Volume 55 Number 2 August 2001 ISSN 117.1-0195

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Mangement System;"'. ~~i~~~...... proving to be a Wha 8

ISO 17025 of a Job? ISO 9001 -2000 ISO 14001 as 9ooo AS/NZS 4804 Health Standards

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Q-Pulse is a PC application for controlling and adding value to management systems. Including ISO 17025, 9001, 2000, 14001 , QS 9000 AS/NZ4804 and Health Standards Eleven modules addressing customers, suppliers, employees, equipment, problems, audit, and documents provides a mechanism for managing your system. Designed as a practical tool which people can relate to, Q-Pulse enables com panies to achieve, maintain and demonstrate compliance to formal standards, cost effectively, by minimising paperwork and administration overload, at the same time providing a mechanism to encourage ownership of the management system and more importantly proving a cultural shift to continual improvement. User Benefits include * Total control solution for Quality System management. All necessary control actions are "flagged" to the user. * Frees up executive time and thereby saves money, enabling "problem solving" by managers and not just "problem reporting". * Provides objective evidence of compliance to auditors and assessment bodies. * Comprehensive Messaging capability, fully e-mail compatible. * Transforms the burden of bureaucratic record keeping to provide invaluable management information. • An intuitive product - easy to use, requires no computer knowledge to maintain. • Highlights areas requiring attention: acts as an early warning system and helps prevent costly failure. • Compatible with all standard PC networks. • Controlled documents available using your Intranet. , * Global solution, over 4,000 worldwide user sites in 50 countries. * Available for (WAN) Thick server and (LAN) Thin server. For a FREE Q-Pulse demo CD, evaluation copy or on site presentation fax this sheet with your details to: ( 09) 478 9895 Name ...... Company...... Tei...... Demo J Evai.J OnSite.J Yes J No --/\ EEl Ltd Tel (09) 478 9800 EMail [email protected] Or Visit our Website www.gaelquality.com Editor Rob Siebers, Wellington New Zealand Journa l of

Editorial Board Ross Anderson, Auckla nd Medical Sue Dunca n, Welli ngton Ca rol Green, Lower Hutt Laboratory Geoff Herd, W hanga rei Roge r Linton, Christchurch Steve Soufflot, Hamilton Science John Sterling, Adelaide Volume 55 Number 2 Ann Thornton, Wel lington August 2001 Fran van Til, Rangiora ISSN 1171 - 0195 Trevor Walmsley, Christchurch Tony Woods, Adelaide

Statistical Adviser Gordon Purdie, Wel li ngton

All ed itorial matter including submitted papers, press releas­ es and books for review should be sent to the Editor: Rob Siebers, Dept. of Medicine, Wellington School of Medicine, PO Box 7343, Welli ngton So uth. Ph one: (04) 385 5999 Ext. 6838. FAX: (04) 389 5725. E- mail : [email protected]. nz. Comprehensive instruc­ tions for authors ca n be found in the N Z J Med Lab Science 2000; 54(3): 108- 10 or on the website (www.nzimls. org. nz). Leading Articl e Submit two copies of the manuscript (and on disk if poss ible) together w ith a covering letter from the corresponding author Asthma in medical laboratory workers stat ing that the w ork is original, is not under consideration for Susan M Tarlo ...... 34-3 5 publication elsewhere, that all listed authors have co ntributed directly to t he planning, execution, analysis or to the w riting of Fellowship Treatises t he paper, and t hat all cited references have been checked Di entamoeba fragilis. A revi ew of a co mmonly detected yet against t he ori gina l article or appropriate data bases. poorly understood parasite of man Contributors and advertisers are responsible for the scientific Graeme Paltridge ...... 36-41 content and views. The opinions expressed in the Journal are not necessarily those of the Editor or Council of the NZIMLS An eva luation and comparison between blood film The New Zealand Journal of Medical Laboratory Science is the microscopy services in government hospital laboratories in official publication of the New Zea land Institute of Medical Laboratory Science (NZIMLS) who owns the copyright. No parts the Mid-Western region of Nepal and the Waikato region in of this publication may be reproduced in anyway without the New Zea land written permission of the NZIMLS. The Journal is published three times per year in April, August and November, printing by Vanessa C J Thomson ...... 42-55 Centurion Print, PO Box 6344, Wellesley St., Auckland. Letters to the Editor The Journal is abstracted by the Cumulative Index to Nursing International Association of Medical Laboratory and Allied Health Literature (CINAHL), Excerpta Medica/EMBASE, Techno log ists membership Chem ical Abstracts, and the Australian Medical Index. Advertisement bookings and enquiries shou ld be addressed Shirley Ga insford ...... , ...... 57 to the Advertising Manager: Trish Re il ly, 48 Towai St., St Heli ers, 57 Auckland 5. Phone: (09) 575 5057 . G Frank Lowrey ...... , ...... En qui ries rega rding subscription and address changes shoul d be addressed to t he Executive Office r of t he NZIM LS: Fra n van Til , Regular Features PO Box 505, Rangiora. Phone: (03) 313 4761 . E-mail : [email protected]. Abstracts, Australian Journal of Medica l Science ...... 58 Advertisers in this issue ...... 66 Instructions for authors ...... 33 NZIMLS Web-Site ...... 56 Ob ituary- John Case ...... 67 Special Interest Groups ...... 59-65

NZ J Med lab Soence 200 1 33 Asthma in medical laboratory workers

Susan M Tarlo, MB BS, MRCP (UK), FRCP(C) Professor of Medicine and Public Health Sciences, University of Toronto, Canada

Occupational asthma describ es asthma caused by a specific workplace Irritant-Induced Asthma or RADS may be induced if the medical exposure and is not due to factors outsid e the workplace. It needs to laboratory worker has an exposure to a very high level of a respiratory be distinguished from asthma which is co incidental to the workplace irritant, such as a spi ll of acetic acid (as reported in a hospital setting by but which may be aggravated by irritant exposu res at work (s imilar to Kern and co ll eagues) (6), or a fire in the laboratory. More commonly, the aggravation which may occur in most asthmatics on exposure to asthma which starts co incidentally to the workplace may be aggravat­ second-hand smoke, paint fumes, dusts or co ld air). Occupational asth­ ed by exposure to respiratory irritants in the medical laboratory, such as ma is most commonly due to an immunologic or presumed immuno­ strong cleaning agents e.g. bleach or other agents, acids, or ammonia logic response to a workplace sensit iser. Thi s may be an lgE mediated (as w hen cleaning an imal cages). Endotoxin exposure may occur from response to a high molecular weight allergen (often a protein), or to an imal feed or an imal cages, and this can aggravate asthma but also in certain chemica ls such as epoxy res ins. However, some workplace sen­ an imal models may act as an adjuvant augmenting sensitisation to sitisers may cause a cl inical response similar to this but w ithout a clear­ natural rubber latex (7). ly identified lgE-mediated response. Less commonly (about 6% of cases of occupational asthma), the mechanism may be a sin gle very high Investigation of workers with suspected occupa­ level irritant airway exposure, resulting in Reactive Airway Dysfunction tional asthma Syndrome (RADS), or Irritant-Induced Asthma (1, 2). Investigation of these workers should be performed as for other patients with sus pected occupational asthma, according to published Medical laboratory causes of occupational asthma guidelines and consensu s statements (8,9). Th e diagnosis should be Th ere are many laboratory settings in w hich occu pational asthma may suspected in any worker w ith new-onset asthma, especially if there is occu r. In most laboratory settings workers wear natural rubber latex worsen ing of symptoms at work and/or improvement on weekends or gloves for protection and/or maintaining sterility. Especially in atopic holidays off work . workers, the use of high protein powdered natural rubber latex gloves An objective diagnosis, of asthma should init ially be confirm ed by w ill expose the worker to a risk of lgE-mediated sensitisation to the pulmonary function testing and/or methacholine chall enge when the gloves and subsequent asthma from natural rubber latex, carri ed in t he patient has been at work. The occupational component to this can be glove powder. The prevalence of natural rubber latex induced occupa­ assessed by evidence of an improvement in serial pea k f low rea dings, tional asthma in hea lthca re work ers has been reported to be 5-17% serial spirometry and/or methacholin e or histamine challenge respo ns­ (3). Among 52 clinica lly sensitised hospital workers from our centre es off work as co mpa red with results whil e workin g. Exam ination of identified up until 1999, w ith positive sk in prick tests to natural rubber eosinophil counts in induced sputum during work periods and times latex, 6 were medical laboratory workers (12%). We previously report­ off work may add to the diagnostic certainty although assessing ed airborne natural rubber latex levels of over 300 nanograms per exhaled nitric oxide levels has not to date been shown to be of va lue cubic litre of air in our haematology laboratory during routine usage of (1 0). The causative agent may be suspected from the history of expo­ powdered natural rubber latex gloves, with a marked reduction after sure and review of material safety data sheets from the work area, but changes to powder-free, lower protein natural rubber latex gloves (4). new sensitising agents are reported each year, so the absence of a Rates of new sensitisation to natural rubber latex gloves in our hospi­ recognised sens itiser on the material safety data sheets does not tal staff also markedly fel l with the change in glove type to low-protein, exclude this possibility. Unfortunately there are few commercial skin powder-free latex gloves (5) . test extracts available for high-molecular weight work-place sensitisers, Other high-molecular weight sensitisers to which medical labora­ and re liable in-vitro immunological tests for these agents are limited to tory staff may have exposure include rats, mice and other laboratory a few centres. Specific cha ll enge tests either in the workplace setting an ima ls (i n research laboratories), and enzymes (e.g. papa in in blood­ or in a co ntroll ed environmental exposu re chamber can also assist in banks, and other enzymes used for biochemical reactions in the labo­ the diagnosis and in identifying the ca usative sensitiser. ratory setting). Irritant-Induced Asthma remains a circumstantial diagnosis, relying Low-molec ular weight sensitisers include glutaraldehyde (e.g. used largely on the exposu re hi story and objective evidence of asthma, with to sterili se eq ui pment in pulmonary function and other laboratories), no prev iously documented resp iratory disease. and medications such as penicill ins which may be mixed by pha rm acy technicians. Radiation technologists also may have exposure to diiso­ Management cya nates e.g. methylene diphenyl diisocyanate has been used in radio­ As w ith occupational asthma in other settings, medical laboratory therapy settings to custom-produce moulds to keep patients in the cor­ workers who have occupational asthma related to a workplace se nsi­ rect position for treatment. tiser should be completely removed from further exposure to that sen­ Other occupational se nsitise rs (e.g. quatternary ammonium com­ sitiser. If occupational asthma is due to natural rubber latex, then a pounds or pine products) may also be present in clean ing agents used change to powder-free, low-protein natural rubber latex glove use by by laboratory workers or t he house-keeping staff in the laboratories, co-workers and persona l use of non-natural rubber latex gloves may be alt hough clean ing agents also are often resp iratory irri tants and it may sufficient to prevent further work-re lated symptoms. In the case of be difficult in all cases to characterise a response as being due to a sen­ other causative sens itisers, it may be possible to change t he laboratory sitiser. agent to a different agent, but in many cases, the worker can on ly

NZ J Med Lab Soence 2001 34 completely avoid exposure by a move to a different laboratory. The out­ References come of occupational asthma has been shown to relate to the duration 1. Brooks SM , Weiss MA, Bernstein IL. Reactive airways dysfunction of exposure to t he work se nsitiser after the onset of asthma, and to t he syndrome (RADS). Persistent asthma syndrome after high level irritant severity of asthma at the time of stopping exposure. The best progno­ exposures. Chest 1985; 88: 376-84. sis is w ith ea rl y diagnosis and removal from further exposure. 2. Tarlo SM, Broder I. Irritant induced occupational asthma . Chest Racal-type air supply respirators may provide short-term protection 1989; 96 297-300. for workers w ith occupational asthma who need occasional exposure 3. Vanderplas 0, Charous BL, Tarlo SM. Latex all ergy. In: Asthma in the to the responsible sens itiser, such as natural rubber latex or an ima ls Workplace. IL Bernstein, M Chan-Yeung, JL Malo, D Bernstein, eds., (10). However, such use has not been shown to be uniformly effective Marcel Decker Inc., New York, 1999. for long periods of work, and avoidance of work areas containing air­ 4. Tarlo SM, Sussman G, Contala A, Swanson MC. Control of airborne borne leve ls of the sensitiser remain preferable. latex by use of powder-free latex gloves. J Allergy C/in !mmunol 1994; As with sensitiser-induced occupational asthma in other settings, 93: 985-9. the patient's asthma should be managed by control of exposure to 5. Tarlo SM, Easty A, Eubanks K, Min F, Liss G. Outcomes of a natural other relevant allergens and respiratory irritants as well as with appro­ rubber latex (NRL) control program in an Ontario teaching hospital priate medications. Workers may be eligible for workers' compensation (Abstract). J Allergy Clin lmmunol 2000; 105 (1, pt. 2): S1092. (in Canada), and consideration should be given to screening of other 6. Kern DG. Outbreak of the reactive airways dysfunction syndrome exposed workers for occupational asthma. Occupational hygiene after a spill of glacial acetic acid. Am Rev Respir Dis 1991; 144: 1058- review of the laboratory environment may assist in reducing exposure 64. for other workers to respiratory sensitisers. 7. Slater JE, Paupore EJ, Elwell MR, Truscott W. Lypopolysaccharide Workers with Irritant-Induced Asthma, can usually continue to augments lgG and lgE responses of mice to the latex allergen Hev b 5. work in the same environment w ith appropriate medical treatment of J Allergy Clin lmmunol 1998; 102 977-83. their asthma, as can workers with workplace aggravation of co inci­ 8. Tarlo SM, Boulet LP, Cartier A. Cockcroft D, Cote J, Hargreave FE, et dental asthma. al. Ca nadian Thoracic Society guidelines for occupational asthma. Can Respir J 1998; 5 289-300. Prevention of occupational asthma in the work­ 9. Chan-Yeung M. Assessment of asthma in the workplace. ACCP place Consensus Committee . College of Chest Physicians. Chest 1995; 108: For many occupational se nsit ise rs it has been shown that the ri sk of 1084-117. occupational asthma in a workplace increases with increasing airborne 10. Tarlo SM. Recent advances in occupational asthma . Curr Opin Pulm exposure levels. As reviewed by Bush and co ll eagues (11 ), laboratory Med 2000; 6: 145-50. animal handlers (who cl ean the cages, feed and ca re for t he animals) 11. Bush RK, Wood RA, Eggleston PA. Laboratory an imal all ergy. J are at much greater risk of se nsit isation than those who use the an i­ Allergy Clin lmmunol 1998; 102: 99- 11 2. mals for experimental purposes (such as technicians, students and 12. Reeb-Whitaker C K, Harrison DJ, Jones RB, Kacergis JB, Myers DD, investigators). At least risk are relatively unexposed workers in the area Paigen B. Control strategies for aeroallergens in an an imal facility. J such as secretaries and administrators. Allergy Clin lmmunol 1999; 103: 139-46. Therefore, ma intaining airborne levels of work se nsitisers in med­ 13. Liss G, Tarlo SM. Changing prevalence of occupational asthma due ical laboratories as low as possible is likely to reduce the risk of occu­ to latex allergy (Abstract). Am J Respir Crit Care Med 2000; 161: A 167. pational asthma. The use of low-protein, powder-free natural rubber latex or non-natural rubber latex gloves in medical laboratories will Address for correspondence: Professor S.M. Tarlo. Division of reduce airborne-natural rubber latex exposures (4). In laboratories with Respiratory Medicine, Toronto Western Hospital, Suite 4-009, Ed ith animals, significant reductions in airborne animal allergen levels can be Cavell Wing, 399 Bathurst St., Toronto, Ontario M5T 2S8, Canada. achieved by 1) housing small mammals in cages with filter sheet tops or fitted filter-bon nett tops, 2) using negative pressure in cages, and 3) handling animals using a ventil ated table (12). In contrast, increasing the room ventilation has little effect (12). Appropriate occupational hygiene measures such as ventilation and use of fume hoods can reduce exposure to some chemical sensitisers and irritants. Education of workers as to the presence and appropriate handling of specific respiratory sensitisers and irritants, and under­ standing of the need for early medical investigation if asthma symp­ toms occur, may also be helpful, particularly for workers exposed to common sensitisers such as natural rubber latex and an imals. Medical su rveillance questionnaires (and sk in prick testing for high molecular weight allergens) may also be useful in some settings in addition to reduction of ai rborne exposure, w here there is a relatively high in ci­ dence of sensitisation and occupational asthma in order to facilitate an early diagnosis and intervention. Although t here is little publi shed data on the effectiveness of intervention measures in reducin g occupation­ al asthma from medical laboratory se nsitise rs, there is preli minary evi­ dence for a benefit from general intervention measures (such as changes in glove use , education, medical surveillance) in reducing occupational asthma related to natural rubber latex (13).

