerations. He was eventually transferred to Massachusetts General Hospital. The patient required intubation with mechanical ventilation and was diagnosed as having Pediatric Acute Respiratory Distress Syndrome (ARDS). Laboratory results revealed dropping oxygen (O2) saturation levels (66% at arrival-reference ranges 97-100%) despite 100% oxygen therapy. Due to increasing complications, the patient was placed on venous-arterial ECMO for cardio-pulmonary support and to avoid multi-system organ failure. Blood gas results pre-ECMO revealed a severe respiratory acidosis (pH 7.33, aPCO2 44 torr, HCO3 22-reference ranges 7.35-7.45, 35-42 torr, 24-28 mmol/L, respectively) and hypoxemia (aPO2 37 torr, O2 saturation 66 %-reference ranges 80-100 torr, 97-100%, respectively). Post-ECMO blood gas results showed significant improvement (pH 7.43,aPCO2 37 torr, aPO2 251 torr, O2 saturation 100%). The patient continually improved and was weaned to venous-venous ECMO and eventually discharged to a rehabilitation center for further recovery. This case study illustrates the importance of laboratory data in effective use of ECMO in non-neonatal populations leading to expanding use of ECMO in treating critically ill patients. Methylenetetrahydrofolate Reductase Enzyme Mutation and Anti-cardiolipin Antibodies in Association with 2nd Trimester Fetal Demise Diana L. Cochran-Black, DrPH, MT(ASCP)SH, Wichita State University, Wichita, KS; Laurie A. Alloway, MSES, MT(ASCP), Center for Reproductive Medicine, Wichita, KS A 28-year-old woman was referred to a reproductive specialist for evaluation of infertility of three years duration. Through the aid of in-vitro fertilization, the patient was able to conceive. The pregnancy progressed without complication until the twenty-sixth week when the fetus died in-utero. An autopsy on the fetus revealed the presence of a large stricture in the umbilical cord.

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Causes of umbilical cord strictures are unknown but it has been proposed that they may be related to antenatal thrombosis formation in either the cord or placenta. Subsequent laboratory testing on the mother revealed two abnormalities, a homozygous C677T mutation on the methylenetetrahydrofolate reductase enzyme (MTHFR) gene and elevated anti-cardiolipin antibodies. A defect in the MTHFR enzyme can lead to a deficiency of folate, B6 and B12 which in turn may cause hyper-homocysteinemia, a risk factor for thrombosis. Anti-cardiolipin antibodies have been linked to thrombotic tendencies due to their action against negatively charged phospholipids. Prenatal therapy for women with defects leading to thrombosis includes daily low dose aspirin and supplements of B6, B12 and folate. During pregnancy, administration of low molecular weight heparin is advised. Saliva Samples Collected from Various Methods are Excellent Materials for Cellular Analysis Fang Yao Stephen Hou, PhD, MB(ASCP)QCYM, Marquette University, Milwaukee, WI The presence of cells in saliva has been described in literature. In fact, DNA / RNA from these cells are used to provide information for genomic studies. Little is known about their composition, except the presence of epithelial cells. The purpose of this study was to characterize cellular populations in saliva samples collected from various methods. Saliva samples were collected by the draining (DRA), draining after gum massage (GUM), or gargling (GAR) method. The absolute number of cells, flow cytometry analysis, and morphology study were used together to describe these samples. As noted previously, epithelial cells were present in all three collection methods. The presence of CD45 positive leukocytes was more pronounced in DRA and GUM methods. Among these leukocytes, mononuclear cells were the major population. The goal here is to provide information on types of cells in saliva. In addition, the potential differences in cellular composition will help us choose the proper collecting method for certain projects. For example, GAR method will be the method of choice for detecting malignancy in oral epithelium. DRA method will provide a population from minimally disturbed samples to study oral mucosal immunity. Cells collected from GUM

method will give us a snapshot of cellular interactions within gum tissues. In summary, saliva samples, with significant amount of cells, are excellent materials for high content analysis. Through proper selection of collection methods and correlating morphology with functional implications, we are able to advance saliva diagnostics, and to gain insight on oral mucosal immunity. Utah Medical Education Council Statewide Laboratory Sciences Workforce Survey JoAnn Fenn, MS, MT(ASCP), University of Utah; Boyd Chappell, MBA, Utah Medical Education Council; Rebecca Christiansen, Utah Public Health Laboratories, Salt Lake City, UT This survey was directed by the Utah Medical Education Council (UMEC) with consultation from a coalition of clinical laboratory professionals in Utah. It was a first attempt to gather data on the state’s clinical laboratory workforce and provide information on age profiles, credentials, vacancies, length of time to fill vacancies, and rural vs. urban workforce issues. A voluntary survey was distributed to 6504 laboratorians, including Clinical Laboratory Scientists(CLS)and Clinical Laboratory Technicians(CLT) working in CLIA certified laboratories across the state. A total of 2548 persons responded, giving a 39.2% response rate. Data was analyzed using SPSS, Excel, and Microsoft Access. The 744 CLS respondents had a mean age of 43.8, with 39.2% >50 years in 2005-2006; in rural laboratories 47.2% of CLS were >50 years, and in several rural counties, 100% of CLS were >50 years. The 166 CLT respondents had a mean age of 37.7 years. Most CLS and CLT respondents worked in hospitals and reference laboratories. Certification was noted in 89.7% of CLS and 61.2% of CLT respondents. In 2008, a follow-up survey of the state’s two major employers of CLS/CLTs showed vacancy rates of 39.7% for CLS and 21.5% for CLT. Average time to fill vacancies was 1.6 months and 1.4 months, respectively. This data suggests that rural areas in Utah will be in dire need to replace retiring CLSs over the next 10 years, and Utah training programs must remain viable to meet the needs of the major laboratory facilities in the state.



Acinetobacter baumannii and MRSA Contamination on Reusable Phlebotomy

Tourniquets

DONNA M HENSLEY, KEVIN J KRAULAND, DAVID L MCGLASSON OBJECTIVE: A study was undertaken to determine the incidence of Acinetobacter baumannii and methicillin resistant Staphylococcus aureus (MRSA) contamination on reusable phlebotomy tourniquets at Wilford Hall Medical Center, Lackland AFB, TX. DESIGN: Reusable tourniquets (n=200) were collected after being used for one day in the outpatient blood collection center (n=100) or during morning blood collection rounds on inpatient wards (n=100). Tourniquets were cultured and growth was screened for A. baumannii and S. aureus. A. baumannii isolates were identified using colonial morphology, oxidase, and GNI+ card on Vitek Legacy. S. aureus isolates were identified and screened for MRSA using colonial morphology, catalase, Staphaurex, and Oxacillin screening agar. RESULTS: Each outpatient tourniquet was used on an average of 33 patients and each inpatient tourniquet was used on an average of 11 patients. The overall contamination rate was 9% (18/200). A. baumannii was isolated from 11% (11/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. Methicillin-susceptible S. aureus was isolated from 2% (2/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. No MRSA was isolated. One outpatient tourniquet had both A. baumannii and methicillin-susceptible S. aureus. CONCLUSIONS: Reusable tourniquets could serve as a potential reservoir for bacterial pathogens. ABBREVIATIONS: CDC = Centers for Disease Control; MRSA = methicillin resistant Staphylococcus

aureus; TSB = trypticase soy broth; TSA II = trypticase soy agar with 5% sheep blood; GNI = gram negative identification; BAMC = Brooke Army Medical Center. INDEX TERMS: MRSA, A. baumannii, tourniquet, infection control Clin Lab Sci 2010;23(3):151 Donna M. Hensley MT(ASCP), 59th Clinical Research Division, Lackland AFB, TX 78236-9908. David L. McGlasson, MS, MLS(ASCP)CM, 59th Clinical Research Division, Lackland AFB, TX 78236-9908 Kevin J Krauland, MD, 59th Laboratory Support Squadron, Lackland AFB, TX 78236-9908 Address for Correspondence: Donna Hensley MT(ASCP), Research Medical Technologist, 59th MDW/SGVUL, 59th Clinical Research Division, 2200 Bergquist Dr, Bldg 4430, Lackland AFB, TX 78236-9908. (210) 292-6690, (210) 292-2897 (fax), [email protected]. INTRODUCTION Nosocomial infections represent a significant public health problem, with a high cost in money, morbidity, and mortality. During the 1990s, the Centers for Disease Control (CDC) estimated that, directly or indirectly, the annual number of deaths related to nosocomial infection was 88,000. The rate of nosocomial infection is estimated at nearly 10/100 patients admitted to the hospital and the estimated annual cost of nosocomial infection with antibiotic-resistant organisms is up to $4.5 billion.1 On average, hospital stays for methicillin-resistant Staphylococcus aureus (MRSA) infections cost $14,000 compared with



$7,600 for all other stays, and the length of hospitalization was more than double-10.0 days for MRSA infections versus 4.6 days for all other stays.2 Common sites of nosocomial infection are the urinary tract, lungs, surgical sites, gastrointestinal tract (particu-larly with Clostridium difficile) and the blood. The site of a nosocomial infection determines which organisms are most likely to be isolated. Escherichia coli causes most nosocomial urinary tract infections.3 Causes of hospital-acquired pneumonia include both gram-positive (Streptococcus pneumonia, methicillin resistant and susceptible S. aureus) and gram-negative (Haemophilus influenza, Enterobacter spp, Klebsiella penumoniae, E. coli) organisms.4 Infections of surgical sites are commonly due to methicillin resistant and susceptible S. aureus, coagulase-negative Staphylococci, Enterococci, and E. coli.5 Acinetobacter is a class of gram-negative aerobe that is ubiquitous in soil and water and is also found as normal flora in healthy individuals. Acinetobacter species have been shown to survive for periods of up to a year on a variety of surfaces such as polystyrene, ceramic, polyvinyl chloride, stainless steel, and rubber. They are an important cause of nosocomial infections, causing pneumonia, burn wound infection, urinary tract infection, sepsis, and endocarditis.6-11 A. baumannii is particularly important among the pathogenic Acinetobacter species as it is characterized by a high level of antimicrobial resistance and is displaying increasing rates of resistance.12 Resistance to meropenem has increased from 5.9% in 1998 to 28.6% in 2005 12 and Doi et al reported a patient infected with A. baumannii that lacked susceptibility to all commercially available antimicrobial drugs.13 These qualities, the ability to survive on a variety of surfaces and a high level of antimicrobial resistance, have lead to a growing concern for A. baumannii as a potential agent for hospital acquired infections. An increase in A.baumannii infections among patients at military medical facilities treating U.S. service members who have been injured in Iraq and Afghanistan has been reported in the literature. Two medical centers, Landstuhl Regional Medical Center and Walter Reed Army Medical Center, identified 102 patients with blood cultures positive for A. baumannii

during the period January 1, 2002 – August 31, 2004. The two medical centers had a combined total of three cases of A. baumannii positive blood culture during the previous two years.14 Brooke Army Medical Center (BAMC) reported twenty-three soldiers wounded in Iraq and subsequently admitted to BAMC who had wounds that were culture positive for A. baumannii during the period of March 2003 to May 2004. Eighteen of the twenty three patients had osteomyelitis which had not been identified at BAMC during the fourteen months preceding March 2003.15 Studies involving environmental and colonization cultures indicate that the source of the A. baumannii infections is nosocomial in origin. A study conducted at BAMC that included 293 soldiers with no history of deployment and who were not healthcare workers found no Acinetobacter nares colonization in any of the participants indicating that A. baumannii nares colo-nization in a normal healthy population is very low.16 A study assessing the bacteriology of war wounds at the time of injury sampled 61 separate acute traumatic injury wounds from 49 casualties upon arrival at the 31st Combat Support Hospital in Baghdad. The study revealed a predominance of gram positive organisms of low virulence and pathogenicity. No multiple drug resistant gram negative organisms were recovered.17 Another study, conducted in Iraq and Kuwait by the Walter Reed Army Institute of Research, found skin colonization in only 1 of 160 patients who were screened and in only 1 of 49 soil samples but A. baumannii-calcoaceticus complex isolates were recovered from treatment areas in all 7 of 7 field hospitals sampled.18 A study at BAMC determined the antimicrobial susceptibilities of 142 A. baumannii-calcoaceticus complex isolates, 95 of which were from wounded U.S. soldiers deployed overseas, and found broad antimicrobial resistance among the isolates tested. The isolates from deployed patients were more resistant than the isolates from nondeployed patients though the reason for this is unclear.19

A. baumannii continues to pose a serious infection control problem in military healthcare settings and has been implicated in one case of occupational transmission from a U.S. serviceman wounded in Iraq to a health care worker.20-23



Previous studies have established that MRSA can also survive for days to months on environmental surfaces, including stethoscopes, tabletops, patient charts, and tourniquets.24-32 Instrumentation procedures involving sterile sites may provide a point of entry for pathogenic organisms. Additionally, pathogens may be spread from patient to patient by contaminated environmental surfaces, equipment, or the hands of healthcare workers.1 Some of these surfaces, such as beds, tables, hygroscopic bandages, curtains, and infusion pumps, have been implicated as reservoirs for transmission of disease in hospital settings.11,33-41 Studies reported in the literature have shown that, while not implicitly implicated in the spread of transmissible disease, reusable tourniquets may serve as a possible bacterial reservoir.26,31,32,41,42 Total S. aureus contamina-tion rates on the tourniquets examined in the studies cited ranged from 5% (10/200) to 77.8% (28/36) 26,31,39,40,41 and contamination rates for MRSA specifically ranged from 0 to 41.7% (15/36).26,31,32,39,40,41 In one study Acinetobacter spp was included on the list of skin flora isolated from reusable tourniquets but the rate of recovery was not given.39 To our knowledge there are no reports in the literature on the subject of A. baumannii contamination rates on reusable tourniquets. The length of time that the tourniquets in the cited studies had been in use varied from one day to 4 years.26,31,32,40 Leitch et al supplied fresh tourniquets and collected them for evaluation after one day of use. They found an MRSA contamination rate of 24.4% (32/131) indicating that daily replacement will not eliminate the potential bacterial reservoir.26 Sacar et al collected tourniquets (n=36) before and after implementation of hospital infection control measures that included an educational program to health care personnel by members of the infection control program that reemphasized infection control measures, repeated every 3 months, and a visual display with color posters that emphasized the importance of handwashing. They found a 36.1% decrease (41.7% to 5.6%) in the number of tourniquets contaminated with MRSA one year after implementation of the new procedures, demonstrating the effectiveness of infection control

procedures in decreasing but not eliminating the rate of contamination.41 These studies indicate that a combination of actions would be needed to eliminate tourniquets as a potential source of bacterial infection. Our study examined MRSA and A. baumannii contamination rates on reusable tourniquets used in outpatient and inpatient settings in a Department of Defense tertiary care hospital. METHODS Reusable tourniquets (Fisher HealthCare, Houston, TX) were collected after being used for one day in the outpatient blood collection center (n=100) or during morning blood collection rounds on inpatient wards (n=100). The used tourniquets were placed in sterile specimen collection bags (VWR International, Suwanee, GA) and transported to the lab. Unused tourniquets (n=10) were included as controls. Tourniquets were transferred to sterile specimen cups, covered with 80 mL trypticase soy broth (TSB) (Becton, Dickinson and Company, Sparks, MD) and incubated at 35 ± 2°C. After overnight incubation the TSBs were subcultured to trypticase soy agar with 5% sheep blood (TSAII, BBL/BD, Sparks, MD) and MacConkey agar (BBL/BD, Sparks, MD). Plates were examined after 18-24 hours incubation at 35 ± 2°C in ambient air. The detection limit for both S. aureus and A. baumannii using this enrichment procedure with disposable tourniquets was determined by serial dilution to be 104 CFU/mL. A. baumannii isolates were identified using colonial morphology, negative oxidase reaction, identification of A. calcoaceticus-baumannii complex using the GNI+ card on a Vitek Legacy instrument (bioMerieux, Durham, NC), and non hemolytic reaction on TSA II. S. aureus isolates were identified using colonial morphology, positive catalase reaction (BD, Sparks, MD), and positive Staphaurex reaction (Remel, Lenexa, KS). Methicillin resistance was determined by inoculating S. aureus isolates to Oxacillin screening agar (BBL/BD, Sparks, MD). Growth on the Oxacillin screening agar was interpreted as methicillin resistance. No growth on the Oxacillin screening agar was interpreted as methicillin susceptibility. No susceptibility testing was performed on the A. calcoaceticus-baumannii complex isolates.



