ASCLS Today

ASCLSToday Masthead 680

Volume 32, Number 4

Strengthening ASCLS Constituent Societies Through Mentorship

Deb Rodahl, MBA, MLS(ASCP)CM, ASCLS President

In my president’s acceptance speech, I noted that I plan to focus my efforts on areas that have been identified as a need in our organization; Leadership Development, Mentorship, Communication, and Professional Involvement. It is time to cover where we are at with Mentorship in ASCLS. 

Last year we recognized the need to provide mentorship support for new leaders in ASCLS. One step toward this goal was to formalize the Mentorship Task Force conversion to a full-fledged committee in ASCLS. This conversion comes with an intent to expand their scope from providing mentorship for new professionals in ASCLS to providing mentorship to any member who seeks support for an ASCLS leadership role they have either taken on or would like to take on. This could be at the constituent society, regional, or national levels. As we mentor new employees in our work environment, we should also be providing support for ASCLS members who want to undertake a new role in our organization. As of this writing, the Mentorship Committee has been appointed and they have begun the work of creating the needed structure and processes for the expanded mentorship scope. Additionally, they are exploring the use of software that would make this process less cumbersome. 

On a different but similar note, I appointed a Leadership Academy Curriculum Task Force last fall. The ASCLS Leadership Academy was originally charged with building future leaders for ASCLS with a specific goal of reaching out to areas of our society where we are struggling to maintain active societies (underserved areas). We have found that as the Leadership Academy evolved at the national level, two things have become apparent. 

  1. Healthy constituent societies were supporting members who were interested in the program and the struggling societies did not have the resources to support their member participation, so underserved areas have remained “underserved.” 
  2. At the same time, many of the healthier societies or regions came together to create local Leadership Academies with a resultant decline in interest for the National Leadership Academy. 

The task force has been charged to sort through this dilemma including redefining the purpose of our leadership academies. It is my desire that we remain true to the original goal of strengthening our constituent societies to develop future leaders in ASCLS, but how we do this could look different in the future. To that end, we are putting the national Leadership Academy on pause for a year to allow the Leadership Academy Committee an opportunity to work with the task force on this project and to help get us to a future state on a shorter timeline.

A third spoke in this conversation is the need for clarity at the national level for how our Leadership Development Committee, Leadership Academy Committee, and now the Mentorship Committee intersect with their work. They have similar goals, which are to develop and support leaders within ASCLS. Work needs to occur to sort this out to ensure a clear line of vision for the Goals and Strategies of each of these committees.

I wish I had more success or progress to share around my goal to increase mentorship in ASCLS. As it turns out mentorship is interwoven in many of our ASCLS initiatives for which we have started pulling on a thread that connects to a much larger area of focus. It is important to take the time to sort through these challenges and develop a comprehensive plan that will lead ASCLS into our future vision.

 

Embracing Technology to Gain Time at the Regional Level

Kim Von Ahsen, MHA, MLS(ASCP)CM, SLSCM, Region VI Director

It doesn’t take a scientist to figure out that the demand for one’s time is probably the greatest pressure in today’s society. Pressure to work more due to shortages in the workforce, pressure to be with loved ones who have milestones we don’t want to miss, and pressure to be caring to one’s mental and physical health. It’s really a testament to the greatness of our ASCLS volunteers when you give us a bit of this finite, precious time to our profession and it made me think “How can I make sure that the time is best used for our ASCLS Region VI Council Members?” In our laboratory processes, we are continuously challenged to look at how to streamline and standardize; why should we not look at our volunteer positions and apply the same theories? Are there positions or functions that could be optimized and efficiencies gained by using technology? For Region VI, we found there were two areas that took a significant amount of time 1) Meeting Agenda and Minutes and 2) Treasurer Reports.

Creating an agenda takes time, not including the distribution of the agenda, related meeting minutes, and public posting/access for members of the meeting, all of which can be a consuming and tedious task. A search was done to look for free technology that could make the Region Secretary’s responsibilities easier for our Region Council Meetings.

We chose the free online product called My Committee and trialed it starting with the 2015-2016 term. My Committee has a free version that allows for one committee and limited storage but this free version has been more than adequate in handling our meetings and council size. My Committee allows you to create and share meeting agendas electronically through the click of a button. It captures minutes and status of action items including committee review of minutes, all while providing members with a central location to collaborate and stay connected between meetings. Also, minutes can be made public and allow for sharing with all members and non-members through a website link which eliminates the need to upload your minutes to another repository. View our public minutes. Meeting minutes are now available same day or next day to attendees.