NZ J Med lab Science 2001 35 Dientamoeba fragilis. A review of a commonly detected yet poorly understood parasite of man

Graeme Paltridge, FNZIMLS; Microbiologtj Laboratory, Canterbury Health Laboratories, Christchurch

Introduction and historical perspectives Taxonomy "To the protozoologist- if not the physician - D. fragilis is now per­ Dobell recogn ised the close structural similarities between the lumen haps the most interesting of al l the intestinal amoebae of man: for we dwell in g stages of the amoeboflage ll ate Histomonas meleagridis (the know less about it than about any of the others, and its life history and causative agent of the disease 'blackhead' in pou ltry) and D. fragilis. activities are still mysterious. Ever since I first saw t his curious organ ism Having reviewed the available evidence, he then came to the conclu­ in 1917, I have been intrigued by its peculiarities and have taken every sion that Dientamoeba represented a stage in the life cycle of the flag­ opportunity of studyin g it further yet after more than 20 years of work ell ate w hich permanently lost its flagella (1). This close resemb lance and cogitation, I am stil l baffled ... " Clifford Dobell, 1940 (1). between structure and division of Histomonas and trichomonads was Although recognised by British army surgeon Lt Col Charles confirmed by both light and electron microscopy studi es of Histomonas Wenyon in 1909, it was Margaret Jepps and Clifford Dobell who in (4,5). Further, the presence of many co mmon antigens in 1917 first described and named Dientamoeba fragilis (2). They recog­ Dientamoeba, Histomonas and Trichomonas was demonstrated con­ nised it as the fourth amoebae after Entamoeba co/1; "Entamoeba" clusive ly by quantitative fluorescent antibody and gel diffusion tech­ nana (sic) and Entamoeba histolytica. Jepps and Dobell proposed the niques (6). Dientamoeba was also found to be antigen ica ll y qu ite dis­ genus Dien tamoeba beca use of the binuclear appea rance of the t inct from En tamoeba histolytica (7) Honi gberg (8) revised the defini­ trophozoites and recog nised the nuclear st ru ctu re alone as sufficient to tion and taxonom ic position of the species which placed it firmly distinguish it f ro m other orga nis ms of the genus Entamoeba. The amongst the flagell ates, and Ca mp et al. (9) usin g electron microscopy species name fragilis was give n because of its extreme frai lness after of pri ma rily the binucleate stage re-described the species and suggest­ leav in g the body. Th ey noted an absence of a cyst stage and reasoned ed it was placed among trichomonads in the fa mily Di enta moebidae. by dint of the orga ni sms lack of appeara nce in form ed stools that it Depending upon w hich scheme is followed, the classification is as out­ was more li ke a Tri chomonad than an amoeba . They also did not con­ lined (10). sider it as a pathogen, although Dobell did later make a noble attempt Subkingdom: Protozoa (Levine et al. 1980) Kingdom: Protozoa (C urliss 1994) to prove otherwise when experimenting w ith tra nsm iss ion studies on Subphylum: Mastigophora Phylum : Parabasa la himself. He tried to ora lly self infect himse lf with a rich suspension of Order: Trichomonad ida Order: Tri chomonadida culture harvested Dientamoeba in mil k. For the next 25 days he exam­ Genus: Dientamoeba Genus: Dientamoeba in ed and cu ltured his stools systematica lly but did not acqu ire the infec­ tion. He then checked himself regularly for the next 1 0 years before he D. fragilis is close ly related to three species of Trichomonas affecting declared with modest understatement that "it is therefore certain, I humans (T. vagina/is, T. tenax, T. hominis) and on the basis of rRNA evi­ thin k, that I fa il ed to acquire infection with Dientamoeba as a result of dence quite distinct from the other flagellates Giardia, Enteromonas, thi s experiment "! (1). Chilomastix and Retortomonas. Classification of the protozoa is how­ Between 1917 and World War II , the few papers published on D. ever conjectural (1 0). A more recent study of the sequence analysis of fragilis considered it a rare organism of wide distribution. Some stud­ 16s-li ke rRNA estab lished that D. fragilis is a trichomonad but it was ies however did show that it had a much higher incidence in institu­ not possible to explain the absence of anatomical features such as tionalised patients. The pathogenicity of D. fragilis was still not proved kin etosomes and flagella, axostyle, costa, pelta and nucleus surround­ (a view that is sti ll held by some workers) although it had been associ­ ed by rough endoplasm ic reticu lum that are common to many other ated with persistent diarrhoea and abdominal distress. Origin al work by Pa rab asa li a. The authors suggest that either D. fragilis is degenerate Burrows and Swerd low in 1956 lin ked strong evidence to postulate and has lost these features or it is truly basal in the sense that those that Dientamoeba fragilis was transmitted by the common human pin­ features had not developed (11 ). D. fragilis is the on ly spec ies in the worm Enterobius vermicularis (3). genus Dientamoeba. There have been approximately 80 papers published in the litera­ ture specifica lly on D. fragilis (papers li sting D. fragilis in surveys not Biology and life cycle included); not many compared to other protozoa such as Giardia Iam­ D. fragilis is described as an amoeboflagellate, but only exists in an biia or, more rece ntly, Cryptosporidium parvum. Latter studies have amoeboid trophozoite form. There is no cyst or flage llated stage . It is give n a much better understanding of its preva lence, taxonomi ca l sta­ re lative ly sma ll, being genera lly in the 5- 12mm range, although it ca n tus, pathoge nicity and laboratory diag nos is, although many are anec­ va ry from 3 to 22 mm . Considerab le size and shape variation ca n occur dotal. Well controll ed studies are lacking. Medica l and ma ny cli nica l on a sing le smear. In fresh preparations, the organism may be actively parasit ology texts have given scant regard to this orga nism despite a motil e, exhi biting distinct differentiat ion between ectoplasm and endo­ common occurrence world-wide and its vexatious role as an agent of pl as m, with hya line pse udopodia that may be lobose or angular. Nuclei diarrhoea and gastrointestin al disturbances. are invisible in wet preparations but food vac uoles co ntaining bacteri a may be prese nt. Th ere may be prog ressive move ment. In stain ed preparations the trophozo ite nucleus is usually see n in the typica l bin-

NZ J Med l ab Science 2001 36 ucleate form but may contain one and on rare occasion s, three and was 50%. Ockert (21) expe ri mentally infected himself with eggs of four nuclei. On average, about 80% of the organisms are bi-nucleated Enterobius from a patient w ho also had D. fragilis and subseq uently and 20% mono-nucleated, but this ratio can vary considerab ly. Th e bi­ developed Dientamoeba and another study using isoelectric point nucleated forms represent an arrested telophase of mitosis, an obser­ determination of D. fragilis in Enterobius eggs (22) helped co nfirm the vation origin ally made by Do bell in 1940 (1) and then confirmed by Bird interrelation between both parasites. Attempts to culture the organism et al. (12) and Camp et al. (9). Each nucleus characteristica ll y consists from Enterobius eggs have not succeeded (19) D. fragilis has also been of four to six fragmented, discrete chromatin granules but they may detected in the eggs of Ascaris !umbricoides (23). appear as compact bodies not unlike those seen of stained prepara­ tions of Endolimax nana. Periphera l nuclear chromatin is absent. Th e The Disease cytoplasm appearance can vary considerably. It may be vacuolated and Prevalence contain ingested debris but it can also appear uniform and clean with Jepps and Dobell in their original paper of 1917 (2) reported their find­ few inclusions. It has been reported that cases of D. fragi!is seen in ings of only seven cases (of which 3 were NZ servicemen!) out of "a appendix sections had ingested red blood cells (13) however there are very large number of persons whose stools we have examined". A lit­ no subsequent reports of this observation. erature review in 1924 found a total of 33 reported cases (24) but sub­ D. fragilis lives in the lumen of the caecum and upper colon, and is sequent studies demonstrated that dientamoebiasis was common and only found in humans. A report by Talis et al. (14) documents a 15.5% cosmopolitan. Infection was very common in institutionalised patients isolation rate of D. fragilis from gallbladder wall scrapings and duode­ with prevalence rates of 74% from a Swedish mental hospital (25), nal juice by microscopy and culture. Talis et al. had reported ga llblad­ 36% from a Dutch mental hospital (26) and 42% from a Panamanian der colonisation in two earlier papers, (15, 16) but no other reports are institution (27). University freshmen were found to be 4.3% infected to be found in the literature that documents any site involvement other (28) as were between 10.4% and 17.1% of navy recruits in the USA than the large intestine. Al l attempts to experimentally infect chicks, (29), and with troops returning from an Asiatic war zone 26.1% were kittens and monkeys have fa iled (1, 17) . infected (30). A large se mi -communal group in Los Angeles had The life cycle of D. fragi!is has been controversia l since Jepps and Dientamoeba observed in 52% of its members and was common in all Do bells observations in 1917. It does not have a cyst stage which is in age groups (31 ). Prevalence in the general population appears to be keeping with most of the Trichomonads, but because of its apparent between 2%-8% (17, 20, 22, 32, 34). Figures from two New Zea land extreme frag ility once passed into the environment, its ability to survive studies were similar with 2.2% (35) and 1.2% (36) respectively, the passage through the gastric juices is high ly im propable. (It is of although a true preva lence w ith the latter cou ld not be determined in terest that the name "frag ilis" has had three reported interpretations. beca use of shortco mings in detection methodology. In a Los Angeles Jepps and Dobell (1) originally noted its extreme fra ilness after it has hospital paediatric outpatient study of chi ldren in the lower to middle left the body, Knoll and Howell (17) suggested it was because the cyto­ socio-economic group D. fragilis was found to be more common than plasm has a clear transparent appearance, hence its name, and Kean Giardia (2 1% vs 17%) (37), and Pre iss et al. (38) found D. fragi lis in (18) observed a striking characteristic of the organisms exploding when 102 of 123 paediatric patients infected by intestinal protozoa. A con­ distilled or tap water was added to them). Attempts to orall y se lf tran s­ troll ed Canad ian study to determine seropreva lence of D. fragi!is in 189 mit D. fragi!is had fai led (1) although Dobell was well aware of the sim­ chi ldren using indirect immunofluorescence revea led that 91% of the ilarities between Dientamoeba and Histomonas and offered the healthy matched controls were positive at a serum dilution of 1:1 0 or hypothesis that perhaps D. fragi!is is transmitted from man to man in greater (39). the egg of the nematode, such as Ascaris or Trichuris. The first real breakthrough as to its means of transmission was by Burrows and Clinical presentation and significance Swerdlow in 1956 (3) in a study of 1 518 appendices. They observed The role of D. fragi!is in human disease has been controversial since its that of 22 appendices harbouring D. fragi!is, 12 were found to contain discovery. Even Dobell, the then doyen of human protozoology, was adults and/or eggs of the pinworm E. vermicularis. As the incidence of after 20 years of studying, apparently unconvinced as to whether it Enterobius in the appendices was 2.9% and of Dientamoeba 1.45% causes disease; "not proven" rather than "guilty" was his verdict (1 ). the theoretical incidence of the two occurring together should have Other workers during this time were, however satisfied that infection been 0.04% however the actual incidence of the two species was with Dientamoeba does produce clinica l symptoms. Weinrich et al. 0. 79%, or 20 times the expected incidence. This led them to postulate (28) in their survey of college students found that persons harbouring whether Enterobius might be a vector of D. fragi!is. They then recov­ D. fragi!is reported more gastrointestinal symptoms than those who ered four worms from one of the Dientamoeba - harbouring appen­ were infected with E. histo!ytica. Sapero (29) reported that 27.3% of dices, sectioned and stained them and examined for evidence of individuals infected with D. fragi!is had clinical symptoms. Hood (40) Dientamoeba within the worm. Sma ll ameboid bodies were detected reviewed 7 cases and co ncluded that "this amoeba undoubtedly pro­ with nuclei resemb li ng those found in D. fragi!is from the lumen of the duces gastrointestinal symptoms". formalin-fixed appendices. There was also indirect evidence concurrent The first to obtain detailed histories from large stud ies were Kean with this investigation when one of the authors developed light diar­ and Ma lloch (18) and Yang and Scholten (19). The former reviewed rhoea and abdominal discomfort, which upon examination of his stools 100 "pure" infections with D. fragi!is from 14,000 patients over a 6 revea led D. fragilis and on further examination Enterobius eggs. Kean year period. The most frequent presenting symptoms were abdominal (18) revi ewed 100 "pure" adu lt infections which were free of other pain , diarrhoea, flatus, nau sea , vom iting and fatigue. Phys ica l signs, parasites and felt t hi s arg ued against the theory that Enterobius plays proctoscopic examination and radiologic studies were negative. The a significant rol e in transm ission. However Yang and Scholten 's (19) highest incidence according to age was in the 40-59 yea rs group and analysis of 43,000 stools submitted for parasitological exam ination it was sli ghtly more common in males than females . Yang and Scholten noted a com bination of D. fragilis and E. vermicularis occurred 9 times exam ined 65,544 preserved stools, of w hich 2664 sam ples from 179 1 more often than theoretically expected . Ce rva et al. (20) examined 414 patients contained D. fragilis alone or in combination with other para­ appendi ces and found trophozoites of D. fragilis in 4.8% and E. ver­ sites. Th ey deta il ed the symptomatology for 255 patients in whom on ly micularis in 8.75%. Th e co-incidence of D. fragilis and E. vermicularis D. fragilis was found and whom deta il ed symptoms had been supplied.

NZ J Med Lab Science 2001 37 More than half had clinical symptoms of diarrhoea, abdominal pains or found eosinophilia present in half and was statistically more significant a combination of these. (Table 1) than in a control group. Anal pruritis has been a finding in a number of symptom descriptions, and cou ld suggest that a concomitant Table 1. Frequency of gastrointestinal and other symptoms in Enterobius infection may be an exp lanation for D. fragilis associated patients in whom only D. fragilis was identified. eosinophili a, even though the worms or their eggs in most cases were not detected. Eosinophi lia is not usually associated with Enterobius % of patient s Symptom infection (48, 49, 50), nor, with the possible exception of Isospora belli, is it associated with intestinal protozoal infections (5 1). Eosinophi li c Yang& Literature< Spe ncer ct al. Spencer et al. %with Scholten (19) 1972 ( 19) (4 1) (42) symptom s+ co litis due to Enterobius has been reported (52) but is cons idered rare. Adnlt Children eos inophilia More work is obviously required to co nfirm the association between D. Diarrhoea 58.4 42.5 68 51 75 fragilis and eosinophilia. Abdommal pain 53.7 16.2 78 60 92 Anal pruritus 11.0 2.7 12 Abnormal s10o l Pathology (bloody, with mucus, loose) 9.8 22.6 Little has been recorded detailing the histopathology of D. fragilis. The Urticaria 6.7 0 first detailed study was made by Burrows et al (53) exam ining four Flaltll ence 5.9 19.9 Fatigue or cases of Dientamoeba infected appendixes, foll owed by a subsequent weakness 5.9 13.4 16 9 33 study by two of the same authors (13) on 11 additional cases. Of their Eos inophilia 5.1 4.3 Alternating total of 1 5 appendixes exam in ed, only three had D. fragilis alone with diarrhoea nnd constipati on 3.9 13.4 42122 17 25 Enterobius, Trichuris, Strongyloides, Giardia, Chilomastix and Nausea or Entamoeba coli variously co-infecting the remaining (12). All appendix­ vomiting 3.5 20.4 26 33 Wetght loss 3.1 102 14 es showed fibrosis of the appendiceal wall and some showed other Constipation 2.4 6.5 pathology such as lymphoid hyperplasia. Control appendixes contain­ Belching 2.0 5.4 20 ing combinations of the co-infecting nematodes or protozoa revea led Tenesmus 1. 2 5.9 3 1 25 Anorex ia or significantly less fibrosis. They also found that in all 15 cases some of malai se 1. 2 5.4 so the D. fragilis trophozoites conta ined ingested red blood ce lls, an Others 2.0 18.3 35 12 observation that does not appear to have been reported elsewhere. No. of pat iems 255 186 They concluded that D. fragi lis probably acts as a low-grade irritant over a period of time producing a minimal injury that in turn creates a A retrospective study of adult patients was made by Spencer et al. (4 1) mini ma l inflammatory response that finally resu lts in an increase in the who detailed the frequency of symptoms of 50 patients (Tab le 1) and fibrous connective tissue of the appendix - "analogous to a low smoul­ by duration with 45. They divided the disease into acute (<7 days), sub dering quiet fire". In a Czech study D. fragilis was found in 4.8% of acute (8-60 days) and chronic (>60 days) presentation. Those with 414 examined appendixes but no changes to the mucous membranes acute symptoms were moderately ill with diarrhoea, abdomin al pain were observed (20). and tenderness (especially to palpation) and nausea whereas those Dientamoeba is not considered to be an invasive organism but two with chronic symptoms had abdominal pa in and diarrhoea. With the reported cases of co litis due to it demonstrated a co lonic wall reaction. latter, abdominal pain occurred 15-60 minutes after meals, was With one case, a 27 year old woman with low grade fever, abdominal described as crampy or burning and was not re li eved by antacids. Two pa in and multiple loose bowel movements demonstrated multiple paediatric studies (37, 38) found diarrhoea was the most common punctate ulcers of approximately 2mm diameter at sigmoidoscopy. finding with acute infections and abdominal pain was most common Biopsy revea led shal low ulceration with evidence of acute and chronic in ch ildren with chronic symptoms. Spencer et al. (42) in a paed iatric inflammation. No organisms were seen on direct sa line preparations study noted that anorexia, irritability and gas were more frequent in despite special stains but after polyvinyl alcohol fixation with subse­ chi ldren with Giardia infection whereas abdominal pain was more fre­ quent trichrome staining many D. fragilis trophozoites were seen . The quent in those with D. fragilis. A case of D. fragilis masquerading as patient was treated with diiodohydroxyquin and recovered (54). Mild allergic co litis was confirmed by colonoscopic biopsy of a 3 year old subacute eosinophilic colitis was diagnosed in a 3-year-old fema le with chron ic diarrhoea, anorexia and vomiting (43). patient with stool-d ia gnosed D. fragilis infection (43). She had chron ic A gender bias with females being infected more than ma les has diarrhoea with mucus and leukocytes in her stools since eight weeks of been noted (19, 20, 44, 45) and one study has observed a spring-sum­ age. Colonoscopy revea led an oedematous and friable mucosa extend­ mer seasona l increase in detection (44). in g diffusely to the sp len ic flexture. No ulcerations or exudates were Em bree and Delage from Canada in a brief paediatric review of the observed. Biopsies all had a normal mucosal architecture but the lami­ role of Dientamoeba concluded that it was a mild disea se at worst and na propria showed a moderate eosinophilic infiltrate, with the prese nce that treatment shou ld on ly be considered with symptomatic ch ildren in of hyperplastic lymphoid nodules. Microaggregates of eosinophils were view of the fact that chronic carriage has not been associated with any observed in the crypt epithelium . The glandular arch itecture was nor­ ill effects (46). In a fol lowing letter Gibbs and Church were most dis­ mal. The patient was treated with iodoquinol, promptly became missive of D. fragilis as a pathogen citing the lack of good scientific evi­ asymptomatic, and remained so after a follow-up of 18 months. The dence to support it (47). They are, however, one of the few dissenting authors conclude that this case illustrates that infection with D. fragilis voices. By far the majority of reports support the role of Dientamoeba may have a cl in ica l picture ind istingu ishable from all erg ic co litis. as a pathogen (13, 17-19, 35-38, 40-45, 54, 56, 60, 66, 70, 71). Of interest in Spencer's adult study (41) was peripheral eosinophilia in 6- Laboratory diagnosis 20%, which was significantly more common in patients with symp­ The trichrome or iron-haematoxylin stained film is the recommended toms over 60 days, when co mpared with those w ith acute and sub way to diagnose D. fragilis (55). Although ski ll ed microscopists exam­ acute illn ess. Low grade eosinophilia has been reported elsewhere (16, ining direct sa lin e wet preparations or iodine wet preparations from 18, 28, 38, 43), but in their study of 35 ch ildren, Spencer et al. (37) concentrates may be able to detect amoeboid bodies and perhaps