RESULTS Each outpatient tourniquet was used on an average of 33 patients and each inpatient tourniquet was used on an average of 11 patients. The overall contamination rate was 9% (18/200). A. baumannii was isolated from 11% (11/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. Methicillin-susceptible S. aureus was isolated from 2% (2/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. One outpatient tourniquet had both A. baumannii and S. aureus. No MRSA was isolated. A. baumannii and S. aureus were not isolated from any of the control tourniquets. DISCUSSION Acinetobacter species are capable of survival on environmental surfaces for months and this creates a potential reservoir for infection.24,37 The incidence of A. baumannii contamination of reusable tourniquets has not previously been studied. Given the problems that A. baumannii has caused in military healthcare facilities since the Gulf War we decided to look at the incidence of A. baumannii on the reusable tourniquets in our facility which is a Department of Defense tertiary care hospital. A. baumannii has a reputation as a hospital-associated pathogen, so we were surprised that the rate of contamination with A. baumannii was so much higher on outpatient than inpatient tourniquets (11.0% vs 3.0%). There are several possible reasons for this. It could be that, on average, the outpatient tourniquets were used on more patients than the inpatient tourniquets (33 vs. 11) thus increasing the opportunity for contamination. Another explanation could be that our outpatient population has a higher rate of colonization with A. baumannii than our inpatient population but this is unlikely since the inpatient population is drawn from the outpatients. It is also possible that one or more of the phlebotomists working in the outpatient drawing facility is colonized with A. baumannii or that other environmental surfaces in the outpatient drawing facility are contaminated with A. baumannii resulting in spread of the A. baumannii to the tourniquets. For the purposes of this study we did not attempt to rule out any of these possibilities.

While Acinetobacter is most commonly thought of as a causative agent of hospital-acquired pneumonia, it is also known to cause community-acquired pneumonia. It is possible that these outpatient tourniquets represent a potential vector for community-acquired A. baumannii infection. One retrospective study of A. baumannii patients found that those with community-acquired disease had a higher 30 day mortality rate than those with hospital-acquired disease (57.8% vs. 35.4%). However, these patients were also significantly more likely to have ever smoked and to have had chronic obstructive pulmonary disease.42 It may be that the same underlying conditions predisposing these patients to develop community-acquired disease also herald a poor prognosis. Whatever the underlying conditions this type of study reinforces the significance of community acquired disease in the infectious disease arena. It was also surprising that in our setting there was no evidence of MRSA contamination on the tourniquets after approximately 4400 subject contacts by the phlebotomists. It is possible that the phlebotomists and infection control programs are more aware of MRSA and take measures such as dedicated tourniquets for known MRSA patients to prevent the spread of MRSA on multi use items such as tourniquets. We feel that the lack of MRSA contamination is the result of an effective infection control program and perhaps the program needs to be broadened to include all potential multi drug resistant pathogens instead of focusing on only the best known ones. All of our tourniquets were replaced on a daily basis for the study and we collected the tourniquets at the end of the day. However, if a tourniquet was contaminated with blood during the process of a venipuncture procedure the tourniquet was disposed of and another was obtained for use. We did not culture any blood contaminated tourniquets nor did we evaluate how often the phlebotomists replaced their tourniquets during the day. Differences in practices with regard to hygiene and infection control as well as the efficacy of sanitation control protocols are other possible contributing factors which we did not attempt to evaluate or control in this study. In addition we did not attempt to identify any differences in the inpatient and



outpatient isolates or determine the antimicrobial susceptibility patterns. We were encouraged by the low rate of contamination of A. baumannii and MRSA on the tourniquets used by the phlebotomy teams in our hospital. However, any rate of contamination is cause for concern. It is likely that a combination of actions would be necessary to eliminate phlebotomy tourniquets as a potential reservoir for nosocomial infections. Even instituting a policy for single use tourniquets would probably not be sufficient since a phlebotomist with poor hand hygiene could transfer pathogens from the last patient to the new tourniquet. Infection control is a constantly evolving process and we must be vigilant in anticipating the need for and implementing the improved methods necessary to provide a safe environment for our patients. DISCLAIMER This material represents the personal statements of the authors and is not intended to constitute an endorsement by the 59th Medical Wing or any other federal entity. ACKNOWLEDGEMENTS This research was performed under the authority of the Department of Defense and the 59th Medical Wing, 59th Clinical Research Division, Lackland AFB, TX, Institutional Review Board. REFERENCES 1. Henderson DK, Fishman N. “Chapter 304: Prevention and

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3. Schaeffer A, Schaeffer E. “Chapter 8: Infections of the urinary tract.” Wein AJ, editor. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders Elsevier; 2007.

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9. Jawad A, Seifert H, Snelling AM et al. Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreak and sporadic isolates. J Clin Micro 1998;36(7):1938-41.

10. Jawad A, Heritage J, Snelling AM et al. Influence of relative humidity and suspending menstrua on survival of Acinetobacter spp. on dry surfaces. J Clin Micro 1996;34(12):2881-7.

11. Catalano M, Quelle LS, Jeric PE et al. Survival of Acinetobacter baumannii on bed rails during an outbreak and during sporadic cases. J Hosp Inf 1999;42:27-35.

12. Perez F, Hujer AM, Hujer KM et al. Global challenge of multidrug-resistant Acinetobacter baumannii. Antimicrob Agents Chemother 2007;370:2030-43.

13. Doi Y, Husain S, Potoski BA et al. Extensively drug-resistant Acinetobacter baumannii. Emerg Infect Dis 2009;15(6):980-2.

14. Centers for Disease Control and Preventions. 2004. Acinetobacter baumannii infections among patients at military medical facilities treating injured US service members, 2002 – 2004. MMWR Morb Mortal Wkly Rep; 53:1063-6.

15. Davis KA, Moran KA, McAllister CK et al. Multi-drug resistant Acinetobacter extremity infections in soldiers. Emerg Infec Dis 2005;11(8):1218-24.

16. Griffith ME, Ellis MW, and Murray CK. Acinetobacter nares colonization of healthy US soldiers. Infect Cont and Hosp Epidemiol 2006;27(7):787-8.

17. Murray CK, Roop SA, Hospenthal DR et al. Bacteriology of war wounds at the time of injury. Military Med 2006;171(9):826-9.

18. Scott PG, Deye A, Srinivasan C et al. An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus com-plex infection in the US military health care system associated with military operations in Iraq. Clin Inf Dis 2007;44(12): 1577-84.

19. Hawley J.S, Murray CK, Griffith ME et al. Susceptibility of Acinetobacter strains isolated from deployed U.S. military personnel. Antimicrob Agents and Chemo 2007; 51(1):376-8.

20. Whitman T. Infection control challenges related to war wound infections in the ICU setting. J Trauma 2007;62(6):S53.

21. Petersen K, Riddle MS, Danko JR et al. Trauma-related infections in battlefield casualties from Iraq. Annals of Surgery 2007;245(5):803-11.

22. Colombo CJ, Mount CA, Popa CA. Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism. Crit Care Med 2008;36(7):S388-94.

23. Whitman TJ, Qasba SS, Timpone JG et al. Occupational transmission of Acinetobacter baumannii from a United States



serviceman wounded in Iraq to a health care worker. Clin Infect Disease 2008;47(4):439-43.

24. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130.

25. Huang R, Mehta S, Weed D et al. Methicillin-resistant Staphylococcus aureus survival on hospital fomites. Infect Control Hosp Epidemiol 2006;27:1267-9.

26. Leitch A, McCormick I, Gunn I et al. Reducing the potential for phlebotomy tourniquets to act as a reservoir for methicillin-resistant Staphylococcus aureus. J of Hosp Infect 2006;63:428-31.

27. Dietze B, Rath A, Wendt C, Martiny H. Survival of MRSA on sterile goods packaging. J Hosp Infect 2001;49(4):255-61.

28. Marinella MA, Pierson C, Chenoweth C. The stethoscope: A potential source of nosocomial infection? Arch Internal Med 1997;157:786-90.

29. Merlin MA, Wong ML, Pryor PW et al. Prevalence of methicillin-resistant Staphylococcus aureus on the stethoscopes of emergency medical services providers. Prehospital Emergency Care 2009;13:71-4.

30. Williams C, Davis DL. Methicillin-resistant Staphylococcus aureus fomite survival. Clin Lab Sci 2009;22(1):34.

31. Franklin GF, Bal AM, McKenzie H. Phlebotomy tourniquets and MRSA. J Hosp Infect 2007;65:173-84.

32. Berman DS, Schaefler S, Simberkogg MS, Rahal JJ. Tourniquets and nosocomial methicillin-resistant Staphylo-coccus aureus infections. NE J of Med 1986;315(8):514-5.

33. Aygun G, Demirkiran O, Utku T et al. Environmental contamination during a Carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit. J Hosp Inf 2002;52:259-62.

34. Wang SH, Sheng WH, Chang YY et al. Healthcare-associated outbreak due to pan-drug resistant Acinetobacter baumannii in a surgical intensive care unit. J Hosp Infect 2003;53(2):97-102.

35. Denton M, Wilcox MH, Parnell P et al. Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit. J Hosp Infect 2004;56(2):106-10.

36. Melamed R, Greenberg D, Porat N et al. Successful control of an Acinetobacter baumannii outbreak in a neonatal intensive care unit. J Hosp Infect 2003;53(1):31-8.

37. Das I, Lambert P, Hill D et al. Carbapenem-resistant Acinetobacter and role of curtains in an outbreak in intensive care units. J of Hosp Infect 2002;50:110-4.

38. Forseter G, Joline C, Wormser GP. Blood contamination of tourniquets used in routine phlebotomy. Amer J Inf Control 1990;18(6):386-90.

39. Golder M, Chan CLH, O’Shea S et al. Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets. Lancet 2000;355:44.

40. Rourke C, Bates C, Read RC. Poor hospital infection control practice in venipuncture and use of tourniquets. J Hosp Inf 2001;49(1):59-61.

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42. Leung WS, Chu CM, Tsang KY et al. Fulminant community-acquired Acinetobacter baumannii pneumonia as a distinct clinical syndrome. Chest 2006;129(1):



CLS to Higher Education Administrator: The Price They Paid

SUZANNE CAMPBELL, BARBARA Y. LACOST

OBJECTIVES: To identify the barriers and/or obstacles these women experienced during their career paths as women clinical laboratory scientists who transitioned to higher education administration. To identify how being a woman influenced their careers as higher education administrators. METHODS: A multi-site case study design was selected for this qualitative research involving a purposive sample of eight research participants. Data collection was guided by ten open-ended questions in seven face-to-face and one telephone semi-formal interviews. SETTINGS AND PARTICIPANTS: The purposive sample included women clinical laboratory scientists who held a current higher education administrative position at the dean’s level, including associate and assistant dean positions, in a university setting. The participants were located in eight higher education institutions in Nebraska, Illinois, Ohio, Tennessee, Missouri, and Texas. MAIN OUTCOMES MEASURES: The price women pay, gender considerations, a need for balance, existence/absence of the glass ceiling for women in higher education administration. RESULTS: Making personal sacrifices, struggling with gender stereotypes, being a woman, knowing you are okay, and possessing the ability to separate the personal from the professional were identified by this group of women as challenging experiences as they obtained and maintained a position as a higher education admini-strator. Additionally, they described the need for balance, a support system, and how they successfully managed their marriage, family, and career. The participants presented conflicting statements concerning

the existence of the glass ceiling for women in higher education administration. CONCLUSION: The participants in this study obtained positions in higher education administration but they indicated they have paid a price. Each of the participants indicated their obstacles included making a personal sacrifice, being treated differently because they were women, and needing to find a balance in their responsibilities related to their careers, marriages, and families. The majority of the participants believe there is a slight increase in the number of opportunities for women in higher education administration. INDEX TERMS: career paths of women clinical laboratory scientists; women higher education admini-strators; barriers/obstacles for women higher education administrators. Clin Lab Sci 2010;23(3):157 Suzanne Campbell, PhD, MT(ASCP), Medical Labora-tory Technician Program, Seward County Community College/Area Technical School, Liberal, Kansas. Barbara Y. LaCost, PhD, College of Education and Human Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska. Address for correspondence: Suzanne Campbell, PhD, MT(ASCP), Program Coordinator and Faculty, Medical Laboratory Technician Program, Seward County Commu-nity College/Area Technical School, 520 N. Washington, Liberal, KS 67901. (620) 417-1403, (620) 417-1449 (fax). suzanne.campbell@ sccc.edu. INTRODUCTION The purpose for conducting this qualitative study was to investigate and document the career paths of women



clinical laboratory scientists who have transitioned from the clinical setting to the higher education arena and held administrative positions at the dean’s level, including assistant and associate dean positions. This research sought to identify: 1) the barriers and/or obstacles these women experienced during their career paths as women clinical laboratory scientists who transitioned to higher education administration and 2) how being a woman influenced their careers as higher education administrators. Three major themes emerged from the data. They included: Getting to the Right Place at the Right Time, The Right Navigational Skills are Required, and The Right Place Comes with a Price. The Right Time – Right Place theme described the three different career stops experienced by each of the participants. These

findings were published in the Summer 2009 edition of Clinical Laboratory Science.1 The Right Navigational Skills theme was developed from two categories: don’t wait for opportunity to knock and communication is the key. These findings were published in the Winter 2010 edition of Clinical Laboratory Science.2 The Right Place Comes with a Price theme findings are presented here. Figure 1 outlines the relationship between the major themes and categories developed from the research data. RESEARCH QUESTIONS To investigate the career paths of women clinical laboratory scientists who held higher education administrative positions, the following questions were considered.

Figure 1: CLS to Higher Education Administrator Research Themes and Categories

Getting to the Right Place at the Right Time

The Right Navigational Skills are Required

The Right Place Comes With a Price

The Clinical Laboratory

Don’t Wait for Opportunity to Knock

The Price Women Pay

Professors in Higher Education

Communication is the Key

Gender Considerations

Higher Education

Administration

The Right Place Requires a

Balancing Act

The Road Block to the Right Place Has a Crack



1. What are the lived experiences of women higher education administrators with a back-ground in clinical laboratory science during their career paths?

2. What skills, training, and/or professional development opportunities enabled these women to become successful higher education administrators when their initial academic area of study was clinical laboratory science?

3. What barriers and/or obstacles have these women experienced during their career paths as women clinical laboratory scientists who transitioned to higher education administra-tion?