After the success of using My Committee, the next position evaluated to determine if technology could enhance and save time was the Region VI Treasurer. The Treasurer is a position for which it is often hard to recruit volunteers because of the belief that it takes a large amount of time and can be difficult to do. Many believe you need to be a great accountant to be successful when sometimes you just need some good technology. Wave  is a small business accounting software that connects to your bank account and allows you to sync your income, expenses, and balance your financial books. The reporting feature eliminates the need for excel spreadsheets or other manual reporting as once transactions are reviewed and categorized, all information is easily captured in the multiple reports available through the software.

Technology tends to be a bad word in relation to the best use of one’s time – social media, TV, and archaic laboratory equipment; however, a well-chosen technology can actually add back time by eliminating unnecessary work. Most importantly, technology wasn’t added to the Region VI Council to replace our wonderful volunteers, rather it was to allow them time to do their best work. Time is best spent building professional networks, addressing our workforce needs, and ensuring safety and quality services through leadership.

Membership Changes Encourage Long Term Membership

In March, the ASCLS Board of Directors approved changes to the Society’s membership dues, which is part of a multiyear effort to modernize and simplify ASCLS membership structures. These changes will be in effect for the coming Society year and will be reflected in the upcoming renewals for 2018-2019 ASCLS membership.

Single regular Professional Category and Dues Reduction: By a three to one margin, most professional members choose to be Professional I members. The Professional II category was created several years ago, when ASCLS was still printing and mailing its journal, to allow members to forgo delivery of the journal. With a completely online journal, the Society no longer enjoys those savings from smaller print runs. There is now a single Professional category. By combining the two, renewing Professional I members will see a slight decrease in annual dues to $96. 

Moving forward, all members will have access to the Clinical Laboratory Science journal, which is now on a new platform, indexed and integrated with the rest of the healthcare community, using a platform developed at Stanford University and utilized by hundreds of other organizations including the American Academy of Pediatrics, American Heart Association, and the British Medical Journal. 

Extending Memberships for New Professionals to Five Years: ASCLS has typically seen poor retention of First Year Professionals as they move from lower dues rates to paying full Professional dues. New professionals will now be eligible to pay the lower dues rate for up to five years, provided they maintain their membership during that time.
Rewarding Renewing Members: Joining ASCLS will now carry a slightly increased price tag, but renewing members will see their dues lowered. Organizations regularly offer promotional dues rates to encourage new members to join, but the members who are most loyal rarely see those benefits personally. ASCLS will now reward membership loyalty by providing lower dues for renewing members than those joining for the first time. Professional membership is reduced from $99 to $96 per year for those renewing their membership, but increased to $108 for those joining. The cost to join is pro-rated throughout the year. Renewing New Professionals and Collaborative members will see similar savings.

Refining Collaborative Member Benefits: Previously, Collaborative membership was open to anyone with a membership in another organization. Ensuring continuing membership in another organization is nearly impossible to efficiently accomplish. With these recent changes by the Board, Collaborative membership is now open to anyone, but the benefits have been narrowed to align with the lower dues paid by these members. Collaborative members will no longer be eligible for registration discounts at the Annual Meeting and the Clinical Laboratory Educators’ Conference. Less than 300 members (out of nearly 9,000) utilize this membership category.

New Sustaining Membership: Many of ASCLS’s most loyal and engaged members have approached the leadership about finding ways to provide more resources to support the Society’s mission. A new Sustaining Membership can be added to any other membership for $100 each year, and carries with it some new perks that will help these dedicated members stand out for the profession.

Emeritus Member Eligibility: Previously, Emeritus Members were required to be retired from “gainful employment.” However, many of our members continue to be involved in the profession (some continuing to work in a variety of capacities) while otherwise being eligible for reduced dues. To allow our most loyal, long-term members to take advantage of these benefits, the Board has changed the eligibility requirement, adopting a suggestion from the House of Delegates meeting in 2017. Moving forward, eligibility is based on the simple calculation of the sum of the member’s age and years of continuous membership equaling at least 90. This does not affect previously enrolled Emeritus Members.