NZ J Med Lab Sc1ence 2001 38 speculate as to the identification of D. fragilis, this organism ca nnot be been used by many investigators using various and mainly xe nic (in the reli ab ly diagnosed unless a permanent sta in ed film of an appropriately presence of other undefined organisms) methods, but the fortuitous prese rved faecal specimen is made. D. fragilis in unstained wet prepa­ development of t he di xenic cu lture has been of va lue in antigenic rations can be confused with faecal leukocytes and other sma ll amoe­ research (62). Axe nic cu lture of D. fragilis (= w ithout other organisms) bae such as E. nana. Laboratories that do not use a permanent stained has bee n unsuccessful to date (62, 69). Culture is, however, not nor­ fi lm as part of their parasitology testing is probably t he ma in reason mally co nsidered a practical diag nostic tool for the routine detection of why D. fragilis has been so apparently under reported. This was high­ intestinal protozoa (55), although it may be of va lue in prevalence stud­ lighted by Windsor and Johnson in the UK, where of an estimated 450 ies (64) diagnostic laboratories they noted that most do not look for this organ­ ism (56). It is imperative that faecal specimens are also promptly pre­ Treatment served in a fixative such as PVA fixative or sod ium acetate-acetic acid Earli er drugs for the treatment of D. fragilis included chiniofon, eme­ formalin fixative (SAF) as the trophozoites undergo rapid deterioration tine, carbarsone and diphetarsone, all of which were reported to clear and autolysis. Most parasitology texts recommend this process as the the organism (17, 18, 40, 65), but which have potentially serious side routine procedure for all parasite examinations. A commercially avail­ effects. Over recent years five other drugs have been regularly used in ab le fixative and sta in; EcoFix™ and EcoStain™ (Meridian Diagnostics, the treatment of D. fragilis. These are iodoquinol, metronidazole, paro­ Inc., Cincinnati, OH, USA) also gave good results (57). momycin, diloxanide furoate and tetracycline. lodoquinol (diidohydrox­ yquin - Yodoxin [Glenwood]. others) a halogenated oxyquinoline, is Table 2. Identification of D. fragilis regarded by many as the drug of choice (31, 37, 41, 42, 67, 70). Being poorly absorbed it acts as a luminicide and is tolerated well, provided Key JXJint microscopic identificat ion of Commems dosage and duration are not exceeded. Metronidazole (F iagyl [Searle]. D. fragilis others) is a nitroimidazole and is rapidly absorbed after ora l adm inis­ A binuclear-uninuclear ratio of 80:20 is Wide variation of these ratios can occur tration. It probably does not reach therapeutic concentrations in the common Karyosomes fragment into 3-6 discrete dot-like May appear unfragmemed and when uni­ large intestine and is not recommended as a cyst eradicator (68). Pre iss pa rt icles each nucleated may mimi c E. nann , E. hartmanni or C. mesnili trophozoites et al. (38) found metronidazole in a paediatric study was not effective Cytoplasm usually uniform and oflen has a Ingestion of bacteria. yeasts, Sphaerita c;pores in 30% of patients, and Oxner et al. (35) noted that treatment with ''peppered" appearance and other bodies as well as vacuolation can fi ll the cy toplasm metronidazole had an unpredictable outcome. Nausea, headache, Usually in 9-12m size range Large size varia ti on can occur (5-20m) metallic taste and anorexia are frequent side effects. Paromomycin (Humatin [Parke-Davis) ) is a poorly absorbed aminoglycoside w ith most of an ora l dose excreted unchanged in the faeces. It is effective A su rvey by Grendun et al (58) found that permanent staining of al l against E. histolytica/dispar cysts (68). Diloxinide furoate (Furamide stools as compared to loose or watery on ly, resulted in a fivefold [Boots)) is a well tolerated luminicide and is also used to eradicate E. greater detection of D. fragilis and recommended that all specimens, histolytica!dispar cysts (68). Tetracycline is regarded as a "safe" and regardless of consistency, shou ld be permanently sta in ed. The use of a efficacious drug (66), alt hough it does have the disadvantage of not preservative is further reinforced by Chang, who observed that D. frag­ being able to be used in treatin g ch ildren or pregnant women (67) ilis trophozoites die and disintegrate within one hour in an isotonic sa lt solution at room temperature (59). The number of organisms excreted Table 3. Recommended drug regimens for D. fragilis (67) daily has been observed to fluctuate markedly. Variations of D. fragi/is excretion of between > 15 x 106/ml to no organisms being seen was Drug Adult Dose Paediatric Dose noted on dai ly recordings over an 80 day period in one infected indi­ lodoquinol 650mg tid x 20 days 40mg/kg.day (max 2g) in 3 doses x 20 days vidual (1 9). In another case history, D. fragilis was detected in only two Paromomycin 25-30mg/kl/day 111 3 doses 25-30mg/kl/day in 3 doses x 7 days \ 7 days of seven stool samples from a nine year old girl, which were examined Tetracycline 50mg q1d x 10 days >8 yrs of age: 40mg/kg/day (max 2g) m 4 on successive days (60). The distribution of organisms within a stool doses >. 10 days can also vary considerably. Greater numbers have been found in the last portion evacuated than in the first (19). The examination of three specimens collected on different days has been found to increase the A problem affecting the treatment recommendations for D. fragilis yield of D. fragilis by 31 .1% when compared with a single examination infections is the lack of randomised double blind clinical trials. All (61 ). An indirect immunofluorescence method to detect D. fragilis has reports in the literature are anecdotal. Chan et al. (69), using a single been described. Antiserum, which was found to be highly specific, was isolate, performed experimental minimal amoebicida l concentrations raised from dixenic culture organisms(= in the presence of two defined (MAC) to iodoquinol (MAC = 128mg/ml), paromomycin (16mg/ml), organisms). D. fragilis was identified with strong fluorescence in seven tetracycline (32mg/ml [questionably)) and metroni dazole (32mg/ml), of nine specimens in <1 minute each. The two specimens of doubtful and this appears to be the only in-vitro testing of susceptibility that has read ings were, on cross-reference w ith routine parasitology results, been made to these drugs. found to be in only very scanty numbers - less than five trophozoites on the sta in ed smea rs (62) Chan et al (63) have also developed an Conclusions enzyme immunoassay to detect D. fragilis in stools w hich has a sensi­ Dientamoeba fragilis has proved to be an en igmatic orga nism taxo­ tivity of 92% and a specificity of 87.9%. Th e lower leve l of specificity nomica ll y, ep idemiologicall y and pathologica ll y. Its position among st was attributed possibly to an inadequate "gold standard" of the Tri chomonadidae has been confirmed by electron microscopy, anti­ microscopy. gen studies, and more recently by molecu lar methods. Described as an Neither immunofluorescence reagents or enzyme immunoassay are unflagellated flagellate, the genus name Dientamoeba is literally a mis­ currently commercia lly available. Culture of D. fragilis in a "pure " state nomer beca use, although it is amoeboid in appea rance, that is where was first obtained in 1929 and is described as one of the easiest of the the sim il arity ends. human intestinal amoebae to iso late and grow in vitro (1). Cu lture has Its life cycle is unique amongst the protozoa infecting humans,

NZ J Med Lab Sc1ence 2001 39 although there is a proved animal example of such a cycle with a flag­ pathology and treatment is well overdue. ellate of poultry, Histomonas meleagridis being paratenically transmit­ ted by the nematode Heterakis gallinae. Evidence that D. fragilis is References transmitted by the common pinworm Enterobius vermicularis, and pos­ 1. Dobe ll C. Intestinal protozoa of monkey and man; life history of D. sibly som e other nematodes, is well documented. The higher than fragi lis; obse rvations, experiments and specu lations. Parasitology expect ed coincidence of D. fragilis and E. vermicularis infection s, micro­ 1940; 32: 441. scopic evidence of the protozoa n in pinworm eggs, and the similarity 2. Jepps MW, Dobe ll C. Dienta moeba fragilis n.g., n. sp., a new intes­ of isoelectri c point co mparison of D. fragilis in cu lture and those in the t inal amoeba from man. Pa rasitology 19 18; 10: 352-67. eggs is all compelli ng evidence. This is even made more so when a doc­ 3. Bu rrows RB, Swerd low MA. Enterobius vermicularis as a probable umented se lf-inoculation experiment of pinworm eggs, as well as vector of Dientamoeba fragilis. Am J Trop Med Hyg 1956; 5: 258-65. anecdotal reports of Dientamoeba researchers who themselves have 4. Hon igberg BM, Bennett CJ. Lightmicroscopic observations on struc­ contracted the infection, have monitored its progress to confirm the ture and division of Histomonas meleagridis (Smith). J Protozoo/1971; nematode link. What is not clear, however, is whether a direct faecal ­ 18: 687-700. oral route or similar can also occur under certain circumstances. The 5. Rvbicka K, Honiberg BM, Holt SC. Fine structure of the mastigont lack of a cyst stage, some simple observations (the resu lts of which give system in cu lture forms of Histomonas meleagridis (Sm ith). support to the species name "fragil is "), and Dobell's experiment of se lf Protistologica 1972; 8: 107-20. inoculation of the trophozoites indicates that it cannot survive the 6. Dwyer DM. Analysis of t he antigenic relationships among stomach-small intestine journey to the colon. Th is would also be in Trichomonas, Histomonas, Dientamoeba, and Entamoeba. 1. keeping with the inability of the trophozoite stages of other protozoa Quantitative fluorescence antibody methods. J Protozoal 1972; 19: to initiate infection, the possible exception being Trichomonas 316-25. (Pentatrichomonas) hominis. Th is intestinal trichomonad also does not 7. Sargeaunt PG, Wi lliams JE. Electrophoetic isoenzyme patterns of the have a cyst stage, yet it is assumed that its trophozoites are transm it­ pathogenic and non-pathogenic intestinal amoebae of man. Trans R ted by faeca l - oral means, and survive the gastric barrier. Soc Trop Med Hyg 1979; 73 225-7. Enterobius is a ve ry common if not a nea rl y universa l infection of 8. Honi gberg BM. Evo lutionary and systematic re lationships in the flag­ children at so me stage in their ea rl y lives, which supports the nema­ ell ate ord er Tri chomonad ida Kirby. J Protozoo/1 963; 10: 20-63. tode lifecycl e invo lve ment. Many adults li kewise acquire Dientamoeba, 9. Ca mp RR, Mattern CFT, Hon igberg BM. Study of Dienta moeba frag­ but do not have an (evident) pinworm infection, and this also raises the ilis Jepps and Dobell. 1. El ectronmicroscopic obse rvations of the binu­ possibility of another means of transmi ss ion . It could, however, be with cl eate stages. 2. Taxonomic position and revi sion of the genus. J these cases that D. fragilis may have been in a quiescent state in adult Protozoo/1974; 21: 69-82 . patients for so me time before symptoms developed, and Enterobius 10. Cox FE G. Classification of the Paras itic Protozoa. In : Cox FEG, infecti on may have gone unnoticed or had sponta neously resolved, Kre ier JP, Wa kelin D, Ed s., Tapley and Wilsons Microbiology and although there is no evidence to support t his postulation. Microbia/Infections. Arn old, London, 1998: 141-55. Is D. fragilis a pathogen? Despite the occasional paper casting 11. Silberman JD, Clark CG, Sog in ML. Dientamoeba fragilis shares a doubts, the majority of evidence and general conse nsus is that it is a recent common evolutionary history with the trichomonads. Mol cause of diarrhoea an d/or abdominal pa in with both an acute and Biochem Parasitol 1996; 76: 311-14. chron ic presentation. Ch ronic carriage without any symptoms may 12. Bird RG, Sargeaunt P, Upton CP. Un i- and binucleate trophozoites occur. Almost all evidence suggests large intestine co lonisation only. of Dientamoeba fragilis. Trans R Soc Trop Med Hyg 1970; 64: 18. The few papers (from the same set of authors) documenting gal lblad­ 13. Swerdlow MA, Burrows RB. Dientamoeba fragilis, and intestinal der involvement have never been substantiated. Although D. fragilis pathogen. JAMA 1955; 158: 176-78. does not invade the colonic wall, histopathology has revealed superfi­ 14. Tal is B, Setin B, Lengy J. Dientamoeba fragilis in human faeces and cial tissue involvement in some cases. bile. Israel J Med Sci 1971; 7 1063-69. Treatment of dientamoebiasis remains a very neg lected aspect of 15. Ta lis B, Stein B. The presence of Dientamoeba fragilis in the gall the disease. There is very little experimental data on drug treatment, bladder. Harefuah 1961; 61:126. and blinded trials, including those using combination therapy, need to 16. Steinitz H, Talis B. The occurrence of amoebas in the biliary tract. be conducted. A standardised in vitro drug testing method using Dapim Refuiim 1964; 23: 2. strains grown axenically needs to be developed to assess drug efficacy. 17. Knoll EW, Howell KM . Studies on Dientamoeba fragilis: its inci­ Two of the four drugs of choice, iodoquinol and paromomycin are not dence and possible pathogenicity. Am J Clin Patho/1945; 15: 178-83. reg istered for genera l use in NZ and on ly issued to individually named 18. Kean BH, Ma ll och CL. The neglected ameba: Dientamoeba fragilis. patient s. They are only held by some hospita ls. Di loxinide furoate is no A report of 100 "pu re " infections. Am J.Dig Dis 1996; 11: 735-46. longer ava il able in NZ. 19. Ya ng J, Scholten TH. Dientamoeba fragi/is: a review with notes on The recogn ition and identification of D. fragilis should pose no its epidemiology, pathogenicity, mode of transm ission, and diagnosis. problems for diligent medical laboratory scientists provided immediate Am J Trop Med Hyg 1977 26: 16-22 . faeca l preservation is made (p referably at the point of co ll ection), and 20. Cerva L, Sc hrotten baum M, Kli ment V. Intestin al pa ras ites: a study a perm anent stain ed film from it is exa mined. Multiple specimens co l­ of human appendices. Folia Parasito/1 991; 38 5-9. lected on different days may be required. EI A testing, w hen commer­ 21. Ockert G. Sur epidemiologie von Dientamoeba fragilis. 2. ci ally ava il abl e, and particularly if it ca n be combined with the current­ Mitteilung : ve rsuch der ubertragung der art mit Enterobius- Ei ern . J ly available Giardia and Cryptosporidium test kits, may offer a good Hyg Epidemiol Microbio/lmmuno/1972; 16: 213-21. altern ative to microscopy in ce rtain settings. D. fragilis is an organism 22. Ockert G, Schmidt T. On the epidemiology of Dientamoeba fragilis with a chequered hi story that has taken a long time to be recognised Jepps and Dobell 1918. 4th communication: evidence of Dientamoeba by the med ica l fraternity as a gastrointestinal pathogen. It should now fragi lis in Enterobius eggs using isoelectric point determination. J Hyg be co nsidered on equa l terms with the other more estab li shed proto­ Epidemiol Microbiollmmunol 1976; 20 : 76-81. zoa that can cause disease . Controll ed research into its epidemiology, 23. Sukanahaketu S. The presence of Dientamoeba fragilis in the

NZ J Med lab Sc1ence 200 1 40 Ascaris lumbricoides ova: the first report from Th ail and. J Med Assoc 49. Mahmoud AAF. Intestinal nematodes (roundworm s) . In: Mandell Thai 1977; 60 256-8. GL, Bennett JE, Dol in R, Ed s. , Principles and Practice of Infectious 24. Ta liaferro WH, Becker ER . A note on t he human intestinal amoeba, Diseases. Ch urch il l Li vingstone, New York, 1995: 2526-3 1. Dientamoeba fragilis. Am J Hyg 1924; 4: 71-4 . 50. Liu LX. Enterobiasis. In: Guerrant RL, Wa lker DH, We ller PF, Eds., 25. Svensson R, Lind ers FJ. Th e chances of detecting infections w ith Tropical Infectious Disease. Churchi ll Livin gstone, Philadelphia, 1999; intestinal protozoa. Acta Med Scandinav 1934; 81: 267. 949-53. 26. Brug SL. Observations on Dientamoeba fragi/is. Ann Trap Med 51. W il son ME, Weller PF. Eosinophilia. In : Guerrant RL, Walker DH, Parasito/1936; 30: 441-52. Weller PF, Eds., Tropical Infectious Diseases. Churchi ll Livingstone, 27. Hakansson EG. Dientamoeba fragilis: some further observations. Phi ladelphia, 1999 1400-19. Am J Trap Med 1937; 17: 349. 52. Liu LX, Ch i J, Upton MP, Ash LR. Eosinoph ilic colitis assocated w ith 28. Wein rich DH, Stabler RM, Arnett JH. E. histolytica and other intes­ larvae of the pinworm Enterobius vermicularis. Lancet 1995; 346: 4 10- tinal protozoa in 1060 coll ege freshmen. Am J Trap Med 1935; 15: 2. 331. 53. Burrows RB, Swerdlow MA, Frost JK, Leeper CK. Pathology of 29. Sapero JJ. Clinical studies of non- dysenteric intestinal amebiasis. Dientamoeba tragi/is infections of the appendix. Am J Trap Med 1954; Am J Trap Med 1939; 19: 497. 3: 1033-9. 30. Sapero JJ, Johnson CM. Entamoeba histolytica and other intestinal 54. Shein R, Gelb A. Colitis due to Dientamoeba fragilis. Am J parasites. U.S Nav Bu//1939; 37: 279. Gastroentero/1983; 78: 634-6. 31. Millet VE, Spencer MJ, Capin MR, Garcia LS, Yatabe JH, Stewart 55. Garcia LS, Bruckner DA. Diagnostic Medical Parasitology. 3rd ed. ME. Intestinal protozoan infection in a semicommunal group. Am J Wash ington, D.C: ASM Press, 1997: 34-53. Trap Med Hyg 1983; 32 54-60. 56. Windsor JJ, Johnson EH. More laboratories should test for 32. Van Gool T, Dankert J. Three emerging protozoal infections in the Dientamoeba fragilis infection. BMJ 1999; 318: 735. Netherlands: Cyc/ospora, Dientamoeba and Microspora infections. 57. Garcia LS, Shimizu RY. Eva luation of intestinal protozoan morphol­ Nederlands Tijdschrift voor Geneeskunde 1996; 140: 155-60. ogy in human fecal specimens preserved in EcoFix: comparison of 33. Ruebush TK, Juranek DD, Brodsky RE. Diagnosis of intestin al para­ Wheatley's trichome stai n and EcoSta in. J Clin Microbial 1998; 36: sites by state and terrritoral publi c health laboratories. J Infect Dis 1974-6. 1976; 138: 114-17. 58. Grendon JH , Digiacomo RF, Frost FJ. Dientamoeba fragilis detection 34. W indsor JJ , Rafay AM, Shenoy AK, Johnson EH. Incidence of methods and preva lence in a survey of state public hea lth laboratori es. Dientamoeba fragilis in faecal sa mples submitted for routine microbio­ Public Health Rep 1991; 106: 322-5. logica l analysis. Br J Biomed Sci 1998; 55: 172-5. 59. Chang SL. Parasitization of the parasite. JAMA 1973; 223: 1510. 35. Oxner RBG, Paltridge GP, Chapman BA, Cook HB, Sheppard PF. 60. Desser SS, Yang YJ. Dientamoeba tragi/is in idiopathic gastroin­ Dientamoeba fragilis: a bowel pathogen? N Z Med J 1987; 100: 64-5. testinal disorders (Letter). Can Med Assoc J 1976; 114: 290, 293. 36. Wright JM . Dientamoeba fragilis: the cl in ical spectrum of disease. 61. Hiatt RA, Markell EK, Ng E. How many stool examinations are nec­ N Z Family Phys 1991; 18: 63-5. essary to detect pathogenic intestina l protozoa? Am J Trap Med Hyg 37. Spencer MJ, Mi ll et VE, Garcia LS, Rhee L, Masterson L. Parasitic 1995; 53: 36-9. infections in a paediatric population. Pediatr Infect Dis 1983; 2: 110-3. 62. Chan FTH, Guan MX, Mackenzie AMR. Application of indirect 38. Preiss U, Ockert G, Broemme S, Otto A. On the clinical importance immunofluorescence to detection of Dientamoeba fragilis in fecal spec­ of Dientamoeba fragilis infections in childhood. J Hyg Epidemiol imens. J Clin Microbiol1993; 31: 1710-4. Microbiollmmuno/1991; 35: 27-34. 63. Chan FTH, Stewart N, Diaz-Mitoma F, Mackenzie AMR. 39. Chan F, Stewart N, Guan M, Robb I, Fuite L, Chan I, et al. Development of an immunoassay to detect Dientamoeba fragilis anti­ Prevalence of Dientamoeba fragilis antibodies in children and recogni­ gen in stools. Conference Procs; 99th General Meeting AMS, Chicago tion of a 39kDa immunodominant protein antigen of the organism. Eur 1999. J Microbia/Infect Dis 1996; 15: 950-4. 64. Sawangjaroen N, Luke R, Prociv P. Diagnosis by faecal culture of 40. Hood M. Diarrhoea caused by D fragilis. Am J Trap Med 1940; 25: Dientamoeba fragilis infections in Australian patients with diarrhoeae. 914. Trans R Soc Trap Med Hyg 1993; 87: 163-5. 41. Spencer MJ, Chapin MR, Garcia LS. Dientamoeba fragilis: a gas­ 65. Keystone JS, Proctor E, Glenn C, Mcintyre L. Safety and efficacy of trointestinal protozoan infection in adults. Am J Gastroenterol 1982; diphetarsone in the treatment of amoebiasis, non-pathogenic amoebi­ 77 565-9. asis and trichiuriasis. Trans R Soc Trap Med Hyg 1983; 77: 84-6. 42. Spencer MJ, Garcia LS, Chapin MR. Dientamoeba fragilis. An intes­ 66. Dardick KR. Tetracycline treatment of Dientamoeba fragilis. Conn tina l pathogen in chi ldren? Am J Dis Child 1979; 133 : 390-3. Med 1983; 47: 69-70. 43. Cuffari C, Oli gny L, Se idman EG. Dientamoeba fragilis masquerad­ 67. Abramowicz M ed. Drugs for parasitic infections. Medical Letter on ing as all ergic co litis. J Pediatr Gastroenterol Nutr 1998; 26: 16-20. Drugs and Therapeutics 1998; 40: 1-12. 44. Grendon JH DiG iacomo RF, Frost FJ. Descriptive features of 68. Pearson RD, We ll er PF, Guerrant RL. Chemotherapy of Parasitic Dientamoeba fragilis infections. J Trap Med Hyg 1995; 98: 309-15. Disease. In: Guerrant RL, Walker DH, We ll er PF Eds ., Tropical In fectious 45. Ayadi A, Bahri I. Dientamoeba fragilis. pathogenic f lage ll ate? Bull Diseases. Churchill Li vingstone, Ph il adelphia, 1999: 215-237. Soc Pathol Exot 1999; 92: 299-301. 69. Chan FTH, Guan MX, Mackenzie AMR, Dia z- Mitoma F. 46. Embree JE, Delage G. Dientamoeba fragilis: a harml ess co mmensa l Susceptibility testin g of Dientamoeba fragilis ATCC30948 w ith or a mil d pathogen? Ca n J Infect Dis 1998; 9: 69-70. iodoqui nol, paromomycin, tetracycline, and metron idazole. Antimicrob 47. Gibbs AP, Church DL. Is it worth looking for Dientamoeba fragilis? Agents Chemother 1994; 38: 1157-60. Can J Infect Dis 1998; 9: 126. 70. Turner JA. Giardiasis and infections w ith Dientamoeba fragilis. 48. Crompton DWT. Gastrointestinal nematodes- Asca ris, Hookworm, Pediatr Clin North Am 1985; 32 : 865-80. Trichuris, and Enterobius. In: Cox FEG, Dreier JP, Wakelin D, Ed s.. 71 . W indsor JJ, Johnson EH . Dientamoeba fragilis.· the unflage ll ated Tapley and Wilsons Microbiology and Microbial Infections. Arnold, human flagellate. Br J Biomed Sci 1999; 56: 293-306. London, 1998: 561-84.