4. How has being a woman influenced their careers as higher education administrators?

This report focuses on the findings related to the research questions that addressed the barriers and/or obstacles these women may have experienced as higher education administrators and how being a woman has influenced their careers. LITERATURE REVIEW The literature reviewed to support the categories of this theme included an assessment of the number of women in higher education administration positions, gender-related considerations, and the glass ceiling theory. Women in Higher Education Administration Positions In 1920, women constituted 47% of the undergraduate enrollment in higher education. Thirty-two percent of college presidents, professors, and instructors were women in 1930. During the period from 1930 to 1960, the proportion of women receiving bachelor degrees and their first professional degrees fell to 24%. During this same time, only 9% of doctoral degree recipients were women. In 1965, the Higher Education Act helped to increase the number of women undergraduates. Legislative actions such as Affirmative Action and Title IX also opened the doors of opportunity for women in higher education. During the 1970s, women faculty and administrators strived to find ways to improve their status within their professions.3

In 1978, women made up 52% of students at the masters level and 40% of students at the doctorate level.4 Women constituted 52% of the total student enrollment in higher education in 1980. During this same period, women made up 25% of full-time faculty in higher education: 8% were full professors, 16% were associate professors, 28% were assistant professors, 29% were instructors, and 18% held deanships.3 During the mid 1990’s, the number of women that were employed as new faculty was 39%. This number of women was almost five times greater than the number of veteran women faculty. It was also noted that research institutions hired women at twice the rate of comprehensive institutions.5 At the close of the 20th century, “Women [held] 27% of all deanships” however, “only 8% of all law school deanships and 3% of medical school deanships [were] held by women.” Additionally, “women are 15% of chief academic officers… but 70% of these positions held by women are in colleges with fewer than 1,000 students. Women chief academic officers are rarely found in research and doctoral universities.” Furthermore, Women comprise 19% of all presidents of

colleges and universities… yet 70% of these women presidents head schools with 3,000 or fewer students, religious or women’s colleges, or two year institutions. Only 2% of all women presidents head major research universities.6

Gender-related Considerations Women were not readily accepted into the “old boy’s network” such as an administrative council. Women have been treated differently because of gender and have often worked in a non-supportive higher education system. Typical male roles were defined by traits such as dominance, achievement, autonomy, and aggression.7 The male role characteristics were accepted in leadership positions. The female role was defined by emotionalism, passivity, timidity, deference, and self-abasement. The female role characteristics were not seen as those of people in leadership positions. Women were perceived as less competent than men. This perceived incompetence was a barrier to women obtaining



educational leadership positions.7,8 To achieve positions as educational leaders, women have been required to perform at a higher skill level than males.9 Women must demonstrate to existing leadership that they are capable of leadership roles. Men dominate education in the number of administrative positions held and the amount of money earned. Men also dominate the decision-making processes that may discourage women from entering administrative ranks.6,7 Women must hold a higher level of certification, i.e., advanced degrees, than men to obtain the same position.10 Women must be aware that administration will promote those who demonstrate leadership characteristics. Presidents and other leaders must recognize and promote a climate providing opportunities for qualified women. It is vital that university leaders support women in leadership roles. Women have also battled an uneven playing field with regard to salary compensation level of formal training, expectations of knowledge or skill level, and under-representation at all levels of higher education.8 The New Agenda discussed by Shavlik and Touchton (1992) called for correction of inequities in hiring, advancement, and salary of female faculty, administrators, and staff.11 For most women, earning a doctoral degree is seen as a benefit when their goal is to obtain an educational leadership position.12,13 To increase the number of women in educational leadership positions, women must obtain the necessary credentials in educational administration, apply for educational administration positions, and encourage other women to strive for positions in educational leadership.7,14 Higher education institutions play a major role in bringing women into the educational leadership ranks. Institutions need to improve female representation in leadership positions. The availability of administrative internships provides development of formal and informal networks, allows women the opportunity to participate in administrative processes and budget preparation, and provides opportunity to observe the decision-making process. Institutions should identify women within their system that have potential leadership skills and a desire to hold leadership

positions, provide opportunities to develop those leadership skills, and select from this group to fill administrative positions.6,8 The campus climate should also provide an institutional atmosphere and environment to foster women’s personal, academic, and professional development.3,15

The Glass Ceiling Theory A 1991 report by the United States Department of Labor defines the glass ceiling as “those artificial barriers based on attitudinal or organizational bias that prevent qualified individuals from advancing upward in their organization into management-level positions.”16 The study further stated, “attitudinal and organizational barriers…are an indication that the progress of minorities and women in corporate America is affected by more than qualifications and career choices.”16 The attitudinal and organizational barriers were identified as ineffective recruitment practices, a lack of development practices and credential building experiences, and the lack of senior-level executive accountability of Equal Employment Opportunity (EEO) responsibilities. Additional follow up studies were conducted to determine the status of the glass ceiling. The 1997 United States Department of Labor report cited barriers similar to the previous reports. The barriers “include lack of good faith efforts in the following areas: management development programs and mentoring, EEO accountability, and outreach and recruitment.17 The conclusion of the report demonstrated the continual existence of the glass ceiling for women and minorities. The existence of the glass ceiling for women in higher education administration is still a topic of debate. When considering the data previously presented, it is possible to conclude “the glass ceiling is still firmly intact in academe at the start of the 21st century.”6 Women experience severe declines in participation rates at each step of the educational system; from their first degree to the doctoral level and then entrance and ascension among faculty ranks.10 In higher education worldwide, the higher the level of administration - the fewer the number of women.10



However, the data also provide hope to those women seeking positions as a higher education administrator. Although the number of women at this level is less than optimal, they are making progress. With continued changes in governing board and administrator attitudes and increased opportunities for women that demonstrate the necessary skills and knowledge, women will continue to gain employment as higher education administrators, thus seeing a crack in the glass ceiling. METHODOLOGY Case Study Design This case study of women higher education administrators with a background in clinical laboratory science sought to illustrate topics using a descriptive mode of the common themes developed from the data.18 The semi-formal interviews were audio recorded for transcription and subsequent data collection, and analysis. After developing the initial categories, the researchers performed axial coding in which the data were assembled and reassembled.19 The axial coding portion of the data analysis included looking for descriptive wording for the topics, turning them into categories, and determining relationships between the topics. The last phase of coding involved the writing of the story line.19 To provide credibility to the data, member checks, rich-thick descriptions, and an external audit were employed.20 Participant Demographics All participants had a previous history of experience in the clinical laboratory. The position titles of this group of women included dean, assistant dean, and associate dean. The majority of the participants were between 50 and 59 years of age. Five of the eight clinical laboratory scientists were married at the time of the study; seven had children. All of the participants had earned advanced degrees: two possessed masters degrees, three earned doctorates of philosophy, one was all but dissertation (ABD), one held a doctorate of arts, and one held an educational doctorate. One woman was an assistant professor, two were associate professors, and

five women were full professors. All had a minimum of ten years experience as a faculty member. Each of the participants was assigned a pseudonym and a university name that corresponded with a Greek letter. The pseudonyms included Ann at Alpha University, Brianna at Beta University, Debra at Delta University, Gwen at Gamma University, Kelly at Kappa University, Lynn at Lambda University, Olive at Omega University, and Teresa at Theta University. RESULTS The theme presented here indicates that women can and do achieve positions in higher education administration, but they pay a price for that achievement. The Right Place Comes with a Price theme was based on four categories: The Price Women Pay, Gender Considerations, The Right Place Requires a Balancing Act, and The Road Block to the Right Place Has a Crack. These categories were supported by eleven codes and each was explored. The Price Women Pay Personal Sacrifice The first category was supported by one code - personal sacrifice. Almost all of the participants commented they had made personal sacrifices in earning the position they held as a higher education administrator. Some of the participants truly believed the sacrifices made were a result of being a woman. Seven of the participants in this study believed that they had paid that price. Ann stressed, “You always pay a price for choosing a professional career. It demands more of your time.” Ann had less time available for social events. However, she made a conscientious effort not to give up time with her children when they were growing up. “I think I have paid more attention to the family. I don’t think I have neglected the family but probably neglected the grandchildren.” Furthermore, Ann said, “I think that women, in order to succeed, have to work harder. You have to be better than the rest of the group that were applying for the position. Noticeably better.” At one point in her career, Brianna had received major grant funding, had a new baby, and was being asked to



move into administration. She stated, “Trying to do all of those things was a bit of a challenge. It was a wild couple of years.” When presented with these oppor-tunities almost simultaneously, Brianna said, “It was almost to the point that I had beaten myself up so badly getting funding, getting tenure that I needed to step back and enjoy the other part I had tried so hard to get – my son.” Although a difficult decision, she decided to move to administration and not continue the grant-funded research. Gender Considerations This category includes several supporting areas that relate to gender issues. The gender related issues include: gender roles/stereotypes, being a woman, knowing you are okay, and separating personal from professional. Gender roles/stereotypes Debra was not readily accepted as the chairperson for the automotive technology program. She stated, “They [faculty] were very concerned that a female was coming as a division head and one who did not teach in their area.” This was seen as a position that should be assumed by a male. Debra was able to eliminate those concerns by demonstrating her ability “to work with people to get them to work together. Being able to go from A to Z on a project.” Teresa’s experience with gender stereotypes occurred during her time in the science department as a faculty member. She commented, “I was exposed to a number of things that [were] probably sexual harassment. I was the only female in the department [and] was very skeptical at first when I moved. The previous two females in that department had not succeeded. There were some real problems and the men thought the last thing they needed was another female in the department. I worked with the men and [did] not make a big deal of it. [I] just interacted with them and served as their token female on many of the committees.” Being a woman The majority of the participants shared experiences unique to them because they are female. Ann’s experience took place when she was in college. During her physical chemistry class, the professor announced to

the class “women didn’t take classes like this” and “what was she doing - to think that she could take this class?” At point one in her biochemistry class, the professor called her up and said, “I don’t know what I am going to do about this because you are getting a higher grade on this test, a higher grade in the course than your husband.” Ann’s reply was to give the earned grades for both. The professor replied, “I can’t do that.” Ann received an A and so did her husband. To demonstrate her abilities as a woman, Teresa commented, “I built a trust to show that I could do the job and I could do it well.” She further added, “I think women have to sometimes work twice as hard to prove that point - where [with] a man, it’s just assumed. It took me a long time to really [see that].” Knowing you are okay Kelly suggested “keep who you are in mind and work within that. People will start to respect that.” She strongly urged women to “be yourself and to be consistent with who you are.” To know who you are and that you are okay may require some place or someone to bounce things off.” Separating personal from professional One coping strategy that was identified by the participants was the ability to separate the personal from the professional. Brianna found herself in a position that required her to close the department where she had close personal ties. The members of this department were her friends and it was very difficult. She stated, “That’s the hard part of being in administration. You have to separate how you feel about people personally from the kind of vision [that is] … the bigger picture of the college.” She shared the internal struggle with making that type of decision. The department faculty,

don’t see how you agonize about the decisions and how you understand that you have people’s careers and jobs in your hands. They don’t see that. Sometimes people think it’s a frivolous decision or that she likes one department over another.

Brianna said, “I don’t think there’s an appreciation and that takes a toll. There’s no appreciation for the fact



that you have to go through this personal agony. That’s hard, that’s really hard.” The Right Place Requires a Balancing Act This category outlines the balancing act these participants were able to carry out that enabled them to obtain and maintain their positions as higher education administrators. These women recognized the need for balancing their career goals with marital and family commitments, and the importance of a support system. A need for balance Six of the participants discussed the need for balance in their lives. They were higher education administrators, mothers, and wives. To be successful in each area, a careful balance of time and effort was necessary. Brianna shared the struggle of “leav[ing] it at work,” dealing with the demands on your time, and trying to carve out time for the family. For her, this is an added stressor. She said,

I leave work and [employees] call me all the way home in the car. I get home, have dinner, do homework [with my son], and have some hour of quality time - there is no time left for me. That’s the biggest stressor in my life.

She commented, “I was up until two o’clock last night because I decided I had to read a book, or make a Christmas list, and I had to have two hours where nobody was asking me to do something.” At a juncture in her career as a CLS program director, Olive made a move that eliminated commuting that had previously taken time away from her daughter. She commented,

It was one of the most difficult decisions I’ve ever made. I enjoyed [the university] immensely and I was tenured. [I was] quite happy with the environment. I really had to do some soul searching because I was going to take a big cut in salary. My daughter was in high school at the time and I was commuting. The hours I was putting in were long. After some soul searching, [I] decided that Omega University is where I belonged.

Support systems The majority of the participants in this study indicated the need for some type of support system. Brianna gave her husband the credit for her ability to balance being a wife, mother, and a professional woman. She commented, “My husband has always been very supportive. In fact, before we were married, I moved to do my post doc and he followed me. We’ve always been a partnership.” Brianna shared, “I had opportunities for faculty appointments around the country and we decided to come back as a joint decision.” Brianna and her husband had flexible schedules that allowed both of them to balance their career and family duties. Teresa also had a very supportive husband. She stated, “He thought I was good and needed to have a career so he was very supportive in that and in moving forward.” At the point in her career when Teresa was considering a chair position, her husband said, “I think you have to take opportunity when it knocks, and you should look at some of these things.” She was called for an interview and offered the position. Maintaining balance Seven of the participants shared their experiences of “keeping three balls in the air at all times.” This was the phrase that Lynn used to describe her attempt at balancing her career goals with her marital and family commitments. She further stated, “Those three balls are in the air almost all of the time for a woman. And knowing how to keep them all balanced [is difficult].” Lynn indicated,

I will leave at noon, no matter what, because Christmas parties will happen at my children’s elementary school, and I will be gone. I do not feel guilty, because all day Saturday, I will be in commencement. I feel no guilt about that at all because it’s just balancing the same thing. I do it guilt free.

