Residency & Fellowship Programs: CP Rotations

Special Hematology

General Hematology Goals and Objectives

Director: Dr. Alexander Kratz
Recommended rotation length: 4 weeks

Patient Care, Interpersonal and Communication Skills PGY1-2:

Review abnormal body fluid/peripheral blood smears from the Core laboratory. Review the clinical history and if necessary review the case with the cytology, hematopathology, and/or microbiology attendings/fellows and refer the patient sample to the appropriate laboratory for subsequent testing. Notify the clinician of the findings and report the findings of the smear as a ‘comment’ in the laboratory information system Webcis.

Patient Care, Interpersonal and Communication Skills PGY3-4:

Select a laboratory project of interest to complete during the rotation.  Examples of appropriate projects may include:  method validation of new instrument or assay, establishing reference ranges, reagent lot crossover, standard operating procedure development, or quality improvement project.

Review abnormal body fluid/peripheral blood smears from the Core laboratory. Review the clinical history and if necessary review the case with the cytology, hematopathology, and/or microbiology attendings/fellows and refer the patient sample to the appropriate laboratory for subsequent testing. Notify the clinician of the findings and report the findings of the smear as a ‘comment’ in the laboratory information system Webcis.

Medical Knowledge, Practice Based Learning and Improvement (same for all PGY levels)

  1. Automated Hematology
    1. Review the indications for peripheral blood cell enumeration and differential analysis
    2. Review the components of a complete blood count including red blood cell (RBC) indices and their derivation, identify spurious white blood count (WBC), RBC, Hgb, and platelet determinations and appropriate corrective action
    3. Review the absolute neutrophil count and its clinical utility, as well as problems associated with band counts
    4. Understand QC procedures
    5. Understand principles of automated and manual reticulocyte enumeration
    6. Interpret results of automated and manual cell counts, recommend appropriate steps for abnormal sample processing, analysis, and result reporting, review abnormal results and correlate results with peripheral blood smear findings and clinical history
  2. Peripheral Blood Smear Analysis
    1. Understand proper preparation and handling of peripheral blood smears, including standard stains and special stains used to identify cellular structures and inclusions
    2. Understand normal RBC, WBC, and platelet morphology and how to estimate WBC and platelet counts
    3. Recognize abnormal RBC, WBC, and platelet morphology; formulate a differential diagnosis; and suggest appropriate laboratory testing for follow-up
    4. Recognize technical artifacts in WBC, RBC, and platelet morphology
    5. Recognize infectious disorders that can be diagnosed by blood smear
    6. Recognize storage disorders and congenital disorders that have morphological manifestations in the peripheral blood smear
  3. Body fluid analysis: CSF, ascitic, pleural fluid, and joint fluid:
    1. Understand clinical indications for body fluid analysis
    2. Understand manual hemocytometer cell counting, understand cytocentrifuge sample preparation and slide staining, identify blood and body fluid cell morphology
    3. Interpret results of body fluid analyses in the appropriate clinical context
    4. Recognize malignant cells and recommend appropriate confirmatory tests, correlate abnormal body fluid cell morphology with cytology, flow cytometry, and other relevant diagnostic test results
    5. Identify body fluid crystals; distinguish between urate and calcium pyrophosphate crystals using polarized light
  4. Manual hematology methods:
    1. Understand principles of microhematocrit determination and its technical limitations
    2. Understand the principles of erythrocyte sedimentation rate
    3. Understand the principle and utility of supravital stains, including reticulocyte stain, Hgb H preparation, and Heinz body preparation
    4. Know the pathophysiology and characteristic laboratory findings of the major disorders causing normocytic, microcytic, and macrocytic anemia, describe iron metabolism and laboratory tests for iron depletion

Professionalism

  1. Attend all laboratory activities
  2. Reliably complete each assigned duty
  3. Complete work-up of each case
  4. Demonstrate dedication to patient care
  5. Maintain correct and cordial relationships with laboratory and clerical personnel, with attendings and with other fellows and residents

Systems Based Practice

  1. Participate in College of American Pathologists and New York state self-inspection
  2. Participate in the evaluation of quality control and proficiency testing
  3. Develop quality improvement and management plans
  4. Collect and interpret data for quality reports


Special Hematology and Coagulation
Goals and Objectives

Director: Dr, Richard O. Francis
Recommended rotation length: 4 weeks

Patient Care, Interpersonal and Communication Skills PGY1-2:

Review daily Hemoglobinopathy cases, look up patient information on all abnormal results, and meet with the lab director daily to discuss them. Familiarize yourself with the tests run in the lab, read the SOPs and packages inserts, and watch how the tests are run. Obtain answers to syllabus questions and go over them with the lab director. Prepare an in-service presentation for the technicians/supervisors.

Patient Care, Interpersonal and Communication Skills PGY3-4:

Review daily Hemoglobinopathy cases, look up patient information on all abnormal results, and meet with the lab director daily to discuss them. Provide consultation to clinicians on the work-up and interpretation of difficult hemoglobinopathy and coagulation cases.  Focus on unfinished areas of the syllabus and/or topics of interest from prior hematology rotation. Prepare an in-service presentation for the technicians/supervisors.

Select a laboratory project of interest to complete during the rotation.  Examples of appropriate projects may include:  method validation of new instrument or assay, establishing reference ranges, reagent lot crossover, standard operating procedure development, or quality improvement project.