NZ J Med Lab Soence 2001 4 1 An evaluation and comparison between blood film microscopy services in government hospital laboratories in the Mid-Western Region of Nepal and the Waikato Region in New Zealand

Vanessa C J Thomson,FNZIMLS Haematology Specialist NZIMLS, INF Tuberculosis and Leprosy Regional Laboratory, Surkhet, Nepal (Current address: Hawkes Bay Regional Hospital Laboratory, Hastings, New Zealand [email protected])

Abstract US$2 00 and population of 21,000,000 people (1). Th e resource poor Introduction: An eva luation of blood fi lm microscopy se rvices w as ca r­ nature and geography of the co untry limit development of health se rv­ ried out in the Mid-Western reg ion of Nepal and the Wa ikato reg ion in ices. National objectives for laboratory services target improvement of New Zea land to define strengths and weaknesses, and thereby further overall quality control, ensuring sufficient manpower is trained for lab­ enha nce t he quality of se rvice provided . oratory work, and ensuring there are sufficient laboratory suppli es (2) . Methods: Questionnaires and bl ood films co mpared qualifications and For three yea rs Intern ational Nepal Fellowshi p, an intern ational non­ experi ence of staff, train ing resources, technique in preparation, exa m­ government orga ni zation (INGO) has bee n assisting the Nepalese gov­ ination, reporting and referral of blood f ilms, and participation in and ernment in its mandate to strengthen laboratory se rvices . Initial surveys assessment of t he extern al quality ass urance prog ram ut il ise d. of govern ment laboratories revea led a lack of resou rces, training and Resu lts: Eva luat ion of the two reg ions w it h intern ational recommen­ quality of laboratory res ults. dations, revea led that w hile many technica l as pects are similar, trainin g New Zea land boasts a popu lation of 3,600,000 peopl e (3), in which and resources are limited in the Mid-Western region. In the Wa ikato laboratory se rvices play a key role in hea lt h ca re. Over t he last 10 - 15 staffing is higher, specia lised staff are easily accessible and abnormal yea rs hea lth reforms have attempted to increase efficiency and improve films are regularly examined. Examination of blood films between the standards, becoming customer orientated in nature. regions revea led a lack of accuracy in t he Mid-Western region, w hil e externa l quality assurance (EQA) programs w ith an emphasis on edu­ In New Zeal and all medica l testing laboratories are assessed for ca tion are of great benefit to laboratories in maintaini ng com petence . accreditation against a combination of the international standards ISO Conclusions: The ability to utili se technology and computers is very 9002 (qua lity management systems) and ISO Guide 25 (technical com ­ li mited, and increasi ng staff numbers is difficult to achi eve in Nepal in petency), but there are no formally documented standards for blood t he immediate future. However, improving reso urces and traini ng of film microscopy eva luation. This st udy assesses blood f il ms simil ar to staff ca n be ac hieved thro ugh reg ular refres her train ing, morphology gui delin es of Intern at ional Accreditation New Zea land (IANZ) (persona l workshops, distribution of abnormal films w ith ed ucational supple­ correspondence, IANZ by cons idering the following items: ments, and supply of blood atlases and sets of teach ing slides. In New • Qualifications, experience and competency of staff performing Zea land it is important for small sate ll ite laboratories to maintain qual­ microscopy ity through regu lar participation in EQA programs and morphology • Standard of textbooks, morpholog ical atlas and other reference workshops, and blood atlases and sets of teaching sli des shou ld be material utilised frequently. • Criteria for preparation and exam ination of blood f il m Key words: microscopy, differential leukocyte count, qua lity control • Specimen coll ection and blood fil m preparation • Stain ing, examination and reporting of blood fi lms Introduction • Referral of a film onto a pathologist or laboratory co lleag ue Blood f ilm microscopy (b lood smears, leukocyte differential count, • Participation in inter-laboratory comparison programme exa mination of a blood fil m specifically for normality or abnormality of In addition, in 1997 and 1998, in both reg ions being examined, an white blood cells, red blood ce lls and pl atelets, but not specifica lly for external quality assessment (EQA) program was started for blood fi lms, ma lari a or microfilaria), is a basic f undamental laboratory procedure w hich is incl uded in the eva luation. This exam ination w ill highlight that ca n easily be utilised in any routine medi ca l laboratory t hroughout strengths and weaknesses and t hus provide information for fu rther t he world . It serves as a diagnostic tool for doctors and other hea lth strengtheni ng and development of laboratories. professionals, as a tool for monitoring disease state, and as a quality co ntrol tool in ve ri fying t he res ults generated by automated analysers. History Thi s study reviews intern ational standard s of blood fi lm microscopy Blood film exa mination has evolved signif ica ntly over the ce nturies and compares those to ro utine laboratory life in a re gion of a devel­ from the discovery of magnifabl e ce ll s to a rapidly evo lving technolog­ oped country (N ew Zea land) and a developing country (Nepal). ica l age. Accord ing to Groner and Simson (4), the hi story of blood ce ll It was not until after 1950 that modern development came to Nepal, analys is can be divided into roughly four phases: one of the poorest nations in t he world w ith a per cap ita GDP of 1. Discovery (1642-1881 ). Lee uwen hook first noted the ce lls of the

NZ J Med Lab Science 2001 42 blood in 1642. Notable events included a) the discovery of platelets by ture of azure Band usua lly eosin B or Y dyes, at pH 6.4-7.0. The refer­ Donne, in 1842, and b) the differentiation between lymphocytes and ence method advocated by the International Committee for granulocytes by Gul liver in 1846. At the end of the 19th century Paul Standardisation in Haematology (ICSH) prefers the use of pure azure B Ehrlich applied ana line dyes. and eosin Y, giving inter-batch consistency and standardisation . 2. Application (1881-1950). Microscopic observations and the quan­ Successf ul sta ining enables accura cy in identifying mature and imma­ tification of the ce llu lar elements of the blood were related to clinical ture leukocytes and abnormal cells (18-19). phenomena. Important discoveries during this phase include a) relating Severa l Romanowsky sta in combin ations are documented for use in the morphology of neutrophils to infection and inflammation and b) a blood film sta ining, including Wright, Giemsa, Wright-G iemsa, May­ detailed cl ass ification of leukemia's on the basis of morphology. Grunwald-Giemsa, Jenner-Gi emsa, Leishman and Field 's (the latter for 3. Consolidation (195 1-1965). It was well recognized that manual rapid staining) (20-26). Films can be stain ed either by manual or auto­ blood film microscopy was tedious, expensive, time consum ing, and mated methods. results were relatively inaccurate therefore ma in developments of this phase focused on automation technology and cost reduction. D. Examination 4. Rediscovery (1965 to present time). This current phase has focused Blood fi lm exam ination has been extensively reviewed by Barbara Bain on observing with more specific chemistries the molecular structure of and Dacie and Lewis (27). Blood f il ms should be examined systemati­ the ce ll s, bridging what is observed microscopically at the ce llular level cally. in blood to what is found clinica lly. Developments in this phase have First, patient identification must be checked and the blood film enab led alternatives for leukocyte classification. matched with the appropri ate blood count report. At this stage the During the 1970s extensive efforts were made to automate the patient's sex, age, ethnic origin and clin ica l details shou ld be noted. leukocyte differential count (5). The last fifteen years have seen a rapid Next, the f il m shou ld be examined macroscopica lly and microscopi­ evolution of tech nology (6), to the extent that latest systems perform ca lly observing adequacy of preparation and stain ing, and cell mor­ not only the complete blood count, and differential leukocyte count, phology. After this initial assessment, if the blood film is deemed unsat­ but also makes and sta ins the blood films, etc (e.g. Coulters GENS). Th e isfactory, a fresh film should be prepared and stained. flagging systems have decreased the workload and cost in the micro­ The film appearances should then be compared with the full blood scopic section significantly, however manual blood film microscopy cou nt and judged whether re sults are co nsistent. Discrepancies due to rema ins a core part of the haematology laboratory. technical errors or abnormality of the specimen must be addressed. For da ily routine work a 100- cell leukocyte differential count is then Blood film processing performed . Three cou nting techniques have been described in an The need for a well-made and well-stain ed blood film is imperative in attempt to compensate for maldistribution of ce ll s. Th ese methods the exam in ation and subsequent reporting of results. include tracking along the length of the fi lm, the modified battlement method and the battlement method on a wedge made film (the latter A. Criteria for preparation and examination of blood film being the NCC LS recommendation). Flagging of abnormal parameters by automated cell counters provides Th e area of the f il m is found where erythrocytes li e in a mono-layer. se lective blood film examination (7). Stud ies conducted by the General Each identified leukocyte ce ll must be placed into the appropriate cat­ Haematology Task Force in the United Kingdom (8), assessed the role egory (e.g segmented neutrophil, blast ce ll, etc). Two methods of and need for manual blood films to be exam in ed with automated counting nucleated erythroid ce ll s are documented - counting nucle­ blood counting systems. One study examining flagg in g criteria - cl ini­ ated erythroid ce ll s with leukocytes or per 100 leukocytes counted. As ca l flag, instrumental flag, delta check flag, confirmed that the higher much has been documented on the decreased accuracy and precision the percentage of the fil ms examined, the less li kely it is to miss signif­ of a manual differentia l count than an automated count, a manual icant pathology. The task force concluded that an intelligent balance count shou ld therefore only be performed if indicated (28-31 ). between the minimum risk and the maximum laboratory efficiency Subsequently morphological appearances of leukocytes, erythrocytes should be sought, taking into consideration, workload, staffing, and and platelets are assessed and commented on. Assessment of leuko­ local expectations. cytes should include examination for a left shift, variant lymphocytes, plasma cells, abnormal myeloid changes (e.g. hyersegmentation, pel­ B. Specimen collection and blood film preparation ger-huet anomaly), toxic changes (e.g. toxic granulation, Dah le bodies), The H20-A document approved by the National Committee for Cli nical pyknotic ce ll s and smear ce lls. Erythrocyte exam ination assesses mor­ Laboratory Standards (NCCLS) in 1992 (9-11), states that whole venous phological va ri ation in size (e.g microcytes, macrocytes), co lour (e.g. blood co llected in tripotassium ethylened iam in e tetra-acetate hypochromasia), shape (e.g. acanthocytes, elliptocytes), inclusions (e.g. (K3EDTA) is the requ ired specimen for film preparation. Alternatively, howell jol ly bodies, pappenheimer bodies) and distribution (e.g. agg lu ­ blood co llected by sk in puncture maybe used. t ination, rou lea ux). Assessment of platelet morphology includes Three different techniques for blood film preparation have been platelet numbers, size, granules, platelet-neutrophil satellism, and described - the wedge-pull technique, the coverslip method, and the platelet clumping . The thorough laboratory worker should also exam­ spinner method. All three methods are well documented, however in in e the blood film for parasites (e.g. malaria, microfil arie). today's laboratory the wedge smear is the most popular and recom­ Clinica l deta ils, sex, age, ethnic origin, blood results, differential mended by the NCCLS (12- 17). Th e blood fil m should be labell ed count and al l morphologica l features should then be co rrelated to pro­ appropriately before staining vide a useful report for the clinician.

C. Staining E. Reporting The NCCLS H20-A document advises the fi lm should be stained within Reporting of leukocyte differential counts continues to be controver­ one hour of preparation, or fixed within one hour with "water-free" sial. Traditionall y, cou nts were reported as a percentage, as the data methanol. This reference method for blood fi lm staining reco mmends were directly ava ila bl e from the blood fil m. From a mathematical per­ the use of a Romanowsky stain . A Romanowsky stain co nsists of a mix- spective, it would appear there are adva ntages to both absolute and

NZ J Med lab Soence 200 1 43 perce ntage reporting. Britain tends toward s reporting abso lutes w hi le much 'l ea ding' information should be give n. the United States continue to report perce ntages, reflected in the 6. Ind ividual reports should be made confidential. NCC LS document. Koe pke et al advocate the reporting of absolute 7. It is unrea listic to identify poor performance by analysis of differen­ cou nts, suggesting it offers a more sensitive indicator of the patient's tial cou nts due to the wide deviation of ce ll distribution, although cl ini ca l condition. when ce ll s are mis-classified (e.g. lymphocytes are cou nted instead of In New Zea land the Auck land Haematology Special Interest Group blast ce ll s) a differential co unt ca n be va lu abl e. So me sc hemes (e.g. UK (HSIG) publi shed a booklet estab lishing standard nomenclature and NEQAS), do not include poor performance in the assessment, as they expression of resu lts (32). Morphologica l features maybe graded 1+ are regard ed as educational. through 4+ or as sli ght, moderate, or marked, etc. It is recommended, 8. The time elapse before return of the analysis of the participants' per­ reporting of abnormal morphology be accompanied with an interpre­ formance shou ld be as short as possible. tative comment where possibl e. 9. EQA should be educational with the main aim to help participants' Generation of reports using interpretative reporting may include improve their performance. A w ide se lection of blood films will help to marking abnormal results, printing reference values, suggesting diag­ stimulate and cha ll enge the participants, provide educational material nostic possibilities, and making recommendations for which additional and to give participants an opportunity to bu il d up sli de libraries. studies may establish the diagnosis. Continuin g ed ucation can be provided through the program (e.g . CAP Computer tech nology has revo lutionised reporting and data trans­ program) or as morphology workshops (e.g . ASCP, New Zealand mission of results, whereby cumu lative resu lts are quickly ava ilable, haematology SIG) (Personal Correspondence. American Society of minimising cost and turnaround time of results, improving cons istency Clinical Pathologists). For developing countries, UK NEQAS WHO col­ of reporting and therefore improving patient care. laborating centres as well as operating international EQA, provide edu­ cation, training and consultancy. F. Referral Access to more specia lised centres are important for laboratory work­ Materials and methods ers, for the referral of abnormal blood films for confirmation of find­ Study subjects ings, diagnosis or fol low-up of haematological abnormalities. Sma ller A representative group in Nepal and New Zea land were chosen as laboratories need access to reg ional and national laboratori es. Blood study subjects (govern ment hospita l laboratories in the Mid-Western f il ms need ing specific expertise (e.g. Class ification of ma laria or micro­ reg ion and Wa ikato reg ion respective ly). Staffed government hospita l fila ria), shou ld be referred to specialised laboratori es. laboratory numbers are similar and both regions have estab lished EQA programs for blood films in the last three yea rs. External quality control and continuing education The Mid-Western reg ion is the poorest reg ion in Nepa l. Of the ten Quality control of ma nual blood f il ms does not so much assess techni­ hospita ls in the reg ion, only six have laboratory staff. Thro ughout the ca l performance as much as the competence of the laboratory worker reg ion, there are 60% laboratory staff vaca ncies in government hospi­ performing the test. External quality assessment (EQA) of blood films, ta ls. No cell counters are ava ilable and reporting is written. Official staff is an extension of internal quality control (IQC). It provides the facility hours are 1Oam - 3pm. Private practice eng ulfs the remaining hours. for training staff in recognition and interpretation of morphological The population of the Mid-Western region is 2,909,753 persons. features and it is a means for assess ing the professional sk ill of staff. The Wa ikato region in New Zea land accommodates one referral hos­ The WHO defines EQA as "a system of objectively checking laboratory pital and four-government satellite hospitals. Each of these laboratories results by means of an external agency ... to establish between-labora­ is automated, with the satellite laboratories accommodating the same tory comparability" (33). model of ce ll counter. This assists w ith comparabil ity and staffing across Blood film assessment is an integral part of many EQA programmes laboratories and cost-effectiveness. Computer link with the referral throughout the world (e.g. Survey program of the Co ll ege of American hospital w il l also be very advantageous when completed. In 1996 the Pathologists (CAP), the United Kingdom national external quality population of the Waikato region was 350, 124. assessment scheme (UK NEQAS), WHO program in collaboration with UK NEQAS, and the Royal College of Pathologist's of Australasia Methods scheme (RCPA). Details of some of these programs are well docu­ Between March 1999 and January 2000, six government hospitals in mented (34-38). the Mid- Western region were visited. Four government hospitals in the Some important aspects of establishing and running an EQA program Waikato region were visited between May and June 1999 (question­ include: naires and blood fi lms were posted to the fifth hospital). Two ques­ 1. Estab li sh ing confidence between participants and organisers is tionna ires assess ro utin e blood film microscopy and the blood film EQA essentia l and ca n be gained by all owing vo luntary participation unt il program . Fou r blood films and a resu lt sheet were distributed for a co nfidence has been established, co nsidering the organiser as an advi­ comparative assessment. sor, never an investigator and making physical in spections co mpletely independent of EQA. 1. Laboratory questionnaire (Appendix 1) 2. Material distributed should rese mble specimens from patients and Where it was possible, the questionnaire was fi ll ed out with the labo­ include both normal fi lms (for differential cell countin g) and abnorma l ratory staff. In Nepa l project laboratory co lleagues assisted in fill ing out fi lms (includ ing rare conditions) . the questionnaire and with translation. The questionnaire was translat­ 3. Stained and covered sli des or 35mm transparencies are better as it ed into Nepa li and available for the government laboratory staff to has been discovered that delays beyond 6-8 hours in sta ining the fi lm refer to if questions were difficu lt to understand. may res ult in unsatisfactory stainin g. To ass ist with questions rega rdin g tra ining of medica l laboratory sc i­ 4. Spec imens should be distributed at least four times a yea r but not entists in New Zea land, haematology lecture rs at Massey Uni vers ity and more than every 2-3 weeks. Auc kl and Institute of Technology were interviewed and a letter se nt to 5. The f il ms ca n be accompanied by the bl ood cou nt with brief clinica l Otago Univers ity. notes and basic blood res ults, although co ntroversy surrounds how