Brianna was offered a position as the vice provost for programs and planning. This was a fairly prestigious position on campus. She was promised flexibility in terms of hours and family commitments but she just did not believe it. In her current position, she was involved in “a lot of very interesting projects and a



number of things that [she] was really vested in.” She was really interested in the new position but yet was unsure about “doing what I see as the more interesting part of the job.” The decision to turn down the position came when she “was just sitting on the porch on day with my son in my lap and I said, ‘Why am I even considering taking on more responsibility now?’ He is too young.” She was the top candidate for the position. When she pulled out, administration tried for weeks to convince her to reconsider. Her decision to remain in her position was her strategy for balancing her career needs with her family needs. The Road Block to the Right Place Has a Crack Although the participants of this research project had conflicting messages with regard to the glass ceiling in higher education administration, the majority did indicate some progress had been made. However, they were quick to point out that women still encounter inequity when compared to their male colleagues. The glass ceiling is now Teflon It has been said that the glass ceiling is breaking for women in the business world and women are now obtaining executive positions. When asked if this was also occurring in higher education, Debra replied, “I disagree. I don’t think it is happening in business either. I think the glass ceiling has turned into a Teflon ceiling and Teflon is much harder to break than glass.” Debra believed that the studies tended to look at the numbers and did not consider the salaries and other related issues. The glass ceiling has a crack The majority of the respondents indicated that progress had been made with regard to the number of women in higher education administration positions. However, most indicated the process had been slow and that the increase in numbers of women administrators did not go all the way to the top. Gwen indicated that she believed the glass ceiling is slowly being broken as she was seeing more and more women university administrators. Even though Gwen affirmed the breaking of the ceiling, she also noted that, “women are still more traditionally [in] academic

affairs, rather than business, finance, and things like that.” Omega University is in a geographic region that Olive described as “very definitely macho-oriented.” But interestingly enough there were female presidents at two of the universities within the system. One of the woman had held the president’s position since 1981. Olive stated, “She’s probably the first female that I really, really respected. If you had to choose someone to represent your institution, she would be the one that I would choose.” Olive further noted, “I think they definitely have shown us where women can go in higher education.” CONCLUSION The Right Place Comes With a Price theme was based on four categories: the Price Women Pay, Gender Considerations, The Right Place Requires a Balancing Act, and the Road Block to the Right Place Has a Crack. Each of the participants shared experiences of personal sacrifice, gender considerations, and the need to balance their responsibilities. Even though these women had obtained positions in higher education administration, they paid a price. They indicated it takes personal sacrifice to be a valued employee and to be an efficient wife and mother. The participants shared their experiences of being treated differently due to their gender. Whether it was an academic advisor, a chemistry professor, or science department colleagues, these women were challenged to demonstrate their abilities as a female. They quickly became aware of the need to realize it was okay to be a woman. Challenges existed when attempting to separate the personal from the professional issues. To be successful as a wife, mother, and higher education administrator, it was imperative these women acquired the skill for balancing their responsibilities. Each of the participants shared the strategies they employed to successfully maintain the balancing act. However, they also noted a need for a support system. Friends, husbands, and other family members comprised their support systems. Having “three balls in the air at all times” accurately described the feelings of



these women as they attempted to balance their career goals with their marital and family commitments. These women higher education administrators were still debating the glass ceiling theory. One participant indicated the glass ceiling had turned to Teflon. She believed the rules were still different for women. Although the majority of the participants indicated progress had been made with regard to the number of women in higher education administration positions, they were not satisfied with the rate of progress or the levels at which the progress occurred. Authors’ note: Readers may access the entire disserta-tion entitled, “Career Paths of Women Clinical Laboratory Scientists Who Have Become Higher Education Administrators” at http://digitalcommons. unl. edu/cehsedaddiss/1. Acknowledgements: The authors would like to thank the women participants of this case study for sharing the experiences of their career paths as they transitioned from being clinical laboratory scientists to becoming higher education administrators. REFERENCES 1. Campbell S, LaCost B. CLS to higher education administrator:

the right place – right time. Clinical Laboratory Science 2009;22(3):185-92.

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Graduate Education in Clinical Laboratory Science Is the Glass Half Full or Half Empty?

KAREN KARNI, JOAN POLANCIC, JOANN FENN, DONNA J. SPANNAUS-MARTIN

OBJECTIVE: To evaluate the 2007 and 1990 data on the number and characteristics of programs offering graduate level degrees in Clinical Laboratory Science. DESIGN/SETTING/PARTICIPANT: Data were col-lected from published sources (Directory of Graduate Programs for Clinical Laboratory Practitioners) and analyzed at the University of Minnesota. Specific data regarding the kinds of advanced programs and the number of graduates per year, the number of program openings and closures, program requirements were collected, as well as data regarding the number and employment of graduates of Master's degree programs at two long-standing public institutions. INTERVENTION: Not Applicable. MAIN OUTCOME MEASURE: The tabulation of degree, program, and graduate data, together with the first position taken by graduates of two M.S. programs. RESULTS: The numbers of graduate level programs and graduates decreased between 1990 and 2007, from 39 to 28 identified Master’s level programs, but with only a slight increase from two to five doctoral programs. Several prominent and historically important Master’s level programs have closed since the first edition (1990) of the Directory. Detailed analysis of the data from two Master's level programs showed that the first positions for graduating students were predom-inantly research related and in the same state as the degree-granting institution. CONCLUSION: The number of advanced programs and graduates are relatively small in clinical laboratory science; however M.S. graduates are successful in obtaining positions. These positions are predominantly geographically related to the degree-granting institution,

indicating an intellectual and economic impact of the programs in the regions they are located. ABBREVIATIONS: ASCLS = American Society for Clinical Laboratory Science; CLS = Clinical Laboratory Science; ASMT = American Society for Medical Technology; TOEFL = Test of English as a Foreign Language. INDEX TERMS: Clinical Laboratory Science; Graduate Education; Health, Manpower; Laboratory Personnel; Students, Health Occupations. Clin Lab Sci 2010;23(3):166 Karen Karni, PhD, CLS(NCA), University of Minnesota, Program in Clinical Laboratory Sciences, Minneapolis, MN 55455 Joan Polancic, MSEd, MLS, American Society for Clinical Laboratory Science (ASCLS), Bethesda, MD 20817-1574 JoAnn Fenn, MS, MT(ASCP), Medical Laboratory Science, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84132 Donna Spannaus-Martin, PhD, MLS, University of Minnesota, Program in Clinical Laboratory Sciences, Minneapolis, MN 55455 Address for Correspondence: Karen Karni, PhD, CLS(NCA), Professor Emeritus, University of Minnesota, Program in Clinical Laboratory Sciences, Mayo Mail Code 711, 420 Delaware St. SE, Minneapolis, MN 55455



Since 1990, the American Society for Clinical Laboratory Science (ASCLS) has published a Directory of Graduate Programs for Clinical Laboratory Practitioners to aid potential students in choosing an advanced program of study at the Master’s or doctoral levels in CLS or its specialty areas. The fifth edition of the Directory was published in November 2007. With a seventeen-year record of chronicling the initiation and closing of programs, the authors looked at trends in numbers of programs, their requirements, and gradu-ates. Li, et al., have evaluated career data and the perceived value of advanced CLS degrees.1, 2 They surveyed M.S. and B.S. graduates and concluded that M.S. degree respondents had more managerial level positions (62% to 36% as compared to B.S. graduates) and had authored more external publications (77% to 33%). CLS M.S. professionals also perceived a greater career enhancement value to their advanced degree. Each group (B.S. and M.S.) stated the most important perceived benefit of having a CLS M.S. degree as “enhanced self-esteem and confidence.” The highest priority of M.S. degree recipients’ motivation for obtaining a CLS advanced degree was personal satisfaction. Fenn and Knight looked at the value of graduate education (Master’s level) in clinical laboratory science among M.S. graduates from the University of Utah between 1969 and 1994.3 They concluded that among these graduates, who had completed a program requiring research and a thesis, the “major benefits of a graduate education are the skills gained that relate to communication through writing, ability to read and interpret scientific literature, acquisition of new technical skills, and improvement of one’s ability to establish successful new technologies in the laboratory.” Unfortunately, little is known about those who have graduated with doctoral degrees in clinical laboratory science, primarily because the numbers of programs and graduates are small. There were only two doctoral programs in clinical laboratory science identified in 1990, and five Ph.D. programs in 2007. METHOD The authors compared the advanced programs (M.S. and Ph.D.) and numbers of graduates using the first

(1990) and fifth (2007) editions of the Directory. Each program's entry for the Directory has information that can be seen in Figure 1. In addition, graduates' information was gathered from the directors of two M.S. programs regarding the graduates’ first positions taken following completion of their graduate degrees. These institutions have kept detailed records of their graduates’ first employment positions. Types and locations of employment were collected for these graduates.

Graduate Directory Information Name of the School and Department Degree Title Level of Degree Awarded Program of Study, including areas of concentration Year Program was Established Numbers of Credits Required for Graduation (semester or

quarter) Research Required? Thesis Required? Other Requirements, e.g., seminars, projects, papers Minimum GPA Considered for Admission (A=4.0) GRE required? Minimum Score Considered. If English is not the primary language, minimum TOEFL

required. Other Prerequisites for Admission Enrollment Dates Application Deadline Usual Time for a Full-time Student to Complete the Degree Usual Time for a Part-time Student to Complete the Degree Tuition and Miscellaneous Fees Availability of Financial Aid – Full-time and Part-time

Students Usual Number of: Full-time Students, Part-time Students,

Graduates/year Research Facilities Available Location of School/Features of the Community Faculty Names, Degrees and Their Research Interests Strengths of the Program Recent Thesis Titles (Examples) Correspondence: to whom directed (Name, address, phone,

fax, email) Figure 1. Information on Each Program Listed in the Graduate Directory RESULTS In clinical laboratory science, there were 39 Master’s programs and two doctoral programs operating in 1990. In 2007, there were 28 Master’s programs and five



doctoral programs. Table 1 shows the 15 master’s level programs and numbers of graduates reported in both the 1990 and 2007 editions of the Directory. Table 2 provides information on the 13 of 15 Master’s level programs that were started after 1990 with the number of graduates reported in 2007. Table 3 indicates the five doctoral level programs in 2007 with numbers of graduates. Table 4 shows the 19 M.S. programs that have been discontinued since 1990. Tables 5 and 6 are an overview of graduate program requirements for admission to CLS M.S. and Ph.D. degree programs. Table 7 provides information about graduates from two recognized programs, at the University of Minnesota and the University of Utah, regarding the type and location of employment obtained following graduation. Table 1. Institutions with Master’s Programs in 1990 and 2007

Usual Number of Graduates/Year Name of Institution 1990 2007 Andrews University (MI) 1-2 1-2 Indiana University – Indianapolis (IN) 3 2 Medical College of Georgia (GA) 0-1 0-2 Michigan State University (MI) CLS 3-6 6 Biomedical Laboratory Option - 2 Quinnipiac University (CT) 19 24 Rosalind Franklin/Finch University (IL) 5 2-5 San Francisco State University (CA) 10-12 7 University of Maryland – Baltimore (MD) 2-3 5 University of Massachusetts – Lowell (MA) 3 5-10 University of Minnesota (MN) 5 4 University of North Dakota (ND) 2-4 12 University of Southern Mississippi (MS) 1 1-3 University of Utah (UT) 5 5 University of Wisconsin – Milwaukee (WI) 1-2 3-4 Virginia Commonwealth University (VA) 2-4 3-5 Range for Total Number of Students 62-75 82-98 Mean Number of Students 4-5 4-5 Median Number of Students 4 4 Total Number of Institutions: 15 Note: Only 15 of 39 institutions identified in 1990 reported offering programs in 2007.

DISCUSSION The number of clinical laboratory science Master’s level programs has decreased over a 17-year period, from 39 in 1990 to 28 in 2007. Over the same time period, the number of doctoral programs increased only slightly from two to five. The total numbers of graduates from

both levels of advanced programs are relatively small, averaging four to five M.S. graduates per program per Table 2. New Master’s Level Programs Identified Between 1990

and 2007

Graduates Name and State Year Started in 2007 Fairleigh Dickinson University (NJ) 2002 1 Long Island University Not 20-25 C.W. Post Campus (NY) reported Louisiana State University (LA) 1980 1-3 Rush University (IL) (2 programs) 2000 17 Thomas Jefferson University (PA) 2000 15 University of Alabama (AL) 1993 8 University of Kentucky (Lexington, KY) Reproductive laboratory science 2002 5 University of Medicine and Dentistry of NJ 1998 3-5 (NJ) (2 programs) 2002 3-5 University of Mississippi Medical Center (MS) 1996 5 University of New Mexico (NM) 2007 - University of Rhode Island (RI) 1986 10 University of Tennessee (TN) 1999 1-2 University of Texas – San Antonia (TX) 1997 1-2

Number of Institutions added after 1990 *15 (13 responding) Range for Total Number of Graduates after 1990 90-103 Mean Number of Graduates 8 Median Number of Graduates 4-5

TOTAL – ALL Master’s Level Programs in 2007 28 TOTAL Number of Graduates in 2007 172-201 Mean Number of Graduates in 2007 6-7 Median Number of Graduates in 2007 5

Table 3. Doctoral Program - 2007 Number of Institution Location Graduates in 2007 Catholic University Washington, DC Not reported Indiana University Indianapolis, IN 1 University of Kentucky Lexington, KY 0-1 University of Mississippi Jackson, MS 5 Virginia Commonwealth Richmond, VA 2-4 University Total Number of Graduates 8-11 year in both 1990 and 2007. The total numbers of doctoral graduates in 2007 were 11 or fewer.



It appears that not many laboratory science practitioners are pursuing advanced degrees within the profession. While some may be enrolled in other kinds of advanced level programs (MBA, education, public health, the basic or clinical sciences) or in other professional programs such as medicine, dentistry, pharmacy or law, the numbers staying within clinical laboratory science and earning the M.S. or doctoral degree remain modest. This is a matter of concern. Li et al.1,2 have stated that M.S. graduates, in contrast to B.S. graduates, hold career enhancement as the major value in holding an advanced degree. Career enhancement, however, may not be sufficient to attract practitioners to pursue and complete an advanced degree in clinical laboratory science. Therefore, graduates of CLS master’s or doctoral programs need to be surveyed concerning their impressions of the degrees for which they were enrolled and graduated. Baccalaureate CLS graduates who choose other kinds of advanced degrees need to be surveyed as well. Table 4. Master’s Level CLS Programs That Have Closed Since 1990.

Name State Brigham Young University Utah Eastern Washington University Washington Emory University Georgia Florida International University Florida George Washington University Washington, DC Georgia State University Georgia Medical University of South Carolina South Carolina Northeastern University Massachusetts Old Dominion University Virginia Oregon Health Sciences University Oregon St. John’s University New York University of Illinois Illinois University of New York – Buffalo New York University of New York – Syracuse New York University of Vermont Vermont University of Wisconsin – Eau Claire Wisconsin Wayne State University Michigan West Virginia University West Virginia Wichita State University Kansas Number of Institutions Closed 19 Note: Four programs that were identified in 1990 did not respond to information for the 2007 Directory: Stanford University, the University of Alberta, Edmonton, Canada, Inter American University of Puerto Rico, San Juan, and University of Puerto Rico, San Juan.

In contrast, ASCLS (ASMT at that time) and Central Michigan University co-sponsored a Master’s level external degree program in either administration or Table 5. Overview of Master’s Level Graduate Program

Requirements in CLS - 2007

Category Requirement No. of Programs Minimum grade point average 3.2 1 3.0 18 2.8 1 2.75 4 2.7 2 2.5 3 Graduate Record Examination Yes 17 Required No 8 International only 1 Recommended 1 TOEFL Required Yes 24 No 2 NR 2 Semester Credits Required for Graduation (not entry level) 51 1 39 1 37 2 36 9 33 3 32 2 31 1 30 7 27 1 23 1 Thesis Required Yes 11 No 10 Optional 7 Time for Completion (full time) 1 calendar year 1 2 years 19 2.5 years 1 2-3 years 1 2-6 years 1 18 months 1 15-18 months 2 3 semesters 1 3-6 semesters 1 NR 1 From the Directory of Graduate Programs for Clinical Laboratory Practitioners, 5th Edition. Bethesda, MD; American Society for Clinical laboratory Science, November 2007. The notation NR indicates no response or unable to interpret. Data does not include two programs that did not respond to the survey.



education from 1973 to 1979.4 During that time, 2,000 allied health practitioners were enrolled, with the vast majority being laboratorians. Their reasons for pursuing the M.S. degree were: 1) personal satisfaction; 2) an impetus for greater job security, increased income and new responsibilities; and 3) an increase in job-related skills. For graduates of the ASMT-CMU program, the most important benefit was increased personal confi-dence.