In addition to these policy changes made by the Board of Directors, the House of Delegates will be considering a number of bylaws changes to reinforce this streamlining process. Those changes are detailed here.

 

Meet the Candidates 2018

The ASCLS Nominations Committee is pleased to present the following candidates for office in the 2018-2019 Society year. Candidates selected by the House of Delegates will take office at the 2018 ASCLS Annual Meeting in Chicago, Illinois.

Member Since 1989

EDUCATION
BA, Medical Technology, College of St. Scholastica
MS, Clinical Laboratory Science, University of North Dakota

CERTIFICATION
MLS(ASCP)CM
 

EMPLOYMENT
Director, Laboratory Services, CentraCare Health, St. Cloud, MN

SOCIETY PARTICIPATION

STATE
2012-2017 – Participant; Speaker; Committee Member: MN Clinical Laboratory Collaborative
2012-2017 – Delegate to HOD 

REGIONAL
2013, 2014, 2015 – Participant and Speaker, ASCLS Region V Meetings
2017 – Speaker, ASLCS-ND State Meeting

NATIONAL
2012-2013 – Vice Chair, Chair Government Affairs Committee
2013-2016 – Committee Member, Advanced Management Institute
2014-2015 – Speaker and Participant, Advance Management Institute
2012, 2017 – Speaker, ASCLS Annual Meeting
2012 – Task Force Member, Direct Access Testing
2015-2016 – Committee Member, ASCLS Executive Vice President Search Committee
2013-2018 – Secretary/Treasurer, ASCLS Board of Directors

STATEMENT OF PHILOSOPHY:
The field of laboratory medicine has been a rewarding profession for me for over thirty-five years. I have had the opportunity to work with many dedicated laboratory professionals who have taught me valuable lessons. Whether we are in our healthcare facilities or on Capitol Hill, it is vital that we share our vision and mission to enhance patient safety and provide the best possible information in the diagnosis and treatment of disease and the promotion of wellness.

Through the networking opportunities offered as a member of ASCLS, the dedication of my colleagues has inspired me to expand my horizons in promotion of the profession. When I think of leaving a professional legacy, I want to know that I have continued to strive for excellence and was able to mentor other colleagues as I was.

As a leader in the laboratory for the past twenty-five years, I have the skills required to assure that we maintain a strong commitment to the laboratory professional. It has been an honor and privilege to be on the ASCLS Board of Directors as the current Secretary/Treasurer. My desire to serve as president-elect would allow me to fulfill my passion of shaping the future of our professional organization.

Member Since 2002

EDUCATION
BS, Medical Technology, Bowling Green State University
MS, Allied Medicine, The Ohio State University
MA & PhD, Education, Policy, and Leadership, The Ohio State University

CERTIFICATION
MT(ASCP)

EMPLOYMENT
Senior Executive Associate Dean, University of Alabama at Birmingham, Birmingham, AL

SOCIETY PARTICIPATION

STATE
2012- 2015 – President, ASCLS-Alabama
2012-2014 – Delegate to House of Delegates

REGIONAL
2015-2018 – Director, Region III
2016 – Meeting Chair, Region III Triennial Meeting

NATIONAL
2013-2014 – Vice Chair, Leadership Development Committee

STATEMENT OF PHILOSOPHY:
As a member of ASCLS for 15 years and a medical laboratory science educator for 15 years, I have always been deeply committed to, and a strong advocate of, ASCLS and our profession. My leadership philosophy is that leadership is a choice. A choice to inspire highly educated, diverse, and autonomous professionals to innovatively and cooperatively achieve a shared vision. The success of this philosophy relies heavily on trust, teamwork, open communication, regular dialogue, and input from all constituents within an organization. The major leadership contribution I would like to make to ASCLS is to build a pipeline of leadership talent within the region with capacity and values in place to succeed beyond my tenure as a director.

As a Region III candidate, I aim to:

  1. Communicate the goals of ASCLS and facilitate alignment of the ASCLS goals to all states within the region.
  2. Facilitate the documentation of succession planning in every state to assure thoughtful and purposeful action toward the development of a future leadership pipeline in the region
  3. Guide states within Region III in the preparation and planning of Annual Meetings and/or other events.