NZ J Med Lab Sc1ence 2001 44 2. Quality control program evaluation end of the trai ning. Th e four-yea r train ing courses now offered at Evaluation of the regiona l Qu ality Control programs operating in the Otago and Massey Universities, and at Auckland University of Mid-Western reg ion and the Wa ikato region comprised of two com­ Technology, for Medica l Laboratory Science, students begi n study of ponents - a questionnaire des igned for program organ isers (Appendix blood films in either their first or third year with a significa nt portion of 2) and a question naire designed for prog ram pa rticipa nts (Appendix 3). practica l sessions co mmitted to bl ood film exam ination. Hae matology graduates should be abl e to perform exam ination on a blood f il m. In 3. Comparative quality control blood films Nepal a laboratory technician receives a two-yea r general train ing whil e Twenty wedge blood f il ms were made from four different EDTA sam­ an assistant may have rece ived a one yea r general tra ining, or have ples and labell ed as QC 1, 2, 3 and 4. After drying they were fixed been given a three month tra ining in malaria exam ination. Most staff immediately and all QC 2 and 3 f ilms and 3 sli des each from QC 1 and in the Mid-Western reg ion did not fee l the initial training for blood fil m 4 were sta ined using May-Grunwald Giemsa in an automated staining exami nation was adequate and wanted refresher traini ng. mach ine. One sli de of each QC sample was given to the laboratories in Competency of Wa ikato reg ional staff is assessed by a senior staff the Waikato and Mid-Western reg ion. Participants were instructed how member, through an evaluation I coaching process, discuss ion and by to process the slides (Appendix 4). The blood smears were designed to participation in surveys. Competency documents record each staff reflect the qua lity control programs between the two regions. (i.e. two member's ab il ity. It was fe lt amongst some staff in the Mid-Western smears stained with information, two smears unstained without infor­ reg ion that competency was assessed from the national quality assess­ mation). ment program. In the Waikato, supervision is given internally by senior staff, and Leukocyte differential count externally by the IANZ accreditation and surveillance visits, or a visit Competent laboratory scientists from one referral hospital and the from a haematologist. External supervision vis its are li nked with the author performed a total of ten 100 -ce ll leukocyte differential counts national quality ass urance program and Tu bercu los is prog ram in the on each of the four lots of quality co ntrol fi lms, usin g the automated Mid-Western region, while intern al supervision visits are from the hos­ stained slides. The differential co unts were put into a sprea dsheet in pital superintendent. Microsoft Exce l. Th e averages were ca lculated on the ten reference co unts for each lot of quality co ntrol, and these beca me the target val­ Ta ble 1. Details of surveyed hospitals. ues. Th e target valu es were plotted on a bar graph, aga inst the partic­ ipating laboratories' res ults, for each differential. Statistica l analysis Lab Reg ion No. of No. of Consul t. Pop. Blood fi lms beds Dr 's 1-J acmatolog ist Served per mont h would have proved inaccurate due to lack of volu me of data, therefore was not performed. Lab A Wa ikato 700 307 Yes 300000+ 2200 Lab B Waikato 23 Referral 5000 150 Lab C Waikato 28 4 Referra l 10 000 180 Lab D Waikato 55 9 Referral 60000 820 Film and interpretative comments LabE M i d~ West 35 No 279 355 50 Lab F M i d~ West 15 4 No 436 3 10 400 Both fi lm and interpretative co mments were co llated into a table in Lab G Mi d-WeSI 15 0 No 368 456 160 Microsoft Word. Th ese were then viewed for any blatant inco nsisten­ Lab H M id-West 15 No 203 830 240 cies. Lab I Mid-WeSI 15 No 2 19456 35 LabJ Mid-West 150 20 No 361 702+ 720 For each blood f ilm a target resu lt was set as foll ows: QC 1 - left shift detected Notes: NB: The population served in the Mid West is the population of QC2 - counting of blast cells with diagnosis of leukaemia or refer- the District only. As many districts do not have doctors, patients are ral referred to these districts with doctors and hospitals. Districts without QC3 - increased number of monocytes, target cells detected. hospitals amount to an added population of 952 375. (Beneficial if, dimorphic or hypochromic cells detected and diagnosis of liver dysfunction). Table 2. Staffing of laboratories QC4 - detection of toxic changes in neutrophils, microcytosis of red cells, fragmented cell s and thrombocytopenia. Laboratory No of staff in Staff ''acnncies Adequacy of Training of slaff the dept staffing doing films In all cases, if a result was reported as need ing referral, this was accept­ able. Lab A 13.2 FTE 0 Adequate Technologist LabB Adequale 2 Technologist A fina l table comparing each laboratory against the above target crite­ I Assistant ria was compiled for direct comparison between reg ions. LabC 1.5 FTE 0 Adequa1e 2 Technolog ist -overstaffed I Assistant I QTA Results LabD 1.5 FTE 0 Understaffed 2 Technologisl LabE Understaffed I Technicia n Laboratory questionnaires 2Assistant Lab F Understaffed I Techn ician In the Waikato reg ion, four out of the five govern ment hos pital's par­ 2Assistant ticipated in the survey, and in the Mid-Western region six out of six pa r­ LabG 2 Understaffed I Techn ician I Assistant ticipated. Tab les 1 and 2 show a hi gher proportion of doctors and hos­ Lab H Adequate I Tech ni cian pital's per population in the Waikato and a hig h proportion of highly 2Assistant Lab I Underslaffed I Ass istant qua lified medi cal laboratory scientists. In the Mid-Western region staff LabJ Adequ ate I Techni cian shortages are common and the level of trai ni ng of staff exam ining blood films is lower. Notes: * FTE - full time equiva lent is the total number of staff workin g 1. Qualifications, experi ence and competency of staff including part-time and cas ual staff. Thi s meas ure is used in New Blood film training in cl uded six weeks of bas ic traini ng foll owed by Zea land but not in Nepal. supervision, for hospital trained medi ca l laboratory sc ientists in New QTA- qualified technica l assistant Zea land, being competent to perform blood fil m microscopy by the

NZ J Med Lab Science 200 1 45 2. Continuing ed ucation 8. Referral Du e to the high number of qua lified med ica l laboratory scientists and In the Wa ikato al l laboratories had a co ll eague to confirm abnormal haematologists at the referral laboratory in the Waikato reg ion, findings if needed (e.g . medica l laboratory scientists, haematologist) refresher training is an ongoing internal activity. Staff also have oppor­ whereas in the Mid-Western region three of the six laboratories had no tunities to attend a morphology works hop, as do other staff from the able co ll eague. Satel lite laboratories in the Wa ikato referred abnorma l small er satellite laboratories. Most staff in the Mid-Western region fi lms and sometimes paras ites onto the referral hospital in the region, have received no refres her traini ng, and if they have, it was a general while the referral hospital review difficult films by group assessment of laboratory training and not specifica lly for bl ood film s. medi ca l laboratory scientists and hae matologists before a definitive Onl y one laboratory in the Mi d-Western reg ion re ported havin g comment is reported . Malarial smears may be referred onto a reference access to resources to ass ist them in blood fil m exam ination (e.g. blood laboratory. atlases, teach ing sli des, etc). In contrast, in the Wa ikato al l laboratories Mid-Western reg ion staff refer results onto the hospital doctor and have atlases I reference books, teaching sl ides that are continua lly occasional ly a pathologist in Kathmandu. being added to through external quality assessment schemes, and internet access. 9. External quality assurance participation All laboratories in the Mid-Western region are expected to participate 3. Criteria for preparation and examination of a blood film in the national external qua lity assurance program organised from the In the Wa ikato a blood fi lm cou ld be exam ined man ually: National Public Health Laboratory in Kathmandu. Waikato laboratories a) as requested by a doctor participate in the program organised by the referral hospital in the b) based on instrument results and flags region, the RCPA survey program or they receive the check samples c) based on cl inical details from the ACSP, or a combination of all three. Internal quality control d) if a sig nifica nt change in previous resu lts has occurred was assessed by ongoing monitoring from sen ior staff and va li dation of e) due to findings on the previous blood f il m film an d interpretative co mments with co mplete blood co unt res ults at In some laboratories however blood films are exam ined on all spec­ sign-out of reports. imens. Contrasted to this automated approach, in the M id-Western region a blood film is ever only exa mined manually if a doctor ord ers Quality assurance program evaluation the test. In the Waikato the aim is to enable rural hospital laboratories to com­ pare their res ults with each other and a central reference laboratory, to 4. Specimen coll ection and blood film preparation expose staff to blood f il m appearances rarely see n, to identify poor per­ All laboratories in both countries use wedge fi lms, however in the formance and as an educational tool. Waikato regional participants Waikato blood f il ms are usually made from EDTA blood, whi le in the find the program beneficial in maintaining professional confidence and Mid-Western region it is common practice for staff to make blood films co mpetence, and the ongoing edu ca tion provides stimulation and directly f rom a sk in puncture. chall enge. In the Mid-Western reg ion the prog ram is a means to assess per­ 5. Staining formance and identify poor performance for foll ow-up refresher tra in­ The Rowmanowsky sta ins used in the Wa ikato are either May­ in g, and thereby improve laboratory standards. Participants find the Grunwald Giemsa or Wright-Giemsa while in the Mid-Western reg ion program beneficial to assess the accuracy of their results, and for com­ all use Wright stain (one also used Le ishman's stain). All laboratories parison against other laboratories. It was noted however that due to have an automated staining mach ine in the Waikato and all stain blood the age of the blood films, staining was difficult. films manually in the Mid-Western region. A comparison can be seen between the two programs in Table 3. Data is insufficient for statistical analysis in both programs, therefore 6. Examination neither program analyse data statistically. However figures 1-2 do show All laboratories agreed that in evaluating the adequacy of the film that on a normal blood film participants' results in the Waikato are preparation and stain ing, the fi lm shou ld be assessed both macroscop­ comparable, whil e in the Mid-Western region there is a wide spread of ically and microscopically. If it was found inadequate in any way the results (Fig. 3-4). film should be remade. Computerisation and automation enables staff in the Waikato to Comparative quality control blood films access all laboratory results, including previous resu lts to ass ist in film In the Wa ikato region, all four participating laboratories examined and exam ination. In the Mid-Western reg ion however staff have access to reported results. Results were reported by medica l laboratory scientists. only those results performed on the same day. In the Mid-Western region, four of the six laboratories participated. A significant difference between both reg ions, is that in the Mid­ Laboratory ass istants only reported a differential count, w hile laborato­ Western reg ion onl y a 10 0-ce ll differen tial co unt is performed, w here­ ry technicians also attempted re porting a fil m co mment, and diag no­ as in the Wa ikato a ma nual 100 -ce ll differential co unt is usua lly only sis. Interestingly, all these staff co unted only normal ce lls and reported perform ed if review of the film indicates an inco rrect or anomalous immature w hite ce lls if seen. automated differential. Further, in the Wa ikato, white ce ll s, red ce ll s and pl atelet morphology is assessed. Leukocyte differential co unt Figures 5 - 8 show the four blood fi lm results in graph form, from all 7. Reporting the participating laboratories. Figure 5 shows that Waikato staff In the Mid-Western region differential percentages are alw ays reported detected a left-shi ft, but most staff in the Mid Western region did not. while in the Waikato differential absolutes are always reported and Figure 6 shows all laboratories in the Wa ikato region counted blast sometim es percentages in addition. Ce ll comments and interpretative ce lls, co mpared to none in the Mid-Western reg ion, although one lab­ comments are much more a feature on computer generated customer oratory reported seeing immature white blood ce ll s. Figure 7 shows orientated reports in the Waikato. Wa ikato laboratori es counted an increase in monocytes, Mid-Western

NZ J Med Lab Science 2001 46 Table 3. Results of the EQA programs Table 4. Comparative quality control study

Wn ikato !l-egion Mld~Wcstcr n region A 8 c D E F G H F

Voluntal)' Participation Yes No QCI -left shift Organisc1·s :nr :ulvisors I inspectors Ad visors Advisors and inspectors y y y y N y N N Physical hi SJ>Ccllons No1 related to th e quality control Supervision is an integral aspect or th e program program QC2 - blast cells y y y y N N N Normal and abnormal films A wide setccllon or nomHll and rarely Nom1al film s only seen film s isdistribUied - leukaemia I referral y y y y N y N N Staining Pre-stained May-Gruuwnld Gicmsa Unstained fhcd film s arc di stributed film s and cover slipped QC3 y y y y N N N N Prcquency Ever} week T\\0 films cvcl}· year · monocytes Clinical notes Clinical deta il s, ogc, sex. lib, MCV. No deta ils mcluded - target cells y y y y N N N N WDC.Pits

Diffcrcnlial count Somctunes rcqu1red Ah\ii)'S - (dimorphic/ N y y y N y N N Cell morphol ogy Co mm ent Somctunes required No hypochromic) · (liver dysfunction) y N N y N N N N lnterprctnliH Comment Usually rcqmrcd No QC4- toxic changes y y y y N N N N Co nfidcntlallly of reports No Yes · microcytes y y y y N N N N A nal~ sis All particip.1tmg lob re~ults arl! co llated All participating lob results arc collated together, photocopied nnd posted. No together, photocopied and posted . No y y y y statistical analysis. statistical analysis. - fragmented cells N N N N · low platelets y y N y N N N N Electronic transfer orresulls Po ~ ~tblc Not possible Time elapse or reporting Two weeks Two months Notes: Y = yes Performance assessment !.Poor performance is uotcd (e.g. !.Poor pcrfomumce is noted b) N=no lymphOC}tCs counted imtead of blast organisers (e.g. wide spread of results cell s). from Utrget re sults). 2.Consistent poor pcrfonmmcc may 2.Foll ow-up mcludes re\ iew of blood result in a phone call to the Ja boratOrJ. film s on next visit to the laboratory. flexibility for extra tests to be added if indicated to assist patient diag­ with the offer of refresher training. and systematic rciTesher training of all J. Lack ofpm1icipation is noted. staff. nosis, while government subsidy of laboratory tests are a great advan­ Ed ucational A wee kl y educational supplement is tage. included. Enables labs to build-up a teaching Thi s contrasts sharply to the Mid-Western region, where staff per­ slide set. Refresher training IS offered, but no morphology \\ orkshop yet form only the tests requested, and the patient pays for each test. While

Limit:-. lions !.Finding bloods with new appearances !.Moti vation of staff blood film examination is under-utilised in the Mid-Western region, and not repeating simtl ar blood film 2.Geography findings too frequently. J.lnsuffident stniTto properly and the quality of service is lower than in the Waikato region, it is 2.0rganisa tt on is time consuming implement th e program. important to acknowledge that in improving the quality, it should be appropriate for the situation. For many diseases, there is no, or li mited reg ion laboratori es did not detect this. Resu lts from blood f il m 4 (fig­ treatment, and therefore the importance to recog ni se different disease ure 8) ind icate a high percentage of neutrophils, yet in the Mid­ states in a blood fi lm for diagnosis is not as great. In add ition, as Western region most laboratories reported relatively normal results. In described earli er, automation of the leukocyte differential count was addition, it can be seen from all these graphs, that there is a wide vari ­ invented not only to improve quality but also as a cost saving tool. In ation between resu lts from the Mid-Western reg ion . Nepal, where staff sa lari es are cheaper, it is more cost-effective to per­ It was noted that staining of the unsta in ed blood films (1 and 4) in form a manual differential leukocyte co unt than install automation. the Mid-Western region was inadequate for proper exam ination. There Thi s however does impede quality. was a delay of seven months, between fi lm preparation and distribu­ Reporting of results from the comparative study and the quality tion. assurance programs, show clearly the lack of qua lity in the Mid­ Table 4 highlights the significant differences between the two reg ion s. Western region. It can also be seen, however, that the situations in Laboratories in the Waikato region ach ieved reporting most of the tar­ which the staff work, are less than optimal compared to the Waikato get results requ ired, whereas in the Mid-Western reg ion, not many of laboratories. Reasons for this lack of performance include limited train­ the target req uirements were reported. Th is aberrance can be attrib­ in g in blood fi lm morphology, low staffing not allowing for co ll eague uted to the lack of fi lm comment and diagnosis reporting. stimulation, coach ing or referral, staff working in isolated situations, limited continuous ed ucation and lack of specia lised staff. To improve Discussion the qua lity of blood film morphology there is clearly a need for further It is clearly seen that blood film morphology services in the Mid­ training of staff, coveri ng adequate staining, exam ination of tech­ Western reg ion are currently in the 'pre-1950's' era, while services in niques and assessment of blood f ilm components. Providing refresher the Waikato region are 'state of the art'. The implications of resources train in g, distribution of blood atlases and teaching slid es, and regu lar or lack of them, is seen through the quality of service ava ilable. exam ination of abnormal films will also improve staff competency, and In both reg ions, many aspects are com parab le. While specimen col­ therefore quality. lection varies in each region, both techniques co rrelate with interna­ In New Zealand it is important for sma ll satellite laboratories to main­ tional recommendations. Wedge smears are made and, Rowmanowsky tain professional competence and interestingly Waikato Quality stains used, however staff, particularly in the Mid-Western region using Assurance program participants find the program particularly beneficial manual methods, need to be aware of maintaining good technique. for this. Exam ination of the actual film is si milar, but more information is ava il ­ Compa red to internationally recognised EQA programs, both reg ion­ able for staff in the Wa ikato region. Ava il abi lity of patient data, clinica l al programs differ. The Waikato reg ional program ali gns close ly to details and laboratory results, including a complete blood count profile, these programs, w ith on ly two sign ificant variables. The frequency of sign ificantly aid in examination and ful ler reporting, ultimately assisting fi lms distributed is higher than the maximum two weekly recommen­ in patient care. dation, and reports are not confidential. Decreasing the current week­ This in turn is related to resource avai lability. Laboratory staff, doc­ ly distribution to two weekly, would assist in the difficulty of findin g tors, hea lth workers and patients in the Waikato reg ion benefit from new blood appearances, and the time consumed by the program, in a state of the art computer systems and ana lysers. There is greater busy laboratory. Usage of computer resources would also benefit

NZ J Med lab Science 2001 47 100 100 90 - "'Cl> 90 - 80 roOl c "'ell 70 -Cl> 80 O'l .....(,) ~c: 60 --Neut Cl> 0.. @ 50 --Lymph 70 ell :E 0. 40 Mono 0. Q) .....0 60 () 30 ~ E o s :; Cl> 50 20 z 10 40 0 lx. X==3<. X 2 3 4 5 6 7 8 9 10 11 2 3 4 5 6 7 8 9 10 11 Laboratories Laboratories

Figure 1. The spread of participant's results of neutrophil percentages Figure 2. The spread of participant's resu lts of all cell types - neu­ from a blood film from a normal pregnant woman distributed in the trophils, lymphocytes, monocytes, eosinophils- from the same quality Waikato regional external quality assurance program. Laboratory one control sample as in figure 1. Laboratory one represents the organising represents the organising laboratory result s. laboratory results.