Table 6. Doctoral Program Requirements in CLS – 2007

Minimum grade point average 3.3 1 2.75 – 3.0 1 3.0 3 Graduate Record Exam required Yes 5 TOEFL required Yes (4) NR (1) 625 1 600*(250) 2 550*(213) 1 Thesis required? Yes 4 Dissertation or 3 1 published articles Usual time for completion 4-5 years 1 (full time) 4 years 3 2-6 years 1 * = computer version

Note, however, the ASMT-CMU Master’s degrees were in education or administration. The institutions surveyed in the five iterations of the Directory offer degrees that are primarily clinical laboratory science and research oriented. Comparisons suggest that, at least in the mid-1970s, practitioners: 1) were more interested in administration or education degrees; 2) preferred the courses in a non-traditional delivery model; and 3) perhaps had more opportunities in these areas. Today it is unknown whether and how many current laboratory practitioners are enrolled in education or administration programs and whether in traditional or non-traditional settings. Again, additional research is needed. Francis, et al.5 studied career progress among bacca-laureate graduates from the medical technology (clinical laboratory sciences) program of the University of Minnesota. Their paper stated “those who achieved advanced degrees were 1.52 times more likely to have progressed in their career when compared with those who had no advanced degrees.” Thus, there are

considerable data to suggest that completion of an advanced degree is beneficial in terms of personal satisfaction, confidence and self-esteem, as well as in career advancement. That 19 M.S. programs closed since 1990 is alarming. The decrease may parallel the decrease in the number of CLS baccalaureate programs during the same time period (from 420 to 224).6 Nonetheless, 19 schools, with fine reputations, are no longer offering students the opportunity to gain a master’s degree in the profession. While the organizers of the Graduate Directory did not collect information regarding graduate program viability, later inquiries to administrators of closed programs did provide anecdotal information regarding the reasons for closure. Reasons included lack of institutional financial support, increased tuition, lack of resources to recruit potential students, and fewer faculty to mentor students. The decline in degree programs is also described by recent studies by Waller et al. (7). Surveying faculty in 2008, the findings in this work showed that 53% of CLS faculty had taught for 16 or more years and that 25% of the faculty were 60 years old or older, close to considering retirement from faculty status. Such turnover of faculty will impact both undergraduate and graduate level programs, and will likely be compounded by the lack of replacement faculty because of the low number of students in advanced degree programs, notably doctoral degree programs in laboratory science. The Waller study indicated that programs average only 4.2 faculty per undergraduate program. Another study conducted in 2007 to 2008, by the Association of Schools of Allied Health Professions, provides similar information for 87 institutitions showing an average of 4.1 faculty for each CLS program.8 Comparatively, Physical Therapy programs averaged 10.1 faculty, Speech Pathology and Audiology averaged 10.2 faculty, and Occupational Therapy averaged 7.2 faculty; all at the advanced degree level. These data do suggest that programs with a higher number of faculty can be better sustained.



Table 7A. University of Minnesota Master’s Program in Clinical Laboratory Science. M.S. Graduates, Positions Taken Following Graduation

& State of First Employment

Student Number Graduation Year First Position Following Graduation State 1 2006 Research Fellow, Univ of Minnesota MN 2 2006 Unknown, Boston MA 3 2006 Asst. Scientist, Univ of Minnesota MN 4 2006 Asst. Scientist, Univ of Minnesota MN 5 2006 Asst. Scientist, Univ of Minnesota MN 6 2005 CLS, Univ of Minnesota Med Ctr, Fairview MN 7 2005 Agricultural Specialist, Board of Animal Health 8 2005 CLS, Fairview – Collaborative Studies MN 9 2004 Med Tech Program student, Univ of Minnesota MN 10 2004 Res. Scientist, Mpls Med Res Fndn, HCMC MN 11 2004 Res. Assistant, Univ of Minnesota MN 12 2004 Sr. Res. Fellow, Univ of Minnesota MN 13 2003 Asst. Scientist, Univ of Minnesota MN 14 2003 Res. Assoc./Lab Mgr, Univ of Michigan MI 15 2002 Res. Assoc., Univ of Minnesota MN 16 2002 Student, Ph.D. Program in Genetics, Univ of Minnesota MN 17 2002 University of Kansas KS 18 2002 Jr. Scientist, Univ of Minnesota MN 19 2001 Scientist, Minnesota State Board of Health MN 20 2001 Res. Assoc., Univ of Kansas Medical Center KS 21 2001 Student, Ph.D. Prog – Ind. U. Purdue Univ @ Indianapolis IN 22 2001 Sci., Dept. Biochem, Molec Bio & Biophysics, Univ of Minnesota MN 23 2000 Student, Medical School, Univ of Minnesota MN 24 2000 Unknown N/K 25 1999 Scientist, Cancer Center, Univ of Minnesota MN 26 1999 Scientist, Dept. of Microbiology, Univ of Minnesota MN 27 1999 Scientist, Lab Med and Path, Univ of Minnesota MN 28 1999 Student, Medical School, Univ of Minnesota MN 29 1999 Student, Ph.D. Program in Biochemistry, The Ohio State Univ OH 30 1999 Faculty Member, Div of Medical Technology, Univ of Minnesota MN 31 1998 Student, Medical School, Univ of North Dakota ND 32 1998 Scientist, Neuroscience Dept., Univ of Illinois IL 33 1998 Scientist, Dept of Lab Med and Path, Univ of Minnesota MN 34 1998 Safety Chemist, Aveda Corporation, Twin Cities MN 35 1997 Forensic Scientist, Bureau of Criminal Apprehension, Twin Cities MN 36 1997 Post Doctoral Fellow, Univ of Minnesota MN 37 1997 Scientist, Allergy Dept., Univ of Minnesota MN 38 1997 Hematology Technical Specialist, Twin Cities Clinic MN 39 1997 Field Application Specialist, Li-Cor Corporation NE 40 1996 Student, MBA Program, Univ of St. Thomas, St. Paul MN 41 1996 Student, M.S. Program in Health Informatics, Univ of Minnesota MN 42 1996 Scientist, Clontech Corp., Palo Alto, CA CA 43 1996 Scientist, Laboratory Animal Veterinary Clinic, Univ of Minnesota MN 44 1996 Hematology Supervisor, Lackland AFB, Texas TX 45 1996 Biotherapeutic Spec., Alexander & Parker Corp N/K 46 1996 Asst, Scientist, Dept. of Medicine, Univ of Minnesota MN 47 1996 Scientist, Laboratory Animal Veterinary Clinic, Univ of Minnesota MN 48 1995 Dentist, California CA 49 1995 Student, Ph.D. Program in Public Health, Univ of Texas TX 50 1995 Student, Ph.D. Program in Pathobiology, Univ of Minnesota MN 51 1994 Instructor, Barry Univ, Miami, FL FL 52 1994 Research Associate, Stanford Univ CA 53 1994 Research Associate, Singapore, Malaysia Malaysia 54 1994 Student, Ph.D. Program in Pathobiology, Univ of Minnesota MN 35 of 54 graduates (64%) took their first position in Minnesota. 8 of 54 graduates (15%) enrolled in advanced studies, e.g., medical school, a Ph.D. program.



Table 7B. University of Utah Master’s Program in Laboratory Medicine and Biomedical Science. M.S. Graduates, Positions Taken Following Graduation & State of First Employment

Student Number Graduation Year First Position Following Graduation State 1 2007 Assistant Professor, Clin Lab Sci Program UT 2 2007 Research Scientist, University of Utah UT 3 2007 Medical School UT 4 2007 Teaching Specialist, ARUP UT 5 2007 Research and Development, ARUP UT 6 2007 Physician’s Assistant Program NV 7 2006 Research Scientist, Biotechnology Company UT 8 2006 Research Scientist, Biotechnology Company UT 9 2006 Medical School UT 10 2005 Immunology Supervisor, ARUP UT 11 2005 Research and Development, ARUP UT 12 2005 Research and Development, ARUP UT 13 2005 Research and Development, ARUP UT 14 2005 Research and Development, ARUP UT 15 2005 Immunology Supervisor, ARUP UT 16 2004 Supervisor, biotechnology Company UT 17 2003 High School Science Teacher – Gifted Program UT 18 2003 MBA Program and Scientist, Res. Lab UT 19 2003 Research Scientist, ARUP Laboratories UT 20 2002 Medical School VT 21 2002 Research Scientist TN 22 2002 Research Scientist, ARUP Laboratories UT 23 2002 Biotechnologist and Supervisor, Myriad Genetics UT 24 2001 Dental School UT 25 2001 Scientist, Heart Transplant Lab, U of Utah UT 26 2001 Instructor – Weber State University UT 27 2000 Staff Technologist, Utah Valley Hosp. blood Bank UT 28 2000 Ph.D. Program in Cell Bio & Immunol UT 29 2000 Biotechnologist, Myriad Genetics UT 30 1999 Staff Technologist, Microbiology Lab – ARUP UT 31 1999 Research Scientist, University of UT UT 32 1999 Supervisor in Microbiology, St. Marks Hospital UT 33 1999 Research Scientist University of Utah UT 34 1999 Research Scientist University of Utah UT 35 1999 Unknown N/K 36 1998 R & D Technologist, Stem Cell lab, U of UT UT 37 1998 Graduate School, MBA Program, U of UT UT 38 1998 Supervisor, Reagents Lab – ARUP UT 39 1997 Group Manager Stat Lab – ARUP UT 40 1997 Research Scientist, University of Utah UT 41 1997 Supervisor, Special Chemistry – ARUP UT 42 1996 Lab Manager, U.S. Army N/K 43 1996 Research Scientist, University of Utah UT 44 1996 Scientist, USAF Research Lab MS 45 1996 Supervisor/Micro Research Scientist Primary Children’s Medical Center UT 46 1996 Ph.D. Program, Canada CAN 47 1996 Staff Technologist, Immunoheme Lab – ARUP UT 48 1996 Research Scientist, Immunoheme Lab, VAMC UT 49 1996 Supervisor, VAMC, Blood Bank UT 50 1995 Unknown N/K 51 1995 Research Technologist, Univ of Utah UT 52 1994 Technical Supervisor – ARUP UT 53 1994 Unknown N/K 54 1994 Research Scientist, University of Utah UT 55 1994 Research Scientist, University of Utah UT 46 of 55 graduates (84%) took their first position in Utah. 7 of 55 graduates (13%) enrolled in advanced studies, e.g., medical school, dental school, a Ph.D. program.



During the same time frame (1990-2007), 13 additional M.S. programs, also from highly reputed colleges and universities, have been initiated. These schools, and their administrators, have recognized the need for and value of the M.S. degree in the profession and their states. Nonetheless, the average number of new Master's programs is less than one per year. From Table 5, one notes that entrance to an M.S. program requires a grade point average of 3.0, with the Graduate Record Examination required by the majority of all programs. For international students, a TOEFL exam is also required. Within M.S. programs, a thesis is required by 11 of the schools (39%), and is optional at another 7 institutions. Those considering new program implementation or curriculum revision, may find existing program criteria to be helpful. At the M.S. level, the predominant numbers are 30 and 36 for semester credits required for graduation, and the minimum TOEFL required is 550. Finally, time for completion of these advanced programs is comparable to other M.S. or Ph.D. programs nationwide. For the M.S. degree, full-time graduate work averages two years, and for the Ph.D. degree, four years. Along with the data provided in Tables 1 through 6, we looked at trends from the schools responding in 2007. For example, at least five institutions now offer post baccalaureate certificate programs—California State University, Dominguez Hills; University of Kentucky; University of Massachusetts – Lowell; University of Medicine and Dentistry of New Jersey; and the University of North Dakota, e.g., with majors in medical technology, cytology, reproductive laboratory science. Six institutions have entry-level master’s degree programs, including the University of Alabama, Medical College of Georgia, Rosalind Franklin University of Medicine and Science (formerly Finch University), Rush University, University of Southern Mississippi, and Thomas Jefferson University. Twelve colleges/universities have online courses, and one of these, the University of Medicine and Dentistry of New Jersey has all of its courses Web-based.

The advent of these new programs and the introduction of online courses have created programs with a different focus from traditional programs. Will Master's programs, with a research focus, remain viable? Will CLS Master's and Doctoral programs graduate sufficient numbers of individuals to fill faculty positions certain to become available in the future? This study uses information provided from the programs described in the first and fifth editions of the Directory. We also sought to ascertain, independently, what first positions and their locations that graduates of master’s level programs accepted following graduation. Two programs were able to supply this kind of data. Information about graduates from the two programs are collected in Table 7A and Table 7B. Note, both of these programs are located in public universities, are science-based, requiring research, a thesis, and its defense. It is apparent that the majority of M.S. graduates of the University of Minnesota and University of Utah take first positions • in research arenas as scientists or specialists in

universities or in industry; • as students in advanced programs – M.D. or Ph.D.;

or • as supervisors/administrators in clinical laboratories,

including the military.

Perhaps those considering implementation of advanced programs may wish to use the data from Tables 7-A and 7-B. Obviously, graduates from the University of Minnesota and the University of Utah have been successful in their first positions. Administrators and graduate school committees, might also be impressed with the impact that these graduates have had on their employers and on the geographical region in which they are employed. Research by graduates has contributed to the intellectual acumen of the sponsoring institutions and to the profession. CONCLUSION Is the glass half-full or half-empty? The findings that new kinds of programs are being started at varying levels, that online courses are being developed, and that graduates of existing programs are successful all support the conclusion that the glass is half-full. There are



concerns, however. The total number of Master's programs has decreased. There are relatively few numbers of graduates in many programs and the ranks of laboratory scientist faculty are aging. It behooves the profession, and faculty and administrators in colleges and universities to consider the implementation of additional CLS advanced programs, not only to better serve potential students and to advance the profession, but also to contribute to the viability of the region in which they reside. REFERENCES 1. Li RC, Bigler WN, Blackwood LL, Venable C, Fenn JP, et al.

CLS advanced degrees and career enhancement. Part 1 – Comparison of career data. Clin Lab Sci, 1998; 11 (1) 21-7.

2. Li RC, et al. CLS advanced degrees and career enhancement. Part 2 – A comparison of perceptions. Clin Lab Sci. 1998; 11 (1) 28-34.

3. Fenn JP, Knight JA. The value of graduate education in clinical laboratory science. Lab Medicine, 1995: 26 (8), 537-41.

4. Karni, K. ASMT/CMU External degree program: An evaluation summary. Am J Med Tech, 1978, 44 (9) 913-20.

5. Francis DP, Hofherr LK, Peddecord KM, Karni KR, Krolak JM. The influence of perceived professional status on the career progression of CLS graduates. Clin Lab Sci, 2001: 14 (3) 160-6.

6. National Accrediting Agency for Clinical Laboratory Science Data on program numbers (5600 N. River Road, Suite 720, Rosemont, IL 60018-5119).

7. Waller, K., Karni, K. Research and scholarship of clinical laboratory science faculty members. In press, Clin Lab Sci, 2010.

8. Institutional Profile Survey 2007-2008. Association of Schools of Allied Health Professions, 4400 Jenifer Street, NW, Suite 333, Washington, DC 20015.



Scholarly Activities of the Most Productive CLS Faculty and Schools in the U.S.A.