Member Since 2004

EDUCATION
BS, Medical Technology,
Northern Kentucky University
MS, Technology Management,
Northern Kentucky University

CERTIFICATION
MLS(ASCP)CM

EMPLOYMENT
Faculty, University of Cincinnati, Cincinnati, OH

SOCIETY PARTICIPATION

STATE
2012- 2016 – Vice President, President, Kentucky Society for Clinical Lab Science
2012- Present – State Meeting Committee Member
2013, 2015, 2016 – Delegate to House of Delegates

REGIONAL
2012-Present – Region Board of Directors

NATIONAL
2017-Present – Director, Board of Directors
2013-2017 – Coordinator ASCLS Scientific Assembly
2017-2018 – Chair, New Board Orientation Committee
2012-Present – Co-Editor, Editor, Reviewer, ASCLS Clinical Lab Investigations
2012-Present – Member, Chair, Promotion of the Profession Committee
2013,2015,2016 – Sergeant of Arms, ASCLS Annual Meeting

STATEMENT OF PHILOSOPHY:
This past year, I have had the opportunity to serve as Region IV Director to complete an open term. I have been involved with ASCLS since 2001, and have served in various state and national roles, and feel I could encourage and mentor others in the society through the role of Region Director. My membership in ASCLS allows me to learn best practices in the field, gain leadership skills, and work with a diverse group of likeminded individuals. If I am appointed as Region Director, I would be sharing what I have gained from the organization and would be in a position to help develop new leaders, excite new members, facilitate the participation of current members, and mentor others into this network of colleagues and friends. Increasing membership as well as retaining our long-term members are vital for the Society and would continue to be a personal goal in the position. I believe in the profession and in being an advocate for the role of the laboratorian in healthcare. It would be an honor to serve the ASCLS membership as a member of the Board of Directors.

 

Member Since 1980

EDUCATION
Medical Laboratory Assistant, St. Paul College
BA, Biology, Hamline University
Medical Technology, St. Paul Ramsey Medical Center

CERTIFICATION
MLS(ASCP)CM

EMPLOYMENT
Instructional Designer/Research Assistant, University of Minnesota, Minneapolis, MN

SOCIETY PARTICIPATION

STATE
2013-Present – MN State Clinical Laboratory Collaborative Meeting
2013-2017 – Member, ASCLS-MN Finical Audit Committee
2012-2014 – Delegate to House of Delegates

REGIONAL
2013-2015 – Chair, Region V Leadership Academy Committee
2016-2017 – Presenter, Region V Leadership Academy Retreat

NATIONAL
2013 – Chair, CEAC Committee
2014-2015 – Chair/Past Chair, Annual Meeting Steering Committee
2016-Present – Vice Chair, Lab Admin/Consult/QA/Accreditation/Industry Scientific Assembly
2017-Present – Member, P.A.C.E. Committee
2017-Present – Member, Leadership Academy Task Force

STATEMENT OF PHILOSOPHY:
I believe that if you are invested in your career, you need to belong to an organization that is rooted in peer leadership. And if you want to help that organization move forward you must be active and involved. I have been an active member of ASCLS for over 35 years, serving on several committees and holding a variety of leadership positions. If I am elected to the position of Region V Director, I will work with the state leaders to recruit and retain membership, promote mentoring, and work with the Leadership Academy to increase the number of candidates from all the states to give them the skills for future leadership opportunities. In addition, I will focus on maintaining two-way communication between the Board of Directors and our membership. This is because it is not only important for our members to understand issues affecting their laboratories, but it is also important for their concerns and issues to be heard by the Board.

Working side by side with the other Board members to promote the laboratory profession, and to focus on its concerns and issues, would be an honor.

Member Since 2004

EDUCATION
A.A.S, Medical Laboratory Technology, Des Moines Area Community College
B.L.S., Liberal Science, Iowa State University
M.H.A, Health Care Administration, University
of Phoenix

CERTIFICATION
MLS(ASCP)CMSLSCM

EMPLOYMENT
Manager of Client Services, Clinical Laboratory, UnityPoint Health – Des Moines, Iowa

SOCIETY PARTICIPATION

STATE
2012- Present – P.A.C.E. Coordinator
2012- Present – Chair, Website
2012-2017 – Delegate to House of Delegates

REGIONAL
2012-2014 – Secretary, Region VI

NATIONAL
2012-2013 – Member, CLMA-ASCLS Regional Taskforce
2013-2014 – Vice Chair, Leadership Academy Committee
2014-2015 – Chair and Facilitator, Leadership Academy Committee
2015-2018 – Member, Board of Directors
2016-2017 – Member, Finance Committee
2016-2017 – Chair, Policy and Procedure Committee
2017-2018 – Member, Executive Committee
2017-2018 – Chair, New Board Orientation Committee

STATEMENT OF PHILOSOPHY:
Pablo Picasso said, “Action is the foundational key to all success”.