60 100 Q) 90 0> 50 80 ~c "'ell 70 ~ 40 O'l ... ~ --Neuts Cl> c: 60 0.. 30 ~ 50 --Lymph s :E ell Mo no 0. 0. 40 20 Q) - Eosin g () 30 ::l --aaso zQ) 10 20 10 0 .._ 0 • .. .. '"' .. Target 2 3 4 5 Target 2 3 4 5 Laboratories Laboratories

Figure 3. The spread of participant's results of neutrophil percentages Figure 4. The spread of participant's resu lts of al l cell types - neu­ from the first survey distributed in the Mid-Western region, from the trophils, lymphocytes, monocytes, eosinophils, basophils - from the national external quality assurance program. Laboratory one results, quality control sample as in figure 3. Laboratory one results, represent represent the target va lue calcu lated from the national organising lab­ the target value ca lculated from the national organising laboratory. oratory.

program organiser's time. One of the greatest benefits of this program quency of films distributed and time elapse of reporting. Participants however, is the strong emphasis on it being educationa l. Satellite labo­ would benefit more, w ith greater emphasis on education as in the ratories are able to build-up a set of teaching films for training and con­ Wa ikato program (e.g. regular morphology workshops, distribution of tinual referral and a weekly educational supplement provides profes­ an educational supplement and abnormal slides w ith the EQA). Over sional stimulation where educational resources are not so readily ava il­ time, lack of educational resources would be improved. able. At the time of evaluation, a morphology workshop had not been Due to time constraints and lack of access to abnormal f ilms, a more organised for participants, but would provide a complement to the comprehensive study of comparative quality between the regions has program in the future. been limited. A follow-up study after two years with both regions usi ng In the M id-Western regional program, while participation in not vol­ the same EQA program and with an emphasis on education would be untary, a level of confidence had already been built with the staff. reveal ing. Physica l inspection of the laboratories has been linked with the quality This evaluation, and comparative study, has beneficial implications for assurance program, and if this were to continue, a strong affirmative the future. Evaluation of other laboratory tests could be undertaken to relationship between participant laboratories and program organiser's improve total quality management of laboratories, in accordance with needs to be further established and maintained. Aspects of the pro­ international recommen dations. Writing custom-designed teaching gram needing review include distribution of unstained blood films, fre- material and providing necessa ry resources for the strengthening of

NZ J Med Lab Science 2001 48 Biomedical scientists needed UK & Repub ic of Ire and

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Blood Film 1 Blood Film 2

OOther OOther 120 1 120 1 • nrbc • nrbc 100 100 •sas •Bas 80 OEos 80 OEos •Mono •Mono 60 60 Lymph Lymph 40 •Neut 40 •Neut OMeta OMeta 20 20 DMyel OMyel 0 •Promyel 0 -, •Promyel Q) ro 0 u.. I -, Q) ro 0 u.. I Ol DBiast .....Ol DBiast ..... ro .....ro .....

Figure 5 Figure 6

Blood Film 3 Blood Film 4 120 120

100 100 O nrbc 80 BOther 80 BBas B nrbc Eos BBas 60 60 I B Mono OEos 40 OLymph 40 OMono I oNeut BLymph 20 20 BMeta ONeut 0 oMyel 0 Q) ro 0 u.. I """) Q) en 0 u.. I ....Ol -Ol ..... ro .....ro .....

Figure 7 Figure 8

Figure 5-8 A bar graph of QC 1-4 leukocyte differential resu lts respec­ tively, from the comparative quality control assessment.

Note: Th e laboratories participating in the Waikato and Mid-Western regions extern al quality ass urance programs do not co rrelate exactly w ith the laboratories involved in the comparative study, therefore se parate numberi ng for the laboratories is used .

NZ J Med Lab Science 2001 51 blood film microscopy services in the Mid-Western region, would later blood. Am J Clin Pathol1978; 70 885-92. lead to providing resou rces for strengthening of the total laboratory 14. Lewis SM, Koepke JA, (eds) Hematology laboratory management service, throughout Nepal. In New Zea land, the extension of the EQA and practice. Butterworth-Heinemann, Oxford, 1995. program to a greater number of satellite laboratories throughout the 15. Dacie JV, Lewis SM. Practica l Haematology. 8th ed . Ch urch ill co untry would assist in strengthening and maintaining the quality se rv­ Livi ngstone, Edi nburgh, 1995. ice in laboratori es. 16. Chanarin I (ed). Laboratory haematology- an account of laborato­ ry techniques. Ch urchil l Li vingstone, Ed inburgh, 1989. Conclusions 17. Simmons A. Hematology: a co mbined theoretical and technical The qua lity of t he blood fi lm microscopy service in the Mid-Western approa ch. 2nd ed . Butterworth-Heinemann, Boston, 1997. region of Nepal lies in co ntrast to services in the Wa ikato reg ion and 18. International Committee for Standardization in Haematology. ISCH international recommendations, largely due to a lack of resources and reference method for staining of blood and bone marrow films by training. Greater co ll aboration between resource poor and rich regions, azure Band eosin Y (Romanowsky sta in). Br J Haematol1984; 57: 707- and countries would assist greatly in bridging the gap. 10. 19. Wittekind D. On the nature of Romanowsky dyes and the Acknowledgements Romanowsky-Giemsa effect. Clin Lab Haematol1979; 1: 247-62. Thanks to Dr Stephen May and Dr Rod MacRorie for their initial inspi­ 20. Powers LW. Diagnostic haematology- clinical and technical princi­ ration, direction and encouragement. I am appreciative of International ples. The CV Mosby Company, St Louis, 1989. Nepal Fellowship, for allowing me study time. Thank you to my good 21. Wittekind DH, Kretschmer V. Sohmer I. Azure B-eosin Y stain as the project co ll eagues, Om Raj Acharya and Shankar Chaudary for helping standa rd Romanowsky-G iemsa sta in. Br J Haematol1982; 51: 391 -3. w ith translation. Thanks also to the IN F Pokhara translation team. To all 22. Kapff CT, Jandl JH. Blood Atlas and Sourcebook of Haematology. of the laboratory staff that participated in this study, in both New 2nd ed. Little, Brown and Company, Boston, 1991. Zea land and Nepal, I am very grateful. I hope we all benefit. My grate­ 23. Jandl JH. Blood textbook of hematology. Little, Brown and ful thanks to Mr Rob in All en and Mrs Sue Webber from the Waikato Company, Boston, 1987. region, for their support and time in the comparative study and EQA 24. Yawata Y. Atlas of blood disease - cytology and histology. Martin program. Also, for t heir co llaboration, in w il lingly including Nepal in Dunitz, 1996. the Waikato EQA program. Th ank you to my friends Cra ig and Juliette 25. W illiams WJ, Beutler E, Erslev AJ, Lichtman MA. Hematology. 4th Drown, working in Nepal with us and also to Ash Fitchett of Hawkes ed. McGraw-Hill Inc, New York, 1990. Bay Regional Hospital laboratory for proof reading this dissertation. 26. EI-Nageh MM, Heuck CC, Appel W, Vandepitte J, Engbaek K, Gibbs W. Basics of quality ass urance for intermediate and peripheral labora­ References tories. World Hea lth Organization Regional office for the Eastern 1. United Nations Development Program me. Nepal development co­ Mediterranean, Alexa ndria, 1992. operation report, 1997. 27. Bain BJ. A beg inner's gu ide to blood ce lls. Blackwell Science, 2. Hi s Majesty's Government of Nepa l Ministry of Hea lth Department London, 1996. of Hea lth Services. Annual report - Department of Health Services 28. Koepke JA. Practical laboratory hematology. Church ill Livingstone 2053/54(1996/97). Kathmandu: His Majesty's Government of Nepa l, Inc, New York, 1991. 1998 Jan 22. 29. Koepke JA, Dotson M, Sh ifman MA. A critical eva luation of the 3. Statistics New Zea land Te Tari Tatau . 1996 census of population and manual I visua l differential leukocyte counting method. Blood Cells dwellings - population structure and internal migration. Welli ngton: 1985; 11: 173-86. Statistics New Zea land Te Tari Tatau, 1998. 30. England JM , Bain BJ. Annotation -total and differential leucocyte 4. Groner W, Simson E. Practical guide to modern hematology analyz­ count. Br J Haematol1976; 33: 1-5 . ers. John W iley and Sons Ltd, Chichester, 1995. 31. Bentley SA. Automated differential white ce ll count: a critical 5. Ba in BJ. Blood ce lls: a practical guide. Gower Medical Publishing, appraisal. Baillieres Clin Haematol1990; 3: 851-69. London, 1989. 32 . Auckland Haematology Special Interest Group. Standardised 6. Pierre RV. The routine differential leukocyte count vs automated dif­ reporting of haematology laboratory results. 3rd ed. 1997. ferential count. Blood Cells 1985; 11: 11-23. 33. Lewis SM. Externa l qua lity assessment in Europe. In : Rowan RM, 7. Koepke JA, Dotson M, Shifman MA, Boyarsky, MW. A flagging sys­ England JM , eds. Automation and quality assurance in haematology. tem for multichannel hematology analyser. Blood Cells 1985; 11: 113- Blackwell Scientific Publications, London, 1986. 25. 34. Koepke JA. The coll ege of American pathologists survey pro­ 8. Roberts B (ed). Standard haematology practice. Oxford Blackwell gramme. In: Rowan RM, England JM, eds. Automation and quality Scientific Publ ications, London, 1991. assurance in haematology. Blackwell Scientific Pub li cations, London, 9. Koepke JA. Rationale for the NCCLS standard H20-T for differential 1986: 62-83. leukocyte countin g. Blood Cells 1985; 11: 161 -71. 35. UK NEQAS Executive. UK national external quality assessment 10. Approved Standard NCCLS Document H20- 12. Reference leuko­ sc hemes 1995-6 - report and directory. Woodcock Graphi cs, Sheffield, cyte differential co unt (proportional) and evaluation of instrumental 1995. methods. National Committee for Clinica l Laboratory Standards 1992 36. Leb lanc A, Goguel A. The French national system for external qual­ March; 12(1) . ity assessment. Clin Lab Haematol1 990; (12 Suppl.1 ): 129-34. 11 . Koepke JA, Ross DW. White blood cel l differential: a cal l for stan­ 37. Lewis SM. Blood film evaluations as a quality control activity. Clin dard s. Blood Cells 1985; 11 : 1-9. Lab Haematol1990; (12 Suppl. 1): 119-27. 12. Gu lati GL, Hyuan BH. Blood smea r examination. Hematol Oncol 38. Lewis SM . Qua lity assessment sc hemes. In: Cavill I (ed). Methods in Clin North Am 1994; 8: 631-49. haematology (4) Quality control. Churchill Livingstone, New York, 13. Nourbakhsh M, Atwood JG, Raccio J, Seligson D. An eva luation of 1982: 14-29. blood smears made by a new method usi ng a spinner and di luted

NZ J Med Lab Science 200 1 52 A N N 0 u N c E M E N T

Bu t we are not mak i ng a huge spl ash of it. Appendix 1 Abnormal's seen) . Questionnaire for Government Hospitals For the purpose of this research, blood film microscopy service is In looking at a blood film: How do staff eva luate the adequacy in fi lm defined as differential count, examination of a blood film specifically preparation and stain in g? for normality or abnormality of white blood cells, red blood cells and platelets. This resea rch does not cover blood film microscopy specifi­ Are Full Blood Count parameters and other laboratory results available cally for malaria or microfilaria. when looking at the blood film? If so, which ones? Reg ion I Country: How is the blood fi lm examined? (eg. Differential count only, com­ Size of Hospital (no. of beds): ments on cells).

No. of Doctors in the hospital: How are blood films reported in the laboratory?

Consultant Haematologist: Yes No Differential count - percentages or absolute values?

Population hospital serves: Ce ll com ments (including inclusions)?

Does this laboratory provide a blood film microscopy service? Interpretative comments? Yes No Does this laboratory participate in an external or internal blood film How many staff work in the department? Quality Assurance Program? If so, please explain fully.

How many staff vacancies are ava il able in the department? When abnormal blood films are see n: Is there another person ava ilable to confirm abnormal findings? Who? Do you feel the department is overstaffed, understaffed, or staffing is adequate? Who are the findings referred onto? (eg . Referral laboratory, se nior techn ician I technolog ist, Doctor, Haematology Co nsultant, How many staff in t hi s laboratory exam blood films? Patholog ist).

What qualifications do the staff exam ining blood films have' I give approval for the above information to be used in a confidential manner. knowing that my name and laboratory name will not be men­ How much training was initially given for blood film examination? tioned, for Vanessa Thomson to write her dissertation for her Fellowship in Haematology (MZIMLS). I understand that the purpose Was the initial training work-site based or from an institution? of this research is to evaluate blood film microscopy services compar­ ing two regions - one in a developing country and one in a developed Did you feel the initial training was adequate? Did you feel confident country, and results maybe used to develop microscopy services in to look at blood fi lms after the train ing' either region. I also understand that this information maybe published or presented in a meeting, and I give approval for this. Do you now feel confident examining blood films? Appendix 2 Describe the staining technique used for blood films in your laborato­ Quality Control Program Evaluation ry. 1. Aims:

In which situations would a blood film be looked at? (eg. Ordered by a 2. How is QC material prepared and distributed? To whom? Doctor, added by lab staff on see ing abnormal Full Blood Count results, etc). 3. How are the results analysed?

How is it judged whether the staff are competent in their blood film 4. What are the beneficial aspects of the program? exam in ation? (eg. Competency documents). 5. Is the program achieving was it was set up to achieve? How? Have staff received refresher training? If so, when and for how long? 6. What follow-up is there for a laboratory w ith consistently abnormal Is supervision given from outside I in side the laboratory to check work? results' Explain. 7. What are the limitations of the program? What access do staff have to resources to ass ist them in blood film exam inations (eg. Blood atlases, teaching sli des). I give approval for the above information to be used in a confidential manner. knowing that my name and laboratory name will not be men­ How many blood fi lms are examined da il y, weekly, monthly, yearly as a tioned, for Vanessa Thomson to write her dissertation for her laboratory I for staff individually. Fellowship in Ha ematology (NZILMS). I understand that the purpose of this research is to evaluate blood film microscopy services comparing How much expe ri ence do staff have in blood film examination? (eg. two regions - one in a developing country and one in a developed

NZ J Med Lab Soence 2001 54 country, and results may be used to develop microscopy services in Appendix 4 either region. I also understand that this information maybe published Blood Fi lm Quality Control Evaluation or presented in a meeting, and I give approval for this. Instructions: Please find enclosed four blood films for microscopic exa mination. Two Appendix 3 blood films are stai ned an d blood parameter I patient information is Quality Control Program Evaluation for Participants given reflecting Qua lity Control in New Zealand. Two blood f ilms are 1. What is the quality of t he blood smears on exam ination? unstained and no blood parameter I patient information is given 2. Does your laboratory use the same staining technique as the blood reflecting Qua lity Control in Nepal. smears received? On the stained blood films perform a differential count, report a 3. Is the reporting I eva luation of results from the QC centre adequate comment on the ce lls and suggest a diagnosis. for your needs 7 On the unstained blood films sta in the sli des and return the sli des 4. What do you consider the beneficial aspects of the program and with your result sheet. For 'QC 1' perform a differential count only. why? For 'QC4' perform a differential count, report a comment on the 5. What does your laboratory do if QC results are not consistent with cells and suggest a diagnosis. results of the other laboratories? Ie. 6. What do you consider the limitations of the Program? QC1 stain, differential count QC2 differential count, film comment, diagnosis I give approval for the above information to be used in a confidential QC3 differential count, fi lm comment, diagnosis manner, knowing that my name and laboratory name will not be men­ QC4 stain, differential count, film comment, diagnosis. tioned, for Vanessa Thomson to write her dissertation for her Fellowship in Haematology (MZIML S). I understand that the purpose Guidance for doing differential count of this research is to evaluate blood film microscopy services compar­ 1. Count early band forms as metamyelocytes and late band forms as ing two regions - one in a developing country and one in a developed segmented neutrophils. country, and results maybe used to develop microscopy services in 2. If nucleated red cells are present, count the number per 100 WBC's either region. I also understand that this information maybe published and report as the number. or presented in a meeting, and I give approval for this. 3. Report all differentials as percentages.

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International Association of Medical Laboratory There is a savin gs accou nt in the UK that is being used up. If this is Technologists membership liquidated it will all ow the office to function to 2004 and then the IAMLT w ill be bankrupt. Dea r Editor, The Council of the IAMLT seems unable to make difficult decisions I am w ri ting to oppose the NZIMLS reta inin g its membershi p of the regarding f inance, it has not even incl uded a statement regarding Internationa l Association of Medica l Laboratory Technologists (IAMLT). f inance in its action plan 2000- 2002. During the 12 years I served as a Council member of the NZIMLS I The NZIMLS had a $36000 deficit last year and has to budget care­ questioned why the NZIMLS should remain a member of the IAMLT. fully. I do not think the NZIMLS can afford to give $1100 annually to an My reasons were primarily: organization that provides no benefit to it that I can see and that is like­ 1) That membership of the IAMLT did not really benefit the NZIMLS and ly to disappear within the next few years. that as the NZIMLS was struggling to rema in f inancial ly viable, the sub­ Shirley Gainsford scription was better spent elsewhere. Valley Diagnostic Laboratortj, Lower Hutt 2) I was very concerned at the f inancial state of the IAMLT itself. The IAMLT has published policy guidelines on Near Patient Testing, the Environment and Educational Requirements for Medical Laboratory Dear Editor, Sciences and is writing them on Qua lity Systems in Medical Laboratory I am also writing in support of the NZIMLS retaining its membership of Science and Continui ng Professiona l Development. The NZIMLS has its the International Association of Medical Laboratory Technologists own poli cies, w hi ch are as good as or better than t hose of the lAM LT. (IAMLT). Each year member orga ni zations are as ked to hold a Biomedica l When I read t hat our Council (NZIMLS) was cons ideri ng withdrawin g Science day with a set theme. Despite encouragement from the from membership of the IAMLT, based on a Motion carri ed at the last NZIMLS few laboratories in New Zea land have co ntributed to this idea. AGM, I was aston ished and saddened by this prospect. Despite t he IAMLT being a Non Governmental Organ isat ion w ithin In my view this would be a retrograde step in the light of interna­ WH O, it has had little success getting W HO to use t he IAMLT to nom­ t ional interchange of medi ca l scientif ic adva nce ment, also in the sig­ inate persons for WHO committees or projects. nifica nt co nt ribution made by New Zea land co lleag ues over the yea rs. Th e IAMLT has established SIGs in t he va riou s di sciplin es and ca ll ed I ce rtain ly re iterate the co mments and hi story outlined, so well, in t he for nominations for t hese committees. Only 25 people responded, 8 of Letter to t he Ed itor by Dennis Reilly (1). w hom were f ro m Microbi ology. Over the past 40 yea rs of my employment in the hea lt h services of I concede that t here is a benefit to the NZIMLS members through the t his country (med ical laboratory technolog ist/manager and CEO of two awards t hat are offered. divisions of t he Cancer Society of NZ) I have enjoyed and appreciated Attempts have been ma de to help less developed countries through t he support and experience shared t hroug h interaction with co ll eagues the Development fund which reli es on donations for fu nds, and the around the world. Country Project in which the IAMLT acts as "broker" between donor Th is has occurred by way of journals and study visits to Australia, and recipient countries. To my knowledge only one or two projects USA, Hungary, Scandanavia and the UK. Some of these contacts have have been developed, although I accept that these initiatives may take continued to this day both professionally and at a personal level. time to expand as member societies are struggling financially. Interestingly, I have found that, invariably, these relationships have At the General Assembly of Delegates (GAD) in 1998 the Treasurer been mutually recognised as beneficial. warned that the IAMLT would be bankrupt by 2002 unless something Consequently, I have always valued our Institute's membership of the was done. This prompted the NZIMLS to seek a legal opinion on thelia­ IAMLT. Also, I continue to believe that our present day NZ qualified bility of the NZIMLS in the event of financial collapse of the lAM LT. The medical laboratory scientists have much to offer in the years ahead at opinion was "generally of the view that the NZIMLS was not at risk" . the international level. Since then the only action taken has been to discontinue the Med Tech G. Frank Lowrtj, MNZM, MNZIMLS (Non Practicing) International Newsletter and replace it with an online newsletter. Few member organisations have bothered to forward news and unfortu­ nately this probably means poorer communication with members, as Reference one has to have access to, or make the effort to go to the website to 1. Reilly D. IAMLT membership (Letter). NZ J Med Lab Science read news, whereas one is more likely to read printed material received 2001; 55: 5. in the hand. At the General Assemb ly of Delegates (GAD) in 2000 the Treasurer Editor's note. projected deficits of $40500 for 2001 and $42000 for 2002. A discus­ Membership of the IAMLT by the NZIMLS will be discussed at the 2001 sion on f inances took place at this meeting late in the day, prompting AGM. At the 2000 AGM a motion was carried "That Council refrain delegates to comment that fi nance should have been further up the from paying t he next subscription until this is discussed at the 2001 agenda or discussed at t he more open forum, the pre GAD meeting. AG M" . The Chairman repli ed that "due to the delay in receiving the auditor's Dennis Reill y, past Presi dent of the NZIMLS an d past Council Member report and budget, Council was not co mpletely awa re of the actual sit­ of the IAMLT, by invitation, prese nted his views on this topic in the uation". Does this mean that an organization that knows it is in a pre­ April, 2001 issue of t he Journal (1). Shirley Ga in sford , past President of carious financial situation is not kee ping a running brief on its the NZIMLS, by invitation, presents her views in this iss ue of the f inances? The major ex penditure of the IAMLT is the cost of running the office. Journal. As Editor, I invited members of the profess ion for their ~ i ews. Thi s is being moved from Sweden to Singapore, not to save money but On ly one, Frank Lowrey, has replied. His views are in this issue of the because the Executive Director is moving there. Council "hopes" that Journa l. the cost will decrease.