KATHY V WALLER, KAREN R KARNI

OBJECTIVES: To assess the research and scholarship of the most productive clinical laboratory science faculty and schools in the United States. DESIGN: In 2008 a national study involving 106 college and university CLS programs was conducted to determine which faculty members were most productive in research activities. A questionnaire was sent electronically to all faculty (n=448) of 106 NAACLS accredited programs. Data from 275 respondents (61%), from 93 programs (89%) were analyzed. SETTING: The study took place at The Ohio State University with collaboration from the University of Minnesota. PARTICIPANTS: Clinical laboratory science faculty within a four-year university or college sponsoring a NAACLS-accredited CLS program, were invited to participate. MAIN OUTCOME MEASURES: To quantitate faculty scholarly productivity by point assessment, to assess the top 10% of faculty based on funding, publications, abstracts, presentations, books and chapters, and to identify the 15 highest ranking institutions in terms of their collective faculty research contributions. CONCLUSIONS: The top 10% of clinical laboratory science faculty (n = 28) are performing almost 50% of scholarship in the profession, with major contributions in funding garnered and international presentations. These individuals also generally hold a doctorate, are full professors and tenured. Among the 15 highest ranked colleges and universities with CLS programs, and by cumulative faculty contributions, most are classified as research institutions.

ABBREVIATIONS: CLS = clinical laboratory science INDEX TERMS: clinical laboratory science faculty, research productivity, scholarship Clin Lab Sci 2010;23(3):175 Kathy V. Waller Ph.D., CLS (NCA), The Ohio State University, Columbus, OH 43210 Karen R. Karni, Ph.D., CLS (NCA), Professor Emeritus, University of Minnesota, Sciences, Minneapolis, MN 55455 Address for Correspondence: Kathy V. Waller Ph.D., CLS (NCA), Associate Professor, The Ohio State University, 535 Atwell Hall, 453 W. 10th Avenue, Columbus, OH 43210, [email protected], 614-292-7303 INTRODUCTION In many colleges and universities in the United States, faculty members are expected to engage in scholarship (research and its sequelae – publications, abstracts, presentations, books, chapters and grants awarded). In addition, educational institutions and their individual programs are often rated and ranked by the research output of their faculty. Faculty members who engage in research and are productive in that research are often rewarded through tenure, promotion, and salary increases. Those who are viewed as being less productive may lose their positions, not be promoted, or suffer from limited salary increases. Thus, research and productivity are important for individual faculty members’ success as well as that of their employing institutions.



In 1996 we conducted a survey of Clinical Laboratory Science (CLS) faculty research activities, in which we evaluated and quantitated the output of individual faculty members as well as of colleges and universities within the profession.1 This article provides an update on what our most productive faculty members are accomplishing in research, as well as which schools can be designated as highest in ranking in their faculty members’ cumulative scholarly activities. MATERIALS AND METHODS A survey questionnaire was sent electronically via SurveyMonkey© to all faculty in National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) accredited college and university based baccalaureate level CLS programs (n=106) in May 2008. The instrument sought information on demographics and faculty involvement in research activities to include time spent in research, numbers of publications, presentations, and grants awarded. Responses were received from 275 of 448 (61%) CLS individuals. Details of the methodology can be seen in a recent article.1 We assigned a numerical value to quantitate various aspects of scholarship as was done in the earlier 1996 study.2 A research score was calculated for each respondent and from these data, the top 10 percent (n = 28) of CLS researchers was identified. Finally, the authors identified the 15 most productive institutions according to all responding faculty members’ scholarship. RESULTS The point determination for scholarly activities is shown in Table 1 and was adapted slightly from the 1996 study.2 Point values increased with increasing value of the activity, and as often related to promotion and tenure decisions. For example, grant monies awarded over $1million dollars were valued at 20 points compared to 3 points for monies awarded for less than $10,000. An international research presentation, or refereed research publication, was each awarded 3 points, while a refereed abstract or chapter in a book received 1 point. Total points were calculated to quantitate individual faculty members as well as overall school research productivity.

Table 1. Point Determinations for Research Activities

Activity Point Value Grant monies awarded

$1 - $9,999 3 points $10,000 - $99,999 5 points $100,000 - $499,999 10 points $500,000 - $999,999 15 points > $ 1 Million 20 points

International research presentation Poster or oral 3 points National research presentation Poster or oral 2 points International “other” presentation 1 point National “other” presentation 1 point Refereed research publication 3 points Refereed abstract 1 point Book (sole author) 5 points Book (editor or co-editor) 2 points Chapter in book 1 point *See Waller KV, Wyatt D, and Karni KR, “Scholarly Activities Among Clinical Laboratory Science Faculty,” Clin Lab Sci 1999;12:19-26 for original establishment of point values by 17 leading CLS educators in 1998. For 2008, one value has been upgraded to award 20 points for funding > $1 million.

Demographic information of the top 10% of CLS faculty contributing to scholarly activities is shown in Table 2. The majority had earned a doctorate (93%); held the academic rank of professor (54%); and were tenured (75%). Figure 1 depicts the percentages of scholarly activities performed by the top 10% of CLS faculty in which individual faculty members’ scholarly activities were itemized and totaled. Here, 28 faculty members were awarded both two-thirds of all funding and presented internationally. They also had 47% and 46% of research publications and refereed abstracts, but relatively low percentages of books and chapters (22% and 29%).



Based upon all faculty point assessments, the most productive 15 CLS programs in the United States with faculty performing research and scholarly activities are listed in Table 3. (These universities are listed alphabetically, and not in rank order).

Table 2. Demographics of the Top 10% of CLS Faculty Contri-buting to Scholarly Activities

Highest Level of Education Frequency (%) Masters 2 7 Doctorate 26 93 Academic Rank Assistant Professor 5 18 Associate Professor 8 29 Professor 15 54 Tenure Status Tenured 21 75 Tenure Track 5 18 Tenure does not apply 2 7 Type of Employing Institution 4-year major research university 14 50 4-year college/university 12 43 Other 2 7

Figure 1. The Top10%* of CLS Faculty Contribute These Percentages of Scholarly Activities

* n =28. DISCUSSION As we stated in 1998,3

An individual within a ‘recognized profession’ participates in, and adds to the profession through, the competent practice of that profession, education of new members to the profession, and contributing to the body of knowledge of the profession. Research and scholarly activities are crucial components to validating and advancing the profession.

Table 3. Top 15 CLS Programs in the United States by Cumulative Faculty Research Productivity

Long Island University at CW Post Louisiana State University Medical College of Georgia* Saint Louis University SUNY at Buffalo* SUNY at Stony Brook The Ohio State University* University of Kentucky* University of Maryland University of Minnesota* University of North Carolina* University of Texas at Galveston* University of Texas at San Antonio* University of Wisconsin – Madison* University of Wisconsin – Milwaukee*

Rankings include all CLS faculty responding from each institution. *Ten of the original 15 programs, ranked in 1996, remained among the top 15 programs in 2008.

This study represents a two decade long investigation of CLS faculty research actitites.4, 5, 6 It supports our 1998 findings that some CLS faculty are highly productive in research, and are similar to other studies. In 1979, for example, Krumland reported that in medicine, 10% of the faculty produced 50% of its publications.7

More recently, Webber and Lee (2009) were cited in The Chronicle of Higher Education for their work that stated, among their findings, that research productivity was enhanced by: Kind of school in which they were employed. Professors at doctoral institutions reported more

refereed journal articles, book reviews and presentations than did professors at master’s and

29%

22%

35%

67%

46%

47%

66%

0 20 40 60 80

Chapters

Books

National Presentations

International Presentations

Refereed Abstracts

Research Publications

Total Funding



baccalaureate institutions, where teaching is more likely to take up a faculty member’s time.

Discipline in which they were employed. “Faculty members in the physical and life sciences had 46 percent more refereed articles than did professors in the arts and humanities. . .”

Parenthood. “. . .being the parent of dependent children had a positive effect on research productivity.”

Our findings have, first, provided quantitative point values for individual faculty members’ research activities and productivity. Other investigators of faculty research may find them useful in their own studies of scholarship. Next, the top 10% of CLS faculty have produced almost 50% of scholarly activities, much like the Krumland studies. The two findings are not unexpected. Seasoned researchers are most apt to win external funding and to present internationally, because of their previous track records and reputations within their professional communities. Again, our studies are similar to those of Webber and Lee in the first two conclusions regarding kind of school and discipline in which one is employed. While this investigation did not look at personal factors, e.g. dependent children of faculty, it fosters further research that should be done regarding the personal status of faculty. The relatively small percentage of the top 10% of faculty who author books and chapters is interesting. Perhaps books and chapters are not rewarded in the same ways that research publications, presentations and grants awarded are viewed. The fact that the 17 CLS “experts” earlier rated them relatively low also suggests they are not as valuable a scholarship indicator as others. Thus, research-oriented faculty may not engage in these activities, because they are not seen as important enough to their own scholarship output. Correspond-ingly, books and chapters reflect a “state of the art” of a discipline as previously published. They do not present new knowledge (such as refereed journal articles) and thus represent secondary presentations.

The cumulative research activities of all responding faculty members give rise to the most productive programs in the United States. Note: these 15 institutions represent the point values for all faculty responding, not just the 28 most productive members. Here there are ten returning institutions from the original 15 highest ranked and as reported in 1999.2 Most are research institutions. Nevertheless, and as can be seen in Table 2 and from our report in Clinical Laboratory Science,1 there is no statistical difference between all faculty from research institutions or four-year colleges. These findings suggest that while individual faculty performing research can be found in any institution, overall, research universities hold the greater numbers of productive faculty. Finally, faculty in clinical laboratory sciences may be similar to those in other colleges and universities. Some faculty members are very productive, like the 28 persons represented in this paper. Some institutions also support highly the research activities of their faculty. It behooves us to strengthen the research efforts of all faculty members to validate and strengthen the practice of laboratory science and to contribute new knowledge to the field. Moreover, promotion, tenure and salary decisions for individual faculty members may be heavily based on research.1

RECOMMENDATIONS As first recommended in 19884 and repeated in 19983, we offer these recommendations to faculty and administrators who wish to increase the scholarship of individuals and that of their programs and schools: Allocate teaching loads according to interest and

skill, i.e., programs may assign more of the teaching to excellent teachers, and more research to excellent researchers, thereby increasing pro-ductivity in both arenas.

Employ faculty who are interested in both research and teaching.

Employ individuals with demonstrated research skills, or the potential to engage in scholarly activities.

Establish collaborations with other researchers. Participate in research conferences.



Encourage graduate assistants to become involved actively in research projects.

Develop research skills for students at the undergraduate as well as the graduate level.

Work together as a profession to identify and generate funding sources.

Two decades later, we offer additional and expanded suggestions, based on this research, together with experience, including observation: For new junior faculty – determine early in your

academic career what are the expectations and rewards of your program and school in research, teaching and service.

For those who teach, primarily – such faculty as well as administrators should value instructors’ accomplishments by disseminating the why and how of why they have been successful teachers. In many schools, teaching and mentoring and success in creative content as well as methods and delivery of instructional materials are rewarded similarly to traditional research.9

Pursue funding sources – local, regional and national – that provide monies for research. While such sources may not mesh exactly with a faculty member’s primary research interests, one can gear a proposal to the goals of the funding organization.

For established researchers – involve yourselves in a strong mentoring role with junior faculty.

For young researchers – “hitch your wagon to a star.” Introduce yourself and your expertise (both actual and potential) to someone who is an established researcher. This individual may find your ideas and experiences to be intriguing to his/her own interests, and invite you to participate in that research.

How is nationally funded research garnered? Much is awarded to those engaged in collab-orative research. Again, collaboration is essential;

find colleagues with whom you can work in a meaningful way.

Be a team player. Promotion and tenure decisions can be quixotic. But, those faculty members who are engaged with one another, support others, and share resources and information are often successful in the review and tenure/promotion process, not only because of their scholarship, but also because of the perception that they are team players, essential to the program and school.

These activities will enhance the status and reputations of individual faculty members within and outside their own schools. They will also strengthen their institution’s standings, especially when programs and schools are compared to, and ranked with, one another. REFERENCES 1. Waller KV, Clutter JE, Karni KR. Research and scholarship of

clinical laboratory science faculty members. Clin Lab Sci 2010; 23(3);Suppl:3-32–8.

2. Waller KV, Wyatt D, Karni KR. Scholarly activities among clinical laboratory science faculty. Clin Lab Sci 1999;12:19-27.

3. Waller KV, Wyatt D, Karni KR. Research productivity and activities of clinical laboratory science faculty: a follow-up study. J Allied Health 1998;27:142-9.

4. Flanigan KS, Ballinger PW, Grant HK et al. Research productivity profile of allied health faculty. J Allied Health 1988;17:87-100.

5. Waller KV, Jordan L, Gierhart J et al. Research skills and the research environment: a needs assessment of allied health faculty. J Allied Health 1988;17:101-13.

6. Waller KV, Schiller MR, Snyder JR. A profile of medical technology educators’ scholarly productivity and research environment. Lab Med 1988;19:655-60.

7. Krumland RB, Will EE, Gorry GA. Scientific publications of a medical school faculty. J Med Educ 1979;54:876-84.

8. June AW (reports). Personal and professional factors affect researchers’ productivity, study finds. Chronicle Higher Educ November 4, 2009. Available from http://chronicle.com/ article/PersonalProfessional/49051/?sid=at&utm_source=at&utm_medium=en. Accessed 2010 May 25.

9. Balogun JA, Sloan PE. Emerging trends in tenure policies and practices in nursing and allied health education. J Allied Health 2006;35:134-41.


EDUCATIONAL TECHNOLOGY

Focus: Online Education and Technology Introduction

VICKI S FREEMAN Medical Laboratory Science (MLS) educators continue to look for new and better ways to teach students the knowledge and skills that they will need when they graduate and become employed in the laboratory field. Educators are also challenged by administration to increase the size of their classes (but with fewer resources), make their programs more cost-effective, and meet workforce needs. In recent years, to meet these demands, distance and online learning opportunities have substantially increased in MLS programs. Currently, nineteen MLS and twenty-five Clinical Laboratory Technology programs are listed as having components of online education.1 Originally, this focus series was planned to discuss distance education and technology. However, as the articles evolved, it became evident that using the narrower term of online education was more precise when coupled with the term technology. The Focus section has been divided among two Clinical Laboratory Science journal issues with the summer issue focusing specifically on technology (Using Technology in Resource Limited Countries for Competency Based Education and Training and Moving from Face-to-Face to Online Teach-ing) and the education supplement discussing effective online education techniques (Staying Connected: Online Education Engagement and Retention using Educational Technology Tools and Preparing Online Students for Comprehensive Examinations). A few definitions are important, as many different terms are employed when discussing these topics. Distance learning is an educational situation where “the instructor and students are separated by time, location, or both”2 and can be either synchronous (real-time, instructor-led event in which all participants are virtually “in class” at the same time) or asynchronous (interaction between instructors and students occurs intermittently with a time delay) using a variety of

distribution methods including technology.2 Online education is also a separation of the teacher and learner, but it uses a computer network to present or distribute educational content with two-way communication via the network so that students may communicate with instructors and each other.3 As you can see, the definition of distance education is broader and inclusive of the definition of online education. Distance education does not have to use technology in order for education to be distributed. However, online education does not necessarily need to be completely “distance,” but can include a combination of modalities, including on-campus sessions. Two other terms that fit into online education are blended learning and web-enhanced courses. In blended learning, instructors “combine face-to-face instruction with online learning and reduced classroom contact hours,” while web-enhanced courses are face-to-face courses that make use of the web through a course management system but do not reduce classroom time. Online resources may be used, but do not replace classroom time.4 Interestingly, students not only expect, but actually demand, that some coursework be available online. As some of the articles in this series will discuss, even students attending face-to-face classes expect to be able to access online resources including downloading previously delivered classroom lectures. But, it is also important to realize that not every student wants to take their education online nor are successful at online learning. Therefore, although faculty members need to find ways to respond to student expectations and enhance the learning of the students, they need to make sure that a variety of learning strategies are available to match the learning styles and needs of their students. "Good teachers have always used a mix of strategies, methods and media to reach their objectives–that’s not new. What is new is that today’s internet-based tools



can facilitate communication, interaction, and collab-orative learning in ways that were not possible before."5 The challenge to faculty is to keep up-to-date on the new tools that are available and find ways to use them in an appropriate and effective manner in their classes. Questions such as whether to allow students to have computers or even cell phones in the classroom have arisen. If e-tools are being used for learning purposes in place of classroom exercises, how does an instructor measure competency? Overseas, MLS programs are moving to more competency-based curricula. Face-to-face contact does not ensure competency any more than online teaching. Also, what techniques can an instructor use to keep in contact with and develop a “presence” in the online classroom if the student is totally online? And, finally, as is necessary with all programs, how can programs assess and evaluate the learning outcomes? The purpose of this focus series is to provide information on the different tools available to an instructor when delivering online education and to show how instructors are using these tools in their courses. Four articles were selected to highlight:

the e-tools that are available and how these tools help to engage and retain online learners;

competency-based education in resource-limited countries and how technology, includ-ing online resources, are used to facilitate the skills development;

how faculty adjust their teaching and their courses to effectively facilitate learning online; and

an assessment of learning outcomes using comprehensive exam scores.