For ASCLS to continue to be the successful professional society for clinical laboratory professionals, we must continue with our actions to advocate for our profession, to build our membership, to meet the needs of all our members, and to set forth the laboratory standards that ensure the highest quality professionals and safety for the patients we serve. I firmly believe that ASCLS has enabled me to grow into the laboratory leader I am today. It has been through my involvement at the state, regional, and national levels that I not only recognized but fully understood my duty to be an advocate for the clinical laboratory profession. This advocacy begins with me placing into action and service as the Region VI Director. I’ve had the great privilege to serve on the ASCLS Board of Directors and desire to continue to lead, mentor, and be a liaison to and for the state societies within Region VI along with representing the members of ASCLS on the national level for a second term. I’m honored to have the opportunity to serve our profession as the Director for Region VI.

Member Since 1982

EDUCATION
PhD, Adult Education, Texas A&M University
MS, Environmental Science, West Virginia University College of Graduate Studies
BS, Medical Technology, West Virginia University

CERTIFICATION
MLS(ASCP)CMBBCM

EMPLOYMENT
Professor Emeritus, University of Texas Health, San Antonio, TX

SOCIETY PARTICIPATION

STATE
2015-2016 – Texas Association for Clinical Laboratory Science (TACLS) annual meeting – co-chair
2015 – Alternate Delegate to HOD

REGIONAL
2007-2011 – Director Region VII

NATIONAL
2011-2012 – ASCLS President-Elect
2011-2013 – ASCLS President
2013-2014 – ASCLS Past-President
2012-Present – Member, Consumer Response Team
2014-2015 – Chair, Body of Knowledge Task Force
2015-2017 – Discipline Leader, ASCLS Entry Level Curriculum Task Force
2015-Present – Trustee, Education & Research Fund
2016-2017 – Member, Root Cause Analysis Task Force

STATEMENT OF PHILOSOPHY:
The ASCLS Judicial Committee not only oversees activities related to by-laws and elections, but also serves as a “court of final say” regarding just and ethical activities of members and the organization. Having previously served on the ASCLS Board and as President, as well as serving in similar capacities for other professional organizations, I believe I have a broad understanding of the issues that might affect ASCLS and its members. In addition, my academic experience and service at all levels within ASCLS have helped me develop the objectivity and capability to impartially interpret and evaluate the many aspects involved in an issue brought before this committee. I would be honored to serve ASCLS as a member of this committee.

Member Since 2007

EDUCATION
PhD, Health Science, Rush University
MS, Clinical Lab Science, Rush University
BS, investigative & Medical Science, Saint Louis University

CERTIFICATION
MLS(ASCP)CM

EMPLOYMENT
Assistant Director of Clinical Microbiology and Assistant Professor, Rush University Medical Center, Chicago, IL

SOCIETY PARTICIPATION

STATE
2012-Present – Board Member, President, President Elect, Past President CSCLS
2012-Present – Board Member, President, President Elect, Secretary ASCLS-IA
2016-Present – Vice Chair, Chair ASCLS-IL Annual Meeting Hospitality Committee
2012, 2014, 2017 – Delegate to House of Delegates

NATIONAL
2014-Present – ASCLS Appointed Member to CLSI

STATEMENT OF PHILOSOPHY:
I am grateful for the opportunity to be considered as a member for the ASCLS Nominations Committee. The role of this committee is probably one of the most difficult for ASCLS-presenting a slate of candidates for members to vote for elected officers who will occupy leadership positions within the society. As a person who has invested in ASCLS, and who has seen the society’s investment in me, I am excited for this opportunity. My goals for this position would be to identify reasons as to why more members of ASCLS are not interested in pursuing leadership positions across all levels of the organization, and then develop tools to help embers succeed.