NZ J Med Lab Science 200 1 57 Abstracts from articles in the Australian Journal of Medical Science, the official publication of the Australian Institute of Medical Scientists.

Faddy S. Drowning and near-drowning: the physiology and Lemierre's synd rome was common in the pre-antibiotic era, with the pathology. Aust J Med Sci 2001; 22 (1): 4-13. greater majority of cases being fatal. Cases are now rare, and although Abstract: Drowning is one of the leading causes of premature death in the mortality rates are comparatively low, reported morbidity rates Austra li a. Hot summer temperatures, a high proportion of the popula­ remain high due to low levels of recognition and delays in diagnosis tion resident in coasta l reg ions and easy access to beaches, rivers and and optimal therapy. A history of pharyngitis is a key indicator foll owed swimming pools ensure that aquatic activities feature strongly in the several days later by signs of severe sepsis. The microbiology laborato­ leisure time of many Australians. The rate of drowning in Australia is ry has a vital role to play in the isolation, accurate identification and 1.6 deaths per 100,000 population, with 80% being male. Drownings prompt reporting of isolation of F. necrophorum. The isolation of this are the most frequent in the 0-5 year age group, followed by the 20- organ ism from blood cu ltures is distinctive enough to confirm a pre­ 49 year age group. Alcohol is estimated to contribute to as many as sumptive clin ica l diagnosis or otherwise initiate further investigation 50% of drowning accidents. Developments in the advanced life sup­ with a provisional diagnosis of postanginal septicaemia or Lemierre's port capabi lities of ambulance officers and publi c awareness of the syndrome. importance of CPR education have led to a large number of drowning Key words: postanginal septicaem ia, thrombophlebitis, metastatic foci, victims be in g ad mitted to the Emergency Department or Intensive Care Fusobacterium necrophorum. Unit for treatment. Th e greatest pathophysiological consequence of near drowning is hypoxae mia, w hich threatens ce rebral, ca rdiac and major organ function. The drowning incident and severa l treatments effect the pathophysiological state of the patient and will res ult in a number of changes to haematological and biochemical markers. Pathology tests help to determine the severity of the injury and guide management in both the acute and long-term stages of treatment. Thi s articl e reviews the pathophysiology of the drowning process, the asso­ ciated patholog ica l changes, current recommendations for treatment and the implications of a number of prognostic indicators on the out­ come of the resuscitative effort. Key words: drowning, near-drowning, physiology, pathology, hypox­ The Doctors Laboratory, London W1, United Kingdom aemia, acidosis, cardiopulmonary resuscitation, review. Medical Laboratory staff planning a working holiday within Glasson JH, Lowe AH, Drew DK. Fungal sinus infections: three the UK are invited to contact us. case studies. Aust J Med Sci 2001, 22(2): 80-3. Short and long term positions are often available and we pay Abstract: Two cases of fungal sinusitis are described in patients who excellent rates. were confirmed immuno-competent, had no history of upper respira­ tory tract trauma, diabetes or local or systemic corticosteroid therapy. For further details please visit our website A third case is reported in which a sample of nasal discharge grew www.tdlplc.co.uk Aspergillis flavus but no abnormal findings were reported on extensive examination of the airways. The role of fungi in various respiratory syn­ dromes is reviewed and issues relating to laboratory diagnosis and ther­ apy discussed. Key words: fungal sinusitis, Asperg illis flavus, Alternaria spp., Bipolaris spp.

Monaghan W. Lemierre's syndrome: clinical presentation and role of the microbiology laboratory. Aust J Med Sci 2001, 22 (2): 72-9. Abstract: Lem ierre's syndrome is a human necrobaci llos is or more specifica ll y, a postanginal septicaem ia. Th is syndrome is characterized by an initial pharyngotonsillar infection followed by thrombophlebitis of the intern al jugular vein (IJV), anaerobic bacteraemia and septic embolisation. Metastatic spread of infection characteristica lly affects the lungs and joints. Cases occur typica lly in previously hea lthy young adu lts. The syndrome is ca used in an overwhelming number of cases by a sing le anaerobic bacterium, Fusobacterium necrophorum.

NZ J Med Lab Science 200 1 58 Haematology

Spec al Interest Group

HSIG Journal Based Learning- Questionnaire thalassaem ia trait. TRUE FALSE CE Update - Anaemias II "Differential diagnosis of microcytic anaemias" 12.Significant numbers of microcytic, hypochromic red ce lls are present Judith L. Meredith, MD, Nancy S. Rosenthal, MD. in 50% of cases of anaem ia of chron ic inflammation Laboratory Medicine Vol. 30, No.8, August 1999, p 538 - 542. TRUE FALSE

Please circle the correct response 13. Reticu locytes are increased in proportion to the degree of anaemia in ch roni c inflammation. 1. A decrease in MCHC correlates with the degree of hypochromia in TRUE FALSE red ce ll s. TR UE FALSE 14. Macrophage cytokine secretion makes iron unavai lable for haemo­ globin synthesis in patients with chron ic inflammatory di sease. 2. Chron ic inflammation is the second most common cause of micro­ TRUE FALSE cyti c anaemi a. TRUE FALSE 15. Th e MCV is useful in distinguishing betwee n the hereditary and acq uired forms of sideroblastic anaemias. 3. Free erythrocyte protoporphyrin is increased in iron deficiency TR UE FALSE anaem ia. TRUE FAL SE 16. 1ro n defi ciency may develop following a case of lead poisoning . TRUE FALSE 4. Serum transferrin receptor level is elevated in the anaem ia of chron­ ic inflammation. 17. Basoph ilic stippli ng may be a feature of sideroblastic anaemia and TRUE FALSE beta thalassaemia but not iron deficiency or ch ron ic inflammation. TRUE FALSE 5. The serum transferrin receptor protein is present only on develop­ ing red ce ll precursors. 18.Free erythrocyte protoporphyrin is raised in sideroblastic anaemia. TRUE FALSE TRUE FALSE

6. A normal RDW is thought to be more consistent with thalassaemia 19.Percentage iron saturation is normal in thalassaemia . than with iron deficiency. TRUE FALSE TRUE FALSE 20 .Serum iron level is raised in sideroblastic anaemia . 7. A cell haemoglobin distribution width (another index of red cel l het­ TRUE FALSE erogeneity) is the standard deviation of the product of the red cel l vol­ ume and MCV. 21. Serum transferrin receptor level is raised in iron deficiency anaemia . TRUE FALSE TRUE FALSE

8. The alpha thalassaemia gene is located on chromosome 11. Obtain a copy of this article from your medical library, or I would happy TRUE FALSE to mail a copy to those requesting th is option . Contact Jacquie· Case , Haematology Dept., Middlemore Hospital, Ota huhu, Auckland Ph 9. HbH levels in th ree gene deletional alpha thalassaem ia may be 2760044, extn 85 15. decreased in concom itant iron deficiency. Or e-ma il: jcase@midd lemore.co.nz. TR UE FALSE Answers on page: 65 10. The peripheral blood smear in beta thalassaemia tra it shows more bizarre features than that in alpha thalassae mia trait. TRUE FALSE

11 . Quantitation of HbA2 is necessary for accurate diag nosis of beta

NZ J Med Lab Sc1ence 2001 59 Microbiology Spec al Interest Group l 'lff;~.

A very successfu l sem inar was held in Hamilton in March. Over 70 peo­ progress after a 6 week course of IV amphotericin and oral fluconazole. ple attended the Friday evening sessions on Occu lt Blood Testing and IANZ registration requ irements. Th anks to Syd ney Sacks, Phi l Barnes, Once upon a time. Chris Jackson - Medlab Hawkes Bay and Linda Manuel for their presentations. It certa inly created a lot of Recently a se ni or lab sc ientist became ill with pyrexia, nausea and loss discussion, and has led to many labs looking close ly at the way they do of appetite. Pre lim inary blood tests showed elevated liver enzymes, things. reduced platelets and a ra ised ESR. The white blood ce ll count was 4.3 The Saturday sem inar had 140 attendin g and 17 presentations cov­ x1 09 /L . Investigations for hepatitis and viral disease proved negative. ering a w ide ra nge of topics. Th anks to all of those who presented - it After 7 days, his condition worsened w ith increased fever and rigors. is not easy to face such a large group, but t he success of t he day is Blood cu ltures were taken and Salmonella paratyphi A was iso lated. dependent on you. Congratulations to Tin a Littlejohn for w inn ing the The organism could not be differentiated from an isolate rece ived in a awa rd for best presentation, and to Chris Jackson for a close second. RCPA Quality Assurance Program a month previously. The patient was Thanks also to our supporters (Bayer, Global Sc ience, Ngaio admitted to hosp ital and after more blood cu ltures were taken was Diagnost ics, bio Merieux, IANZ and Hea lth Wa ikato) and to the tea m treated with IV Ceftriaxone. Just a month later, the sa me organism was w ho spen t numerous stressful hours in organising the se minar isolated f rom the blood of a lab sc ientist working in the Microbiology (Catherine Tacker, Kay Stockman, Matt Akehurst, Gail Nielson, Tina department of the local hospital. This staff member had a two week Jowsey, Karen Jowsey, Jennie Frost, Carla Sha il er, Jan Bird, Chris Pickett, history of fever, headache and joint pa in. and Steve Soufflot). This case study ill ustrat es the va lue of taking blood cu ltures from Next years sem inar w ill move to the South Island for the first t ime. It patients w ith pyrexia, and remi nds us of the risks we all fa ce of con ­ is to be held in Christchurch in May. Ju li e Vin cen t (Canterbury Hea lth tracting laboratory acquired infections while handli ng viru lent organ­ Laboratories) is the sem inar coord inator. isms. Th e abstracts from this years sem in ar are included below. Steve So ufflot, MRSA screening methods in NZ hospitals. Henrietta Maguire - MSIG Conve nor. Wellington Hospital A questionnaire on MRSA screening methods was sent out to 18 hos­ The case of the sore foot. Joan Byrne - Wellington Hospital pital laboratories nationwide. All hospitals include a nasal and groin A 27 year old Samoan office worker who had earl ier been diagnosed swab in their screen and swabs from ulcer/wound sites. Only a few with SLE suffered a fall and presented to the Emergency Department include invasive devices eg. urinary catheters or faeces (in patients w ith with a fractured foot. Th is resu lted in ongoing pa in, w hich was treated diarrhoea) in the scree n. with a steroid injection. An abscess subsequently developed which on In the survey of MRSA screens during February 2001, only 40% of culture grew a pure growth of Salmonella Typhimurium. Although positive patients were detected by MRSA screening. 12% of MRSA stool samples were never received in the laboratory, the source of the screens were detected by enrichment broth only. organism was thought to be a self-li miting diarrhoeal illness she suf­ As expected, laboratori es vary in their methods of processing screen­ fe red w hile holidaying in Samoa. The importance of a correct diag­ ing swabs. All labs use an MSA plate containing methicill in/oxacillin as nosis was high li ghted by the Infectious Disease physicians w ho indicat­ their se lective agar. Two labs don't inoculate a primary so li d medium, ed that an abscess would normally have been treated with Penicillin whil e five labs do not use enrichment broths. and Flucloxacillin, which in this case would have been inappropriate. Most labs keep their primary isolation medium up for 48hrs (24-72 hrs). Of those t hat use en richment broth, 70% incubate for 24h rs Cryptococcal meningitis - a case study. Nicola Gelston - Wellington while 30% incubate for 48hrs. Plates sub-cultured from the broths are Hospital sp lit almost 50/50 between 24hr and 48hr incubation. TAT for negative A case study foll owin g a young male patient who developed crypto­ screens vary from 24hrs for one lab (no enrichment broth used) to 96 cocca l meningitis after a prolonged co urse of immunosuppressant hrs (three labs). Eight labs have a TAT of 48hrs and the remaining six drugs, including prednisone, for the treatment of sa rcoidosis. labs put their negative results out after 72 hrs. The microbiology laboratory exam ined 7 CS F specimens between Pub lished studies suggest that enrichment broths shou ld be used in October 2000 and March 2001. Cryptococcus neoformans was isolat­ MRSA screen ing and that 24hr is sufficient incubation time for t he ed on t he second CSF with a posit ive India Ink stain, encapsulated yeast broth. Th is survey may give labs some food for thought and ideas for cell s see n in t he gram stain, growth on blood agar, chocolate aga r and adapting methods if requ ired . SAB agar, and a cryptococca l antigen t it re of 1:16000. Addit ionally the openin g pressu re record ed on performing t he lumbar puncture was Urinalysis beyond 2000. Carrie Swanson - Medlab Hamilton 45cm (normal is <20cm) which is co nsistent w it h Cryptococca l meni n­ An evaluation of t he Sysmex UF1 00 and UF 50 urine ce ll cou nt ana ly­ gitis. sers in a cl inica l workplace, and our reasons for ut ilisation. The further CS F exa minations were done to monitor the pat ient's Th e Sys mex UF 10 0 and UF 50 are semi-automated urin e analyse rs uti I-

NZ J Med Lab Science 2001 60 ising flow cytometry to differentiate and determine concentrations of bird-life from contact w ith infected sparrows, and contacted the stained elements by simultaneous measurement of their scatter, fluo­ Department of Conservation which, together with the Massey rescence and impedance. They have preset parameters which flag University and the National Centre for Di sease Investigation, began a abnormal results (including glomerular red cells) indicating a manual national study of bird deaths. microscopy is requ ired. The UF 100 is able to be interli nked w ith a dip­ It was found that STM 160 was present in many different species of stick processor, and ca n ana lyse 100 sa mples per hour. The UF50 birds, although sparrows predominated. Bird deaths were recorded processes 50 sa mples per hour, has a superior probe design and an throughout New Zea land. STM 160 has now also bee n isolated from anti-ca rryove r function. dogs, cattle, horses, rabbits, goats, poultry and deer. There are no widely recogn ised UF1 00 urine reference standa rd s. We Macrorestriction DNA analysis using pu lsed-field gel electrophoresis obtained presumptive standards after statistical ana lysis of a two week of Xba 1 digests showed that all isolates since 1999, both human and trial of all urines received, using the Sysmex UF1 00 and a manual ce ll non-human, belong to the same clone. cou nt (Kovasl ide). Reports of infection w ith STM 160 from co untries other than New The UF1 00 was purchased to improve analysis accuracy and assur­ Zea land are rare. It is still not known how this unusual phage type was ance, to reduce manual urine microscopy vo lumes, and to decrease introduced into New Zealand. staff costs. It fulfils our expectations in that the results obtained are reproducible and accurate, we have decreased our manual microscopy Out on a LIM. Tina Littlejohn - Medlab Central, Palmerston North. rate substantial ly, and hence saved technologist t ime. In conjunction w ith our Infectious Diseases Physician implementing a prevention strategy towards perinatal Group B Streptococcal (GBS) dis­ A touch of Danish culture. Tess Urbanski- Medlab BOP ease at MidCentral Health, our laboratory included a LIM broth into our 551 enteric media was developed and used by Statens Serum Institute, gen ital swab cu lture regime. I conducted a study of the increased iso­ Copenhagen, Denmark for more than 20 years, for the isolation and lation rate of Group B Streptococcus after the addition of the LIM identif ication of enteric pathoge ns (with the exception of broth. Ca mpylobacter). An eva luation study of this media performed in LIM broth is Todd-Hewitt containing co li stin and naladixic acid Taura nga showed a compa rison of 551to XLD/HE and CIN agar for iso­ (Oxoid-Giobal Sc ience). lation of Salmonella spp and Yersinia enterocolitica. The study of 1065 A vaginal and rectal swab from pregnant women to be taken at 35- faeces specimens tested showed comparable isolation of Sa lmonella 37 weeks gestation was recommended. With this timing there is a pos­ spp and Yersinia enterocolitica, and showed improved isolation of itive predictive va lue of 85% and negative predictive va lue of 97%. Th e Yersin ia when both 55 1 and CIN aga r were used together. Th is was USC DC morbidity and mortality weekly report guidelines suggested because some isolates grew on CIN only and some on SS I only. The cost that by add ing a selective media iso lation rates should increase by up of t he SS I agar plates was comparable to XLD/HE agar plates and the to 50%. work involved to identify organisms growing was assessed by t he num­ By decreasing the use of prophylactic antibiotics on GBS carrier ber of urea broths, TSI slopes and LI A slopes set up from both media. women during labour the adverse effects are redu ced. For example, Th e number of urea broths set up from SS I was co nsiderably lower than with random administration on a population of four million deliveries from the XLD/HE - 196 and 302 respective ly. Th is was due to the easy an nually you woul d expect ten deaths per year from anaphylaxis, identification of Proteus spp, w hich gave a strong phenylalanine ass uming a 25% co lon isation rate. In most populations stu died 10- decarboxylase positive reaction on SS I. The number of TS I/ LI A slopes 30% of pregnant women are co lon ised with GBS. Of all infants born used was comparable with 133 and 140 respectively. to these colon ised mothers approximately 1-2% will develop early Note: Sin ce this study we have tria led a XLD/SSI split plate. Our labora­ onset invasive disease. tory has decided to routinely set up an XLD/SSI sp lit plates plus a CIN In my study I co llected statistics on 1200 samples over three months. plate for routine culture of our faeces specimens. We have done this to From 1200 specimens we had 273 (23%) positive for GBS. Out of the save cost and time setting up urea broths and to improve the isolation 273 positives, 192 were positive from the LIM broth only. Therefore by of Yersinia enterocolitica. including a LIM broth to our routine culture protocol we have increased our isolation rate of GBS by 70%. "Birds of a feather". Jenny Bennett, Charlotte Kieft, Graeme A LIM broth is now part of our routine culture regime and we are MacKereth, Carolyn Nicol - ESR continuing to encourage the correct t iming of samples and a specimen At the end of 1999, an uncommon phage type of Salmonella from both sites. Typhumurium, STM 160, was seen - one case in November and two cases in December, all of them in Canterbury. The on ly previous case of Selexid. Joanna Stewart - Diagnostic Medlab this phage type occurred in November 1998, also from Canterbury. In Se lexid is the trade name given to the pro-drug pivmecillinam. It is an 2000 cases continued to occur in Canterbury at the rate of one or two ora ll y ad ministered b-lactam antibiotic for empirica l use in treatin g a month, until July, w hen the f irst case was seen in South land. From acute urinary tract infections. The drug has a narrow spectrum of activ­ then on, cases occurred w ith greater and greater frequency, and ity, being highly specific against Enterobacteriaceae, particularly E. coli beca me more w idespread, until now cases are see n in nearly every the most common urinary isolate. hea lth district in New Zea land, although still predominantly in Increas ing resista nce against reg ularl y used antibiotics may warrant Canterbury. the introduction of another drug that has shown to not induce resist­ At the sa me time as the human cases of STM 160, it was noted that ance. By continuing to use standard antibiotics there is a risk of resist­ sparrows were dying in unusual numbers in the Canterbury reg ion. The ance levels reaching, in some cases, more than 10%. Th is could lea d to f irst non-human isolate se nt to ESR was from a cat, which had no con­ the drugs becoming ineffectual in treating more serious diseases. nection to t he human cases. This was followed by a post mortem iso­ In t he 20 year history of pivmecil li nam use in Scandinavia there has late from a cockatoo. The cockatoo had died after eating a sparrow been no increasing res istance to this antibiotic. It does not share gen­ which had flown into its cage at a w ild life park in Christchurch. The eral cross-res istance w ith other penicill ins. Susceptibi lity studies at owner of the wildlife park was concerned at the possible risk to native DM L have shown a 4% resistance level of E. coli to mecil linam. This is