I hope that these articles encourage clinical laboratory educators to at least try some of the online tools that are available on most campuses or at least incorporate some web-based educational resources in their courses. REFERENCES 1. Directory of NAACLS approved Online Clinical Laboratory

Education Programs. http://www.ascls.org/leadership/sa/esa .asp#CLEP-Online. January, 2010. [Accessed March 29, 2010]

2. From An E-Learning Glossary http://www3.imperial.ac.uk/ict/ services/teachingandresearchservices/elearning/aboutelearning/elearningglossary#d. [Accessed March 29, 2010]

3. Keegan D. Distance Education: International Perspectives. Routledge. 1988.

4. Dziuban CD, Hartman JL, and Moskal PD. Blended Learning. ECAR research bulletin. March 30, 2004, Volume 7. Accessed at www.educause.edu/ecar/ [Accessed March 29, 2010]

5. The Node Learning Technologies Network. (2001). The Node's Guide to Blended Learning: Getting the Most out of Your Classroom and the Internet.

The Focus section seeks to publish relevant and timely continuing education for clinical laboratory practitioners. Section editors, topics, and authors are selected in advance to cover current areas of interest in each discipline. Readers can obtain continuing education credit (CE) through P.A.C.E.® by completing the continuing education registration form, recording answers to the examination, and mailing a photocopy of it with the appropriate fee to the address designated on the form. Suggestions for future Focus topics and authors, and manuscripts appropriate for CE credit are encouraged. Direct all inquiries to the Clin Lab Sci Editorial Office, Westminster Publishers, 315 Westminster Court, Brandon MS 39047. (601) 214-5028, (202) 315-5843 (fax). [email protected].



Using Technology in Resource Limited Countries for Competency Based Education and Training

WENDY ARNESON

ABSTRACT: Competency based education and training (CBET) helps to prepare graduates of medical laboratory science programs for the specific needs of the workforce. This is especially important in resource-limited countries where shortage of laboratory personnel creates a large demand for skilled graduates. Internet and other technology can be useful to teach specific tasks in CBET. Even in resource-limited countries, technology can be used in the implementation of competency based education and training curricula in medical laboratory programs. INDEX TERMS: competency based education and training, medical laboratory curriculum, principle learning outcomes, information and communication technology LEARNING OBJECTIVES 1. Define competency based education and training

(CBET) 2 Describe the curriculum needs in developing

countries 3. Explain the process of CBET curriculum

development for medical laboratory programs 4. Justify the use of internet and other technology in

CBET curricula for medical laboratory programs 5. Describe an example CBET curriculum for a

resource limited country Clin Lab Sci 2010;23(3);182 Wendy Arneson, MS, MT (ASCP), ASCP Consultant, American Society for Clinical Pathology, Chicago, IL. Address of Correspondence: Wendy L Arneson, MS, MT(ASCP), 9724 N Riverside Rd, Mequon, WI 53092, [email protected].

INTRODUCTION Technology is useful in the implementation of competency based education and training (CBET) curriculum in medical laboratory programs, even in resource-limited countries. Uninterrupted power and access to internet are priorities in many medical laboratory programs in developing countries and students often have access to internet cafes and computer centers on and off campus. As students become aware of careers in medical laboratories in resource-limited countries, they want access to education and training that adequately prepares them for the workforce and provides opportunities for advancement. Competency based education and training often meets those needs since it provides for the education aspect, the knowledge and moral development, and the training aspect, supervised practice for proficiency in a skill or profession. First, an introduction to CBET is helpful. Education is defined as to develop mentally, morally or aesthetically by instruction while training is defined as making prepared by exercise for a test of skill. Training is associated with psychomotor skills which require some motor activity which proceeds from mental activity.1 Medical laboratory professionals must draw upon critical thinking, ethical practices as well as hand-eye coordination in order to carry out even the most simple daily tasks and thus, medical laboratory education uses both education and training throughout the curriculum. Traditional post-secondary education is often organized based on the knowledge and subject matter to be taught in a specific time interval. The course leader determines which learning objectives should be addressed within a semester and develops a list of topical lectures and supporting laboratory exercises. In CBET, the units of



instruction, course modules, are organized around learner mastery of specific tasks and knowledge to achieve competency. In order for CBET to be effective, the competencies are selected based on specific needs that all learners should master, provided sufficient time and appropriate educational methods are used. CBET is often described as learner outcome oriented rather than teacher and time oriented.2 Competency based education and training are concentrated on outcomes connected with scope of practice. Outcomes are taught with increasing complexity so that foundational knowledge can be built upon.3 Competencies taught in CBET are measured using benchmark assessments, provide for individual development of student performance, and ideally, allow for individual student-paced instruction.2,4,5 Compet-ency-based education and training are considered more efficient in many programs, including businesses and industries that have been built around the competency-based model.6,7 Curriculum needs in Developing Countries Many developing countries suffer from a lack of skilled medical laboratorians coupled with an increasing demand for laboratory services. The cost of post-secondary education, while significantly less than in developed countries, still represents a significant barrier to students in long-term educational programs. Likewise, access is limited. Some larger countries, such as Tanzania, have rapidly increased the number of health care facilities which provide laboratory services at the primary, secondary, tertiary, or reference healthcare levels and have clearly defined occupational roles for each level. Thus, education and training in developing countries should take into consideration laboratory scope of practice and provide for the needs of the healthcare system. In addition, curricula that address career laddering serve both the healthcare system and the individual’s needs. As an example, Tanzania has developed CBET medical laboratory curricula to provide for laboratory technicians with competencies to meet the needs of three tiers of laboratory service. For example, a module from the 2nd year of the MLT curriculum is named “Laboratory Specimen Collection and Transportation.”

Students are given time in this module to develop competencies in seven outcomes. One outcome and its four associated tasks is shown in Table 1. A module from the third year of the MLT curriculum is named “Laboratory Quality System Management.” Students are provided with time to gain competencies in eleven outcomes. One of these outcomes and its associated tasks are shown in Table 2. These national standardized CBET curricula are based on specific scope of practice and help to supply more laboratorians at each tier of service. Table 1. One Outcome and the Associated Tasks from 2nd Year

MLT Course Module

Outcome Number 2.1. Use specimen collection equipment and laboratory ware correctly and with care. Tasks for Outcome 2.1:

a) identify specimen collection equipment and laboratory ware b) Explain the function of specimen collection equipment and

laboratory ware c) Explain the steps for use of specimen collection equipment

and laboratory ware d) Use specimen collection equipment and laboratory ware

according to procedures

Table 2. One Outcome and the Associated Tasks from 3rd Year

MLT Course Module

Outcome Number 3.1. Describe quality essential at the pre- analytical phase. Tasks for Outcome 3.1:

a) Explain pre-analytical phase of the quality assurance cycle b) List quality system essentials of the pre-analytical phase c) Describe proper packaging, storage and transportation of

laboratory specimens d) Explain personnel competence assessment e) Describe laboratory services at a regional level with the use of

an organogram f) Describe procedures for laboratory biosafety and

containment g) Explain the importance of preparing and recording on

temperature charts

Process of CBET development for Medical Laboratory Programs Competency based education and training originated in vocational training in the late 1970s but are gradually becoming incorporated into other educational settings.8 The competency approach is commonly employed in



undergraduate and postgraduate public health and medical education in many countries including US, UK, New Zealand, and Australia.9,10 This approach is also being used in medical laboratory programs in Eastern and Southern Africa. The curriculum must address the mission of the educational program, which is to provide entry level medical laboratorians for the laboratory service. Functional analysis of the occupational roles, referring to governmental job descriptions, the national laboratory strategic plan, and standardized test menus helps to clarify the mission statement. Instructional goals and objectives can be developed to further capture the means by which an educational program will implement its stated mission, as specified in accreditation criteria. The goal of professional education clarifies the intent of the educational program to produce graduates who are able to apply core educational knowledge.11 The first step of a competency based curriculum is to develop outcomes that address the needs of the profession.12 These outcomes are often subdivided into principal learning outcomes (PLO), enabling outcomes (EO), and sub-enabling outcome (SEO) statements. It is helpful to first order PLOs from basic to complex so that organization into units of instruction and programmatic structure is less difficult. The next step is to develop tasks and competencies specifically for each SEO that are measurable behaviors. The most specific type of outcome statement is the task activity described as a learning objective. Since the tasks are written to be measurable behaviors, assessment is targeted to the task. Specifying the type of assessment for each behavior, as well as benchmarks or standards, helps to complete the competency based outcomes. Identifying the average number of instructional hours is helpful in the next step of forming the competencies into units of instruction and ultimately in forming the curriculum structure, particularly for student-paced instruction. The third step is to cluster sub-enabling outcomes with their tasks into units of instruction such as course modules. This helps to organize competencies into related areas of expertise. The total instructional hours of the sub-enabling outcomes and tasks are added up to

determine total instructional hours for each course module and can be converted to credit hours according to the formula provided by the institution. This information along with the assessment methods and other key information should be specified in the course module syllabi along with institutional requirements. Names of course modules will often take a more competency based approach rather than a subject based approach, e.g., Customer Care and Communication versus Laboratory Management. The last step is to distribute course modules into programmatic structure based on weeks, semesters, quarters, or years to fit the institutional calendar. It is important, as with any curriculum, to consider prerequisite tasks and competencies addressed in earlier or co-current semesters. Outcomes within course modules should build on previous outcomes so that foundational knowledge and skills can be reinforced and applied to intermediate and advanced competencies. In developing countries, new skill(s) are being introduced into laboratory service such as automation and the quality systems approach. To implement the competency based curriculum in developing countries, new technologies and competencies in the delivery of laboratory services should be taught to tutors, faculty, and clinical instructors. A program for training of trainers (TOT) can be part of the implementation stage of competency based curriculum. Role of Technology in Medical Laboratory Program CBET Curricula The use of information and communication technology (ICT) to enhance education has been ongoing in the USA for the past four decades.13 However ICT is valued in providing education in medical laboratory programs, one often assumes that technology is not available in developing countries. Nonetheless, medical laboratory education in developing countries has progressed from giving oral lectures, writing on the chalkboard, and demonstrating a few laboratory procedures to using computers, computer projectors, multi-head micro-scopes, digital microscopy, and the internet. Technology provides excellent support for teaching competency-based education and training in that it can



help to clearly demonstrate principles that may be difficult to grasp with traditional teaching methods. Computerized presentation slides such as Microsoft PowerPoint® are being used for animated demonstrations, illustrating steps of a procedure, and creating job aids and handouts. These new technologies can assist in individual and group learning.14 Although most students in developing countries don’t carry a laptop computer to class, they frequently do carry a flash drive with them. Students often have access to student computer centers or internet cafes on or near campus, so they appreciate the opportunity to receive the lecture notes and practice exercises on a flash drive after the presentation to view on a computer or to print out handouts for additional study. Although students are used to note-taking in class, these presentation notes can help to organize foundation knowledge and pose questions that lead toward application and critical thinking. Some of the competencies in medical laboratory programs in developing countries involve method evaluation, research, and epidemiology projects. Medical laboratory students are taught how to search for literature and references for their research projects and to write scientific papers. Internet technology is becoming available in some universities and medical laboratory schools to provide access to online journals and periodicals, animated demonstrations and video clips, and online textbooks. This is especially helpful to medical laboratory programs since library resources in many cases are either absent or severely outdated. Access to internet resources gives them an economical way to support their research projects. However, using internet resources should not encourage a “cut and paste” mentality in students. Educational standards expect that students writing research papers do more than gather information or “scoop and smush, copy and paste” when they research.15 Online textbooks are available that are extremely helpful to medical laboratory faculty and students in resource limited countries, particularly when appropriate textbooks are expensive, become obsolete quickly, or are difficult to find. Some examples include the online biotechnology textbooks and a microbiology textbook at URL:

http://www.ncbi.nlm.nih.gov/About/primer/index.html

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi? book=mboc4.

http://pathmicro.med.sc.edu/book/welcome.htm This paper provided information about use of technology in competency based education and training in medical laboratory programs in resource limited countries. This information may be useful to medical laboratory educators in the USA as they consider approaches and make decisions for competency-based program planning and curriculum development. REFERENCES 1. Merriam-Webster Online Dictionary. 11th Edition. 2010.

Merriam-Webster, Inc. URL: http://www.marriam-webster. com Accessed 5/1/2010.

2. Thomson P. Competency-Based Training: Some Development and Assessment Issues for Policy Makers. 1991. TAFE National Centre for Research and Development: Leabrook, Australia. ERIC: ED 333231.

3. Competencies and Learning Objectives. Council on Education for Public Health, Distribution authorized: February 19, 2006. URL: http:// www.ceph.org. Accessed 3/1/2010.

4. Norton RE. Competency-Based Education and Training: A Humanistic and Realistic Approach to Technical and Vocational Instruction. 1987. Paper presented at the Regional Workshop on Technical/Vocational Teacher Training in Chiba City, Japan. ERIC: ED 279910.

5. Foyster J. Getting to Grips with Competency-Based Training and Assessment. 1990. TAFE National Centre for Research and Development: Leabrook, Australia. ERIC: ED 317849.

6. Watson A. Competency-Based Vocational Education and Self-Paced Learning. 1990. Monograph Series, Technology University: Sydney, Australia. ERIC: ED 324443.

7. Delker PV. Basic Skills Education in Business and Industry: Factors for Success or Failure. 1990. Contractor Report, Office of Technology Assessment, United States Congress.

8. Power L., Cohen J. Competency-Based Education and Training Delivery: Status, Analysis and Recommendations. 2005. USAID. URL: http://pdf.usaid.gov/pdf_docs/PNAD P013 . pdf

9. Wai-Ching L. Competency based medical training: review. BMJ 2002;325:693-6.

10. Woodhouse L, Cardelle L, Godin S, Shive S, et al. Transforming a Master of Public Health Program to Address Public Health Practice Needs. Prev Chronic Dis 2006;3(1): 1-6. URL http://www.cdc.gov/pcd/issues/2006/jan/05_0099. htm.

11. Council on Education for Public Health, Report February 2006. URL: http:// www.ceph.org. Accessed 3/1/2010.

12. Sullivan RS, McIntosh N. The Competency-Based Approach to Training. JHPIEGO Strategy Paper 1995. JHPIEGO



Corporation. URL: http://www.reproline.jhu.edu/english/ 6read/6training/cbt/cbt.htm#References. Accessed 3/1/2010.