Member Since 2002

EDUCATION
BS, Microbiology Mississippi University for Women
BS, Medical Technology, University of Tennessee Health Science Center, Memphis
MS, Clinical Lab Science, University of Tennessee Health Science Center, Memphis

CERTIFICATION
MLS(ASCP)CM

EMPLOYMENT
Evening Shift Supervisor, Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN

SOCIETY PARTICIPATION

STATE
2017-2018 – Chair, ASCLS-TN Nominations Committee
2017-2018 – Chair, Exhibit Committee, Tennessee’s Annual Laboratory Conference
2015-2016 – Chair, Nominations Committee, ASCLS-TN
2014-2015 – Past-President, ASCLS-TN
2013-2014 – President, ASCLS-TN
2013-2014 – Co-Chair, Planning Committee, Tennessee’s Annual Laboratory Conference
2012-2017 – Delegate to House of Delegates

REGIONAL
2012-2014 – Member, Region III Council

NATIONAL
2015-Present – Member, Nominations Committee
2013-Present – Member, Leadership Academy Committee
2015-2016 – Primary Instructor, Leadership Academy
2014-2016 – Chair and Vice Chair, Leadership Academy
2013-2014 – Trustee Education & Research Fund

STATEMENT OF PHILOSOPHY:
I believe that the survival of ASCLS in the very immediate present and future is 100% dependent on its ability as an organization to be attractive to members, new and old alike. Membership numbers are still troubling, and the direct cause is our leadership. We do not have poor leadership by any means, but we have extremely overworked and overcommitted leadership that cannot realistically manage the sheer volume of duties that are required to run the organization at the level of excellence it deserves. One of the first steps to finding a solution that will work for ASCLS is finding the leaders that will acknowledge the challenges we face and still have the passion, desire, ideas, and the courage (and time!) to stick with their ideas long enough to see them through. We need leaders that can bring strength to the organization and revitalize our membership. I feel the members serving on the nominations committee play a very important role in finding those leaders, and I would be honored to serve ASCLS in that capacity.
Working side by side with the other Board members to promote the laboratory profession, and to focus on its concerns and issues, would be an honor.

A Case of Blue-Green Neutrophil Inclusions

S. Renee Hodgkins, PhD, MT(ASCP); Jennifer Jones, MLS(ASCP)CM

A 43-year-old female presented with syncope one day after routine umbilical hernia repair surgery. A CT scan revealed an abdominal wall hematoma. The patient rapidly progressed to multi-organ failure requiring continuous renal replacement therapy for acute kidney injury. Two days post-surgery, she was transferred to a large medical center. She arrived intubated with mechanical ventilation for acute hypoxic respiratory failure and symptoms of hemorrhagic shock and liver failure. The patient’s past medical history is significant for congenital heart disease, ventricular septal defect repair, and obesity. 

Lactic acid, troponin-I, and procalcitonin were elevated upon admission to the medical center. Liver enzymes were markedly elevated and renal function was severely impaired. CBC showed an elevated WBC count with a left shift and normocytic anemia. Evaluation of the peripheral smear demonstrated blue-green inclusions in the neutrophils and monocytes. These findings were acknowledged but not reported on the patient chart. 

Due to the severity of the multi-organ failure, the patient’s family chose to discontinue medical treatment, and the patient died shortly after discontinuation of care, approximately three days post elective surgery. 

Blue-green inclusions in the neutrophil have been reported in association with hepatic failure and have earned the coined term, “death crystals,” as most patients with these inclusions decline rapidly and death is imminent. Discussions have been ongoing about the importance of reporting these inclusions. 

The blue-green inclusions were originally thought to represent hepatic injury. Recently, they have been found in cases with tissue injury but with no evidence of hepatic injury or elevated liver enzymes. In these few cases, there has been an elevation in LDH suggesting some level of tissue damage.1 Because of the hepatic injury association, the nature of these crystals was thought to be a “blood-borne bile product” in circulation.2 However, more recent studies have shown them to be bile (Fouchet) stain negative.3 These inclusions have shown to contain high lipid content using Oil Red O and transmission electron microscopy.3 These inclusions have also been found to be acid-fast (long Ziehl-Neelsen method) by Hodgson et al. Similarities between these crystals and the composition of sea-blue histocytes have been noted further suggesting the association of these crystals with tissue injury.3 These inclusions are thought to contain lipofuscin-like deposits representing lysosomal degradation products that have been phagocytosed by neutrophils and monocytes because of their staining, lipid content and acid fast nature.3 The inclusions are more often found in neutrophils than in the monocytes, possibly due to the phagocytic efficiency of neutrophils in circulation.3 