Medical Knowledge, Practice Based Learning and Improvement Coagulation (same for all PGY levels)

  1. Problem Set 1: Primary Hemostasis
    1. Understand the role endothelium and subendothelial components play in maintaining normal blood flow and the formation of a clot with endothelial injury
    2. Understand the role of platelets in primary hemostasis including platelet subcellular structure, receptors, ligands, and also endothelial factors that are involved in primary hemostasis
    3. Draw a schematic diagram of the steps of primary hemostasis:  Adhesion, Activation, Aggregation
  2. Problem Set 2: Abnormal Hemostasis and Platelet Function Testing
    1. Observe a bleeding time test, Accumetrics VerifyNow P2Y12 and aspirin assay, and optical platelet function study being performed
    2. Review the bleeding time test and what can cause abnormal bleeding times
    3. Review platelet function studies and be able to draw the patterns and describe the clinical and laboratory characteristics of:
      1. Bernard-Soulier Disease
      2. Glanzmann’s thrombasthenia
      3. Storage Pool Disorders such as Hermansky-Pudlak syndrome,
      4.  Acquired platelet abnormalities such as:
        1. Drugs: aspirin, Plavix, and GPIIb/IIIa antagonists.
        2. Myelodysplastic syndromes
  3. Problem Set 3: Secondary Hemostasis and Basic Coagulation Screening
    1. Observe a PT and aPTT being performed on the automated instrument
    2. Understand the methods of clot detection in automated instruments
    3. Draw the intrinsic, extrinsic, and common pathway of coagulation
    4. Review how an aPTT reagent measures coagulation and what causes abnormalities in the aPTT
    5. Review how an PT reagent measures coagulation and what causes abnormalities in the PT
    6. Be able to derive the ISI and describe how an INR calculation is performed
  4. Problem Set 4: Factor Deficiencies
    1. Observe the steps of functional coagulation factor determination
    2. Review the algorithm for working up an isolated elevated PT and isolated elevated PTT
    3. Review mixing studies and their interpretation
    4. Describe the clinical and laboratory findings of hemophilia A, B, and C
  5. Problem Set 5: Factor VIII Inhibitors
    1. Observe and review a mixing study and Bethesda Assay
    2. Describe the clinical and laboratory findings of a factor VIII inhibitor
  6. Problem Set 6: Lupus Anticoagulants
    1. Observe and understand how a DRVVT, DRVVT-C, STAClot, Tissue Thromboplastin Inhibition time
    2. Review mixing studies
    3. List the criteria for diagnosing a lupus anticoagulant
    4. List the criteria for diagnosing the antiphospholipid antibody syndrome
    5. Describe the clinical consequences of having and antiphospholipid antibody.
  7. Problem Set 7: von Willebrand Disease
    1. Observe a von Willebrand Antigen and Ristocetin cofactor assay, Ristocetin aggregation
    2. Review the PFA-100, Cone-Plate Analyzer, and other novel von Willebrand Disease screening tests
    3. Review how von Willebrand multimers are performed
    4. Review the algorithm for working up an isolated elevated PTT in a patient with a bleeding history
    5. Understand the laboratory and clinical presentation of the various types of von Willebrand disease (type I, IIA, IIB, III) and how vWD is treated
  8. Problem Set 8: Thrombophilias
    1. Observe Factor VIII, protein C, protein S, lupus anticoagulant, and antithrombin assays
    2. Observe Factor V Leiden, MTHFR, and Prothrombin G20210(genetic tests performed in molecular pathology)
    3. Review the activated protein C resistance functional assay
    4. Review the laboratory findings and clinical presentation of acquired and inherited thromobphilias (e.g. PC, PS, AT Deficiency)
    5. Review the laboratory assessment of arterial thrombosis and stroke in a young patient
  9. Problem Set 9: Heparin
    1. Observe heparin and LMWH anti-Xa assays
    2. Review heparin and LMWH therapy:  structure, mechanism of action, pharmacokinetics, dosage, reversal
    3. Review heparin resistance and assays to test for it
  10. Problem Set 10: Heparin Induced Thrombocytopenia and Novel Anticoagulants
    1. Review pathophysiology of HIT
    2. Describe the 4 T’s for diagnosing HIT
    3. Know how the HITPF4 assay is performed and its sensitivity and specificity for HIT
    4. Know how the serotonin release assay is performed and the sensitivity and specificity of the test

Special Hematology (same for all PGY levels)

  1. Week One:
    1. Review hemoglobin biochemistry, physiology, and genetics
    2. Become familiar with laboratory techniques for hemoglobinopathy diagnosis
      1. HPLC
      2. Electrophoresis
      3. Isoelectric Focusing
      4. Capillary Zone electrophoresis
      5. Sickle Solubility
      6. Molecular testing:  gap PCR, ARMS, dot blot, reverse dot blot, RFLP, etc.
    3. Review the Thalassemias
      1. Alpha thalassemia trait, hemoglobin H disease, hemoglobin Bart’s
      2. Beta thalassemia trait, Beta thalassemia intermedia, beta thalassemia major
      3. Delta-beta thalassemia and gamma, delta beta thalassemias
    4. Review Sickle Trait and Sickle Cell Disease
    5. Review Structural hemoglobin variants (S, G, D, E, O, etc)
  2. Week Two:
    1. Review Structural hemoglobin variants that are also thalassemic
    2. Understand how structural variants interact with alpha and beta thalassemias
  3. Week Three - Four:
    1. Review intrinsic and extrinsic red cell defects: G6PD, pyruvate kinase deficiency, paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis/elliptocytosis
    2. Review the osmotic fragility test, the Ham test, and CD55/59

Professionalism

  1. Attend all laboratory activities
  2. Reliably complete each assigned duty
  3. Complete work-up of each case
  4. Demonstrate dedication to patient care
  5. Maintain correct and cordial relationships with laboratory and clerical personnel, with attendings and with other fellows and residents

Systems Based Practice

  1. Participate in College of American Pathologists and New York state self-inspection
  2. Participate in the evaluation of quality control and proficiency testing
  3. Develop quality improvement and management plans
  4. Collect and interpret data for quality reports

 

 
 
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