13. Watson D. Understanding the relationship between ICT and education means exploring innovation and change. Educ Inf Technol 2006;11:199–216.

14. Greer R, Bares A. Beyond media stickiness and cognitive imprinting: Rethinking creativity in cooperative work & learning with ICTs. Educ Inf Technol. 2007;12:123–36.

15. McKenzie J. Beyond Cut-and-Paste: Engaging Students in Wrestling with Questions of Import. From Now On: the educational technology journal. 2008; 18 (1) URL: http://www.fno.org Accessed 03/01/2010.



Moving from Face-to-Face to Online Teaching

MUNEEZA ESANI ABSTRACT Transitioning from face-to-face to online teaching can be challenging but is also rewarding. It is challenging to create a sense of social presence so that the online student feels a part of the learning community. It is difficult to assess the level of student learning and to regularly communicate with them without being face-to-face. Online students may require constant feedback and clarifications on difficult concepts which can be very time consuming for the faculty. The paper will discuss creative instructional strategies that will help faculty overcome some of the challenges and make their transition from face-to-face to online teaching an easier process. Advantages and rewards of online teaching are also discussed. LEARNING OBJECTIVE 1. Compare and contrast instructor-student inter-

action in face-to-face courses vs. online courses. 2. Discuss the importance of social presence in online

education. 3. List some strategies that will motivate an online

learner to actively participate in an online course. 4. Discuss the “non-stop” nature of online teaching

and learning. 5. List two advantages of online teaching. Clin Lab Sci 2010;23(3);187 Muneeza Esani, MHA, MT(ASCP), Clinical Laboratory Sciences Program, University of Texas Medical Branch, Galveston, TX Address of Correspondence: Muneeza Esani, Clinical Laboratory Sciences Program, 4.426 Health Professions and Nursing Bldg, 301 University Blvd, Galveston, TX 77555, [email protected], 409-772-9456.

INTRODUCTION Classroom lectures, paper exams and face-to-face communication are used to accomplish the cognitive objectives in most CLS programs across the country. However, in recent years, CLS education has reached beyond the classroom setting to a wider student audience that is not able to attend the on-campus classroom. Online education connects instructors and students with resources, virtual communication and remote activities using a course management system as the primary means of instruction. Transitioning from on-campus to online teaching brings about some challenges and surprises. This article will focus on the ways in which faculty must adjust their teaching in order to effectively facilitate learning online. Creating an environment of social presence is essential for the success of online education. Garrison et al. defined social presence as the ability of participants within the online learning community to project their personal characteristics into the community and present themselves as real people.1 The connection and feeling of being part of a learning community is somewhat lacking in online education and it is not unusual for an online student to feel isolated. Creating a sense of social presence creates a level of comfort and enhances interactions between students and the instructor, which makes the learning environment fulfilling for online learners and instructors.2,3 As Mykota and Duncan pointed out, the primary function of social presence is cognitive learning. When students perceive their experience as enjoyable, satisfying, and personally and professionally fulfilling, they tend to interact more, which results in enhanced learning. When the online environment is lacking social presence, the participants see it as impersonal and, in turn, the amount of information that is shared with others decreases.4

Gunawardena and Zittle examined the effectiveness of social presence in online education and reported that a direct relationship exists between social presence and



student satisfaction. They found that students with high perception of social presence had higher perceptions of learning and were 60% more satisfied with their instructor compared to students that had low percep-tion of social presence.5 This was also confirmed by a comparative analysis of student motivation involving 12 e-learning university courses performed by Rovai (2007). The results of this study provide evidence that social presence is a major contributor to the satisfaction and motivation of online learners. This can be accomplished early in the course by the instructor sharing background information, professional exper-iences, personal and professional interests and challenges.6 An introductory exercise where the students and instructor share their backgrounds can be all it takes. Alternatively, instructors can divide the students into groups and let them share contact information to create a buddy system. Relationships established at the beginning of the course create social presence and provide a support system. Thus, the understanding of the social presence theory and development of an environment conducive to sharing early in the online education process contributes to the overall success of the online educational experience. Whether face-to-face or online, acquisition of knowledge and obtaining a higher order of critical thinking are goals of higher education. In the face-to-face setting, this is evident through classroom discussions, laboratory exercises, and oral and written examinations. Instructors have regular contact with students and are able to assess their prior learning and their level of cognitive knowledge in every class. They rely on a number of unobtrusive visual cues from their students to enhance their delivery. A quick glance, for example, reveals who is attentively taking notes, pondering a difficult concept, or preparing to make a comment. The student who is frustrated, confused, tired, or bored is equally evident. The attentive instructor consciously and subconsciously receives and analyzes these visual cues and adjusts the course delivery to meet needs of the class during a particular lesson. Challenges of Online Teaching When teaching online, faculty has few, if any, visual cues. Those cues that do exist are filtered through technological devices such as video monitors. It is

difficult to carry on a stimulating teacher-class discussion when spontaneity is altered by technical requirements and distance. The teacher might never really know, for example, if students are asleep, talking among themselves, or even in the room. If the course is purely online, the lectures may be recorded in any of several formats and may or may not be viewed by students. Furthermore, the level and depth of prior learning and critical thinking skills of learners in the online setting is not always displayed to the instructor. Under those circumstances, a pre-assessment is necessary to assess the knowledge and skills that an online student possesses prior to the beginning of the course. Moreover, online students need a structured system of acquiring cognitive knowledge to produce positive learning outcomes. The instructor should provide a logical flow of lessons as well as activities that assess and reinforce student learning on a regular basis so that adjustments to instruction can be made in a timely manner.7 Although face-to-face interaction is limited in this setting, discussion boards, blogs and/or chat rooms can be used for communication with the instructor and with other students. Most students will take responsibility for their learning and actively participate in discussion board type activities, particularly if it is a graded event. However, there are always some that will not participate no matter what the consequences. Compared to the traditional face-to-face courses, online courses require more development and design time and the delivery is more labor intensive. Visser’s (2000) study compared his own experience as an instructor of a new online course with prior experience teaching a regular classroom course. His results indicated that the time and labor-intensive work that is required in online course development and delivery are greater than that of regular classroom teaching.8 The instructor must start preparing for an online course long before the course starts. This requires hours in front of a computer screen typing every instruction that could be verbally communicated in a face-to-face setting with minimal effort.9 This is because every aspect of the course must be carefully organized with explicit and detailed instructions. There is little room for making changes while the course is in progress because instructors do not have regular meetings with students to clarify



instructions. The same is true for providing feedback. All communication with online learners must occur in writing, via email or formal announcements on an online content management system such as Blackboard. As a result, there is some lag time before the online learner receives and reads the message. Often the learners work on their course content at night or on weekends, and need answers to their questions during that time. This means the instructor must be available to them after normal office hours. This “non-stop” nature of online learning along with the need to provide constant feedback and clarification may give a sense of omnipresence to the faculty.10 Constant messages from learners can be time-consuming and labor intensive to review and respond to. In addition to corresponding with online learners, grading of exams and papers and other responsibilities, such as other courses, are enough to overwhelm an instructor. Although quick response and feedback are the nature of the online environment, an instructor can use simple strategies, such as including the probable response time in the syllabus, to inform learners about expected response time. Lewis and Abdul-Hamid suggested that common problems, questions and their responses can be collected over time and feedback comments can be copied and pasted for a quicker response.11 Alternatively, a frequently asked questions’ section can be posted on the content management website where necessary. Finally, the organization of the course is extremely important and using clear instructions will help to avoid the need for additional clarifications. Advantages of Online Teaching Some of the frequently mentioned advantages of online teaching are that it is convenient, efficient, challenging and can be fun and rewarding. Such courses also provide the opportunity to work with new and emerging cutting edge technologies.12 Online instructors can teach from anywhere in the world as long as they have an internet connection. There is no class time missed due to illness, educational conferences, public holidays or even natural disasters. In addition to convenience, the online environment also offers excitement as well as new challenges for both learners and the instructor. The instructor can create interactive learning tools for teaching challenging concepts, which is more interesting and exciting for the learner than

using still pictures or verbiage in a face-to-face lecture. However, every online instructor must face the challenge of mastering the course management system and keep up with emerging technologies. If the university or CLS department provides technical support and training, the process becomes less frustrating and more enjoyable. Finally, online learning produces a deeper level of thinking and understanding of course materials vs. face to face learning due to the written nature of all communications. An online and phone interview of 21 university faculty conducted by thejournal.com provided some subjective data regarding online learning. More than half of the interviewees felt that learning in online environment is more profound as the discussions seem both broader and deeper. They also felt that, in such an environment, the quality of student contributions are more refined as they have time to mull concepts over as they write prior to posting. The fact that students must take the time to write their thoughts down, and the realization that those thoughts have the potential of being permanently exposed to others via discussion board or the like, brings about a deeper level of discourse.13 Moreover, the quality of discussion can be tied to the course participation grade which again motivates students to put greater thought into what they write. Another study conducted by Asynchronous Learning Network interviewed 20 university faculties that taught both face-to-face and online, representing various departments in their schools. This was a semi structured interview where faculty answered 14 questions which were then coded and the most frequently coded passages were determined. The faculty in this study frequently spoke of being more reflective or careful in crafting their own responses in an online discussion and also mentioned the higher quality of questions and comments from online learners.12 Both studies show that discussions and learning can be superior in an online environment compared to face-to-face environment. Both of the above mentioned studies are qualitative and do not provide quantitative data which is certainly needed to explore this further. Overall, online teaching has its advantages and can be a fulfilling and satisfying experience for an instructor. Most online instructors will agree that teaching online is no less rewarding than teaching face-to-face. A study



conducted in 2006 showed that faculty experiences with online teaching were gratifying, stimulating and rewarding.14 In a classroom setting, the instructor might feel good about an ‘aha’ moment when the students display understanding of difficult concepts. The experience is quite similar when an online student posts something thought-provoking on discussion board. Moreover, if learners have related work experience such as in a CLT to CLS program, the course facilitator or instructor learns from them as well. These learners may have access to case studies and the latest testing methodologies that can be shared with everyone involved in the course. Overall, the experience of a course instructor can be rewarding in traditional, virtual, or blended environments. As classroom venues transition from traditional to virtual, the role of an instructor changes. The instructor must recognize the nature of online learning and adjust their instruction to create a learner-centered environment. Creating a climate of social presence, paying close attention to course design, thoughtful use of creative instructional strategies, and encouraging knowledge sharing will assist instructors in managing the demands of web-based instruction effectively. REFERENCES 1. Garrison DR, Anderson T, Archer W. Critical thinking,

cognitive presence and computer conferencing in distance education. American Journal of Distance Education. 2001;15:7-23.

2. Aargon SR. Creating social presence in online environments. New Directions for Adult and Continuing Education. 2003;100:57-68.

3. De Gagne JC, Walters, K. Online teaching experience: A qualitative metasynthesis (QMS). MERLOT Journal of Online Learning and Teaching. 2009;5:577-87.

4. Mykota D, Duncan R. Learning characteristics as predictors of online social presence. Canadian Journal of Education. 2007;30:157-70.

5. Gunawardena, C. N., & Zittle, F. J. (1997) Social presence as a predictor of satisfaction within a computer-mediated con-ferencing environment. The American journal of Distance Education, 11(3), 8-26.

6. Rovai A, Ponton M, Wighhting M, Baker J. A comparative analysis of student motivation in traditional classroom and e-learning courses. International Journal on E-Learning. 2007; 6(3):413-32.

7. Garrison DR, Cleveland-Innes M. Facilitating cognitive presence in online learning interaction is not enough. Journal of Distance Education. 2005; 19:133-48.

8. Visser JA. Faculty work in developing and teaching Web-based distance courses: A case study of time and effort. The American Journal of Distance Education. 2000; 14:21-32.

9. Anderson T, Rourke L, Garrison DR, Archer W. Assessing teaching presence in a computer conference context. Journal of Asynchronous Learning Networks. 2001;5:1-17.

10. Conceicao-Runlee S, Reilly K. Experiences of faculty members who interact with students in an online environment. 1999 Oct. Paper presented at the Midwest Research to Practice Conference, University of Missouri-St. Louis.

11. Lewis CC, Abdul-Hamid H. Implementing effective online teaching practices: Voices of exemplary faculty. Innovative Higher Education. 2006; 31:83-98.

12. Coppola NW, Hiltz SR, Rotter, NG. Becoming a virtual professor: Pedagogical roles and asynchronous learning net-works. Journal of Management Information Systems. 2002;18:169-78.

13. Teaching College Courses Online vs Face-to-Face. Available from thejournal.com/Articles/2001/04/01/Teaching-College-Courses-Online-vs-FacetoFace. Accessed 2010 Feb 23.

14. Conceicao S. Faculty lived experiences in the online environ-ment. Adult Education Quarterly. 2006;57:26-45.



Continuing Education Questions

SUMMER 2010 To receive 1.0 contact hours of basic level P.A.C.E.® credit for the Focus: Educational Technology questions, insert your answers in the appropriate spots on the answer sheet that follows; then complete and mail the form as directed. 1. A key element of competency based education and

training is that it is: a. Organized based on the subject matter and

topics b. Focused toward specific teaching objectives c. Described as teacher and time oriented d. Structured for mastery of specific knowledge

and tasks

2. An example of a course module as part of CBET medical laboratory curriculum would be: a. Clinical Chemistry I b. Biochemical Diagnostic Testing c. Biochemical Pathology d. Introduction to Clinical Chemistry

3. The process of competency based education and training begins with: a. Generating lists of the lectures and lab exercises b. Clustering objectives with their tasks into

courses c. Performing functional analysis of occupational

roles d. Distributing the courses into semesters and

years 4. The medical laboratory curriculum in developing

countries needs to: a. Be connected with scope of practice b. Allow each individual to pace their own

instruction c. Provide for a few highly skilled graduates d. Focus on lectures and demonstration

laboratories

5. Technology that is commonly used in medical laboratory programs in developing countries include: a. Laptop computers for students in each lecture

classroom b. Presentation slides to illustrate principles of lab

techniques c. Electronic files to cut and paste information

into research papers d. Access to distance online education for

articulation programs 6. Identify the true statement regarding technology

uses in developing countries: a. More material should be covered with

computerized presentations than by oral lectures

b. Online references discourage critical thinking skills needed in manual literature searches

c. Computerized presentations usually take the place of interactive teaching strategies

d. Case studies and lecture notes can be shared with students on their flash drives

7. What is the primary mode of communication

between the instructor and learners in an online course? a. Email b. Video and computer conferencing c. Personal visits d. Course management system

8. Social presence is important in online education

because learners must: a. feel that they are part of a learning community b. participate in social events in their community c. get technical assistance when needed d. learn to communicate with the instructor



9. Which of the following strategies will motivate an online learner to actively participate in an online course? a. Offering stimulating classroom discussions b. Requiring discussion board as a part of the

student grade c. Providing a detailed syllabus with clear

instructions d. Offering weekly office hours

10. One reason that teaching a online course is more

time consuming than a face-to-face course is that an online course requires a. a slower pace b. covering more didactic information c. more graded exercises d. constant feedback and clarification to the

learners

11. Teaching online can be exciting because the instructor gets the opportunity to: a. work with new and emerging technologies b. work over the weekend c. keep in touch with the students constantly d. teach on public holidays

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