Another interesting predictor of survival for a patient with blue-green inclusions in the neutrophils and monocytes is the severity of lactic acidosis at the time of discovery. The patient in our case study was thought to have aspirated while under anesthesia during her elective surgery leading to the question of whether the lactic acidosis was due to lung injury. This is supported by her initial arterial blood gas results while on mechanical ventilation and 100% oxygen: 7.31/29/82/15.9 (pH 7.35-7.45, pCO2 35-45 mmHg, pO2 80-100 mmHg, HCO3 21-28 mmol/L). Additionally, her blood gas lactic acid was 9.7 mmol/l (reference range 0.5-2.0). Hodgson et al suggest that arterial lactic acid may be a stronger predictor of survival than liver enzymes when blue-green inclusions are detected noting that those with severe lactic acidosis were more commonly associated with death. The patient in this case demonstrated blood gas lactic acid values as high as 12.9 mmol/L (Table 1) which is consistent with the reported association between arterial lactic acid >5.0 mmol/L and increased likelihood of demise.3 

When reviewing cases presented in the literature, most patients with blue-green inclusions had varying degrees of hepatic injury indicated by the liver enzymes.1-6 While not all patients with blue-green inclusions were found to have hepatic injury, the association of the inclusions with hepatic injury may be a direct result of failure to report the inclusions when seen. A recent study at the University of Rochester instituted an “increased awareness” campaign that lead to an increase in detection of the blue-green inclusions, although still overall a rare finding at approximately 1 per month.6 This increase in detection revealed cases that did not have a direct relationship with liver injury including metastatic cancer and sepsis; however, all of the patients had mild to severe elevations in liver enzymes.6 Unfortunately in this study, arterial lactic acid was not a reported laboratory value. 

The appearance of these blue-green inclusions in the neutrophils and monocytes and the association with a high mortality rate give credence to the importance of reporting these inclusions particularly in the context of elevated liver enzymes and lactic acidosis. Further study of these blue-green inclusions is necessary to evaluate the nature of their appearance and the outcome for the patient.

Figure 1

Table 1

Date
(time)

WBC
4.5-11 x103/µL

PLT
150-144 x103/µL
AST
7-40 U/L
ALT
7-56 U/L
Lactic Acid
0.5-2.0 MMOL/L
Procalcitonin
0.0-0.5 NG/ML
BUN
7-25 MG/DL
Creatine
0.4-1.00 MG/DL

11/16
1500

23.3 93     9.7 5.07 51 4.56
1525 22.1 91            
1813         12.4      
1908 15.0 75     11.9      
2105 16.5 72 3648 3147 8.9   54 4.93
11/17
0110
15.6 69     12.2      
0335 21.1 81 4979 3459 12.9   45 4.28
0830 24.5 70     12.5   36 3.46

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

  1. Courville, E., S. Crisman, M. Linden and S. Yohe. Green neutrophilic inclusions are frequently associated with liver injury and may portend short term mortality in critically ill patients. 2017. Laboratory Medicine. 48:1:18-23. DOI: 10.1093/labmed/lmw064
  2. Harris, V., J. Malysz, and M. Smith. Green neutrophilic inclusions in liver disease. 2009. Journal of Clinical Pathology. 62:853-854. doi:10.1136/jcp.2009.064766
  3. Hodgson, T., A. Ruskova, C. Shugg, et al. Green neutrophil and monocyte inclusions – time to acknowledge and report. 2015. British Journal of Haematology. 170:229-235. doi: 10.1111/bjh.13434
  4. Haberichter, K. and D. Crisan. Green neutrophilic inclusions and acute hepatic failure: clinical significance and brief review of the literature. 2017. Annals of Clinical & Laboratory Science. 47:1. 
  5. Jazaerly, T. and A. Gabali. Green neutrophilic inclusions could be a sign of impending death! 2014. Blood. 123:614. doi:10.1182/blood-2013-10-535856
  6. Patel, N., C. Hoffman, B. Goldman, et al. Green inclusions in neutrophils and monocytes are an indicator of acute liver injury and high mortality. 2017. Acta Haematologica. 138:85-90. DOI: 10.1159/000477794