NZ J Med lab Sc1ence 2001 61 sim ilar to the resistance leve ls found in Scandinavia. A Va ncomycin resistant Enterococcus species was isolated from an Apart from the normal allergy risk as w ith other penicillins, mecilli­ elderly CAPO patient. The organism was identified as E. gal!inarum nam has few side effects. This is larg ely due to rapid absorption in the when tested by API Rapi d ID 32 Strep. BBL GP Crystal, methyl 0-a lpha­ gut, w hich reduces intesti nal concentrations, and its narrow spectrum glucopyranoside (MDG or MADGE ) broth, and motility testing identi­ of activity. fied the Enterococcus as E. faecium . This antibiotic is be in g re-introduced to the New Zea land market. Th e organism was confirmed by ESR as E faecium using PCR tech­ niques. ESR recommends t he use of add itional tests, such as MDG (or A case of having gone to the dogs. Gail Nielson - Health Waikato, MADGE) Broth, 6.5% NaCI and motility testing to confirm the identifi­ Hamilton ca tion of Enterococcus faecium Hydatid Disease is thought to be extremely rare in New Zea land today, although it can be found worldwide in mainly rural areas. It is a tissue infection caused by the larval stages of the E. granulosis tapeworm. It is a notifiable disease with an average of five new cases reported each year. Humans can be an accidental intermediate host at the egg stage after contact w ith an infected dog. Having been swa ll owed, the egg hatches in the sma ll bowel and re leases an oncosphere. This penetrates the intestinal wa ll, migrates through the bloodstream into various organs, and develops into cysts. Because hydatids can be dormant in the human body for 10-20 years, diagnosis is sometim es difficu lt wit h symptoms mimicking other diseases. These are abdominal pain in We are regularly looking for upper right quadrant, jaundice, bloody sputum and/or chest pain, temporary laboratory scientists, with fever, fatigue, or joint pain. Diagnosis can be made by a physical exam, experience in medical microbiology, X-rays, CT sca ns, aspiration of cyst fluid for microbiology, and blood tests (hydatid complement fixation, hydatid ha emagglutination and for our central London laboratory. latex agglutination - all of w hich can be all negative in the presence of If interested, please contact us: the disease). In July 2000 a liver aspirate, from an 83 year old man , was found to GR Micro Ltd co ntain hydatid protoscolices and hooklets in the gram stain . These Medical & Environmental Microbiological Services were co nfirmed by the trichrome stain . Treatment can involve long Tel: +44 20 7388 7320 Fax: +44 20 7388 7324 term chemotherapy (at least 12 months), surgery and PAIR d.felmingham@ grmicro.co. uk www.grmicro.co.uk (Percutaneous hydatid cyst Aspiration, In stillation of a sco li cide, and Reaspiration). Outcome depends on individual cases and follow-up every 1-2 years is recommended in the WHO guidelines.

Baa baa black sheep. Bruce Dove - Diagnostic Medlab Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. It is primarily a disease of domesticated and w il d an im als, particu larly herbivores, w ith humans becoming infected incidentally when brought into contact with diseased an imals or contaminated an imal products. Cutaneous anthrax is the most common form of the disease (approx. 95%). Usually acquired via inj ured sk in, the infection leads to the for­ mation of a painless ulcer with a black necrotic center, the characteris­ tic eschar. The infection may disseminate and 20% of untreated cases will resu lt in death. The bacterium read ily grows on routine laboratory media such as blood agar after 24hrs aerobic incubation at 370C. On blood agar large non-, or weakly haemolytic co lonies form, which on aging devel­ op the characteristic "Medusa Head" appearance. It is invariably sensi­ tive to penicillin . An arm swab from a perso n who had a lesion resemb ling that ca used by Bacillus anthracis w ith the cl inica l particu lars " ?Anthrax" was rece ived for investigation at our laboratory. Fortunately, instead of growing this bacterium, the more commonly encountered organism Pseudomonas aeruginosa was iso lated. This ca n ca use a lesion charac­ terised by necrosis and surrounding erythema (somewhat similar to anthrax) and is known as ecthyma gangrenosum.

VRE : putting theory to practice. Jane Hunter- Labplus Auckland Thirteen cases of VRE have been iso lated in New Zea land since 1996. For infection control purposes it is important to rapidly and reliably identify Vancomycin Resistant Enterococci to spec ies level.

NZ J Med lab Soence 200 1 62 Transfusion science special Interest Group

NICE Abstracts enced life on the ot her side of the fence. Patient X is Charge of a Transfusion Medicine Department and has rece ntly de livered a beauti­ What does my signature mean? Roger Austin, NZBS- Auckland ful baby boy. Her pregnancy was uneventful, but she is RH negative, so We sign our names to all sorts of documents. Do we really understand had routine blood tests, and requested her husband be grouped. what our signature mea ns? What are we agreeing to, what are we tak­ De livery went well, but in 3 weeks later haemorrhaged, requ iring ing responsibility for? Read t he implied fine print. hospita lising and a blood transfusion. Di scuss ion on t ransfusion in this population group would be welcome. The MUD (Matched Unrelated Donors) pool .NZ Bone Marrow Donor Registry. Raewyn Fisher, Auckland Why don't we trust the couriers? Graeme Bennett, Medlab Timaru W hy do we need a reg istry of Maori an d Pacif ic Island donors? What A look at the tra nsformation of the blood supply, f rom Timaru Hospital have we achi eved so far? tryin g to provide all its own blood to t he new, fl ash, efficient NZBS. A number of interesting and praise worthy obse rvations are abl e to A case history of neonatal alloimmune thrombocytopenia and be made by an "outsider" in such areas as wastage, supply, t est ing and its association with HLA" . Gill Morley, Hastings Hospital couriers.

Thrombotic thrombocytopenic purpura: case presentation and What is going on here! Iris Lee, NZBS- Wellington review of the literature. Geoff Herd, Whangarei Hospital An investigation into the continued inability to Leucodeplete the Thrombotic Thrombocytopenia Purpura (TIP) is an uncommon multi­ platelet apheresis co ll ections from one particu lar donor. system disorder which comprises microangiopathic haemolytic anaemia, thrombocytopenia and fever with a variable degree of renal ABO blood groups and transplantation. Kim Gribben, NZBS­ in sufficiency and fluctuating neurological abnormalities. Auckland TIP occurs in a heterogeneous group of patients with an increased Does the ABO bl ood group compatibility between donor and recipient incidence in association w ith preg nancy, autoimmune diso rders, infec­ organ transpl ants ca use a significant difference in the outcome of tion, malignancy, drug ex posure, bone marrow transpl antation and transpl ants? A review of the va ri ous medical st udi es perform ed. HIV- 1 infection. Recent studies suggest that endotheli al ce ll damage caused by Blood donors. Peter Webster, Nelson unknown plasma factor(s) may lead to the re lease of abnormally large Are we looking after this very va luable resource the way we shou ld, or von W illebrand Factor mult imers which promote the deposition of are they just being treated as the suppli er of a product we need. platelet microthrombi. Exchange transfusion with plasma or plasma cryosupernatant is the " ... And on that farm he had A, B, DEA, M, R, S, T, Qa ... " Simon ma instay of treatment along with corticosteroids, anti-platelet agents Benson, NZBS- Auckland and vincristine. " .. . Old Macdonald has a farm, and on that fa rm he has ... " a w ide This paper includes an illustrative case presentation and review of the variety of animals in some of which have been described blood group current literature on this obscure but fascinating disease. systems with complexities to rival those in humans. From 3 simple groups in cats to over 30 in horses, there is more to The friendly islands : an overview on blood donation. Tala Teu, our four-legged friends than meets the eye. Middlemore Hospital A summary of the service provided by t he Transfusion Laboratory in A is for apple sauce, B is for boysenberries... Sue Steele, Medlab Tong a, mainly on Tongatapu island . The di scuss ion w ill focus mainly on Ta uranga the w hole process of obtaining blood f rom a donor up to the stage Resea rch shows that t here is a blood-type profile for many aspects of w here the unit of blood is compatible and safe for transfusion to a our lives. According to bl ood type lifestyle ca n be adapted to deal w ith patient stress, maximise your hea lth and ove rcome disease.

Fossil! fuel. Adeline Tjia, Middlemore Hospital Are you my mother? Grant Bush , Medlab Tauranga Middlemore Hospital is a major burns unit for New Zealand. Part of the I am a group AB, you are a group 0 .. . treatment of these patients is the transfusion of blood and blood prod­ ucts. Mostly, this causes few problems for Blood Bank, occasionally as A changing ABO population? Leigh Mosen, NZBS- Auckland in this case problems arise. My presentation w ill discuss this case . A look at t he ratios of blood groups at Auckland and Starship Hospitals. With our chang ing ethnic population, are our blood groups The other side of the fence. Sue Melvin, lnvercargil changi ng too? A case study on a transfusion med icine scientist who recently experi-

NZ J Med Lab Sc1ence 2001 63 Cha nges. Tracy ln der, NZBS- Otago the way we do things be different? "Even if you are on the ri ght track, if yo u just sit there yo u w ill get run over" . Profound words in this ever-chang ing world we live in . I have Hereditary haemachromatosis. Claire Lamont, NZBS- Auckland observed a number of changes in my Tran sfusion Medicine lifetime (all Peopl e from Iris h/C eltic decent are more incl ined to suffer from this dis­ 2 years of it!) and am on ly too well aware that if we do not have the ease affecting the liver and beli eve it or not, it has little to do with their ability and willingn ess to adapt to such chang es w e will be left behind . alcohol co nsumption. Thu s affirming the importance of co ntinuing education and support of staff. Leucodepletion: pooled buffy coat platelets. Donna Beswick, NZBS- Waikato Case study of an AML patient multi-transfused. Natalie Fletcher, With the introduction of Leucodepletion a new method of platelet Tokoroa Hospital preparation has been put into practice at NZBS Waikato ... - ... an A ma le patient was diagnosed with AML aged 17yrs. He was multi­ overview of this method. transfused w ith red cells, platelets and plasma to treat anaemia caused by chemotherapy. He has had two bone marrow tra nsp lants and is cur­ Poster presentation. Scott Reilly, NZBS- Wellington rently in remission again but recently diagnosed with haemachromato­ My poster will present an information based flow-chart for the process sis, one unit being venesectioned fortnightly! What's up with that! and diagnosis of HDN.

How much is enough? Ray Scott, NZBS Ozone and transfusion science. Colleen Behr, NZBS- Auckland The demand for fractionated blood products must be supported by an Ozone is believed to act as a selective and rapid oxid izer of viruses (H IV. appropriate and timely supply of plasma. Th is presentation will identi­ Herpes simplex and zoster, cytomegalovirus, Epstein-Barr, myxoviruses fy the factors affecting the supply of plasma in New Zea land, and the and retrovi ruses), bacteria (co li form and staphylococcus) and vira lly approach taken to determine an accepta bl e balance between plas ma in fected ce ll membranes. Although used on nearly 500,000 patients in supply, fractionated product stock levels and clini ca l demand. Western Europe sin ce the 1960's, the therapeutic use of medica l ozone is largely unknown. Sometimes ca ll ed bi o-oxidative therapy or auto­ Leucodepletion. Amanda Hayward, NZBS- Waika to hemotherapy, mixtures of ozo ne and oxygen are mixed with blood An overvi ew of what we, in Waikato, have bee n up to for the last 2 before re-infusion by cl inician s. months. Cou ld ozo ne treated bl ood donations be the answer to finally eli mi ­ nating transfusion-transmitted disease? CompoXmas. Andrew Mills, NZBS- Waikato All we want for Xm as is.. .. ! HDN and antibody identification -a discomfort zone. Lorna Wall, NZBS- Auckland CMV in the age of leucodepletion. Brydon Broadley, NZBS­ Nobody likes to fee l that what they thoug ht was a si mple case of anti­ Christchurch body identifica tion was not. While one thin ks they are in the comfort This is a brief presentation discuss ing CMV and the transfusion of zo ne and it becomes the dis-comfort zone . What next7 blood and blood products. W il l the introduction of leukodepletion alter the management of CMV in New Zea land7 Southerner derailed. Jacinta Payne, NZBS- Otago On the 8th January, 2001 the Dunedin transfusion service received a Serious Hazard of Intra-Operative Transfusion (SHIT). Alan Neal, sea m team message " Emergency A&E, eta not sure, Southerner Rotorua Hospital derailed north Oamaru, DISASTER PLAN " A personal account and Serious adverse reactions to Blood or Blood products occur infrequent­ review of our efforts to effectively deal with this situation. ly (thankfully), however like any good 'boy scout' we shou ld "Be Prepared" to quickly respond to these events. A rare complication to a Abbott Prism™- infectious serology screening in half the time. Blood Transfusion shall be presented, which with the help of all the Vanessa Moriarty, NZBS- Christchurch 'Transfusion team' resulted in a successful outcome. The introduction of the Abbott Prism™ analyser into the New Zealand Blood Service Donor Accreditation Laboratory in Christchurch is set to "Kell or not to Kell''. Diane Matheson, Rotorua Hospital have an effect on work-flows in this department. Va li dation of the Cli nica lly sign ifica nt antibodies are commonly stimulated by Blood Prism™ is currently underway in both Auckland and Christchurch transfusion. Should we consider women of 'Child bearing age' as spe­ Laboratories, working towards a standardised accreditation scheme cial. throughout New Zea land. The different methodology employed by this analyser, in compariso n to the sc reen ing methods in place in Red, white and blue. Charlotte Sankey, Rotorua Hospital Christchu rch, indicate t hat infectious se rology sc reening will be more These co lours all have so mething in co mmon, other than featu rin g on efficient, with the ad ded benefits of increased sensitivity and specifici­ many of the worl d's flags. Th ey are all invo lved in a severe & poten­ ty. Th ere is a potential for an increased throughput and faster output tially life threatening co mplication of transfusion . Thi s link will be of accredited units at New Zea land Bl ood Se rvice Christchurch. exp lain ed through a case study and a brief overvi ew of this type of reaction . Cold Hearted. Astrid van den Berg, NZBS- Waikato A case study on the problem s and solutions associated w ith ca rdi ac NAT testing. Heather Richards, NZBS- Auckland surgery on a patient with cold agg lutinin disease. Later in the yea r a new tech nology in Blood screen in g ca ll ed NAT (Nucleic Acid Testing) will be introduced by the New Zea land Blood Quatro™ SP400 Blood Grouping analyser. Jeanette Jordan, NZBS­ Service to enhance the safety of the blood supply. With every new Christchurch process ways of doing things must be different. What is NAT? How w ill Genera l overview of the capabi lities of the Quatro™ SP400 and the

NZ J Med Lab Sci ence 2001 64 effect it w ill have on the workflow and the lives of the donor accredi­ AAA case with a twist. Nadene Hoskins and Stacey Fox, LabCare tation staff in Christchurch NZBS . Where we are cu rrently in va lidation New Plymouth and what problems we are facing. We received a crossmatch request for a 75-year-old female who was admitted to A&E with query AAA. A check of our abnormal file showed Conditioned cryo. Christine Van Tilburg, NZBS- Auckland she was 0 Rh(D) negative with anti-D, we had on ly 15 0 Rh(D) nega­ It's a Rache ll e Hunter productl t ive units in the bank and the nearest ce nter to get more than 3 hours away. However t he outcome was not w hat we expected. The supply of blood for transfusion to a forward surg ical team: the New Zealand experience. Malcolm Rees, Royal New Zealand Case study of an AAA patient. Tirath Lakshman, NZBS- Wellington Army Medical Corps, 2nd Field Hospital, Linton Military Camp, Linton Case study of a 78-year old ma le with a query AAA with a req uest for Th e supply of blood for t ransfu sion, in a safe and timely manner is one six un its of blood urge ntly from Accident and Emergency. of the crit ical medical/ logistical constra ints for a forward surgica l team. This presentation describes the standards, equipment and processes used to transport blood to the New Zealand Forward Surgical Team (FST) in Suai, East Timor. The supply and equipment validation systems employed were devel­ oped by a co-operative approach between the New Zea land Army and the New Zea land Blood Service (NZBS) These systems w ill be discussed in the course of the presentation.

Review of white cell counting. Tony Mace, Pathlab Hamiltion This paper wi ll look at the development of white ce ll cou nting to pres­ ent day.

A case study. Bev Nickle, Pathlab Hamilton A case study that may provoke discussion on ethi ca l and moral issues.

"Statistical figures on red cell usage for Christchurch blood bank and the local hospitals". Gemma Fang, NZBS- Christchurch Usin g graphica l figures, as management tools, to illustrate the season­ al changes on red ce ll s usage.

Do u or do u not? Tony Morgan, Hastings Hospital A review of Weak D Test ing and how we utili ze the resu lts obtain ed .

D.A.R.E. Sheryl Khull, NZBS- Manawatu Drugs, Antibodies, Reactions, and Explanations. A case study of a clas­ sic case of drug-induced auto-immune haemolytic anaemia.

So you've got new equipment ... and when did you say you were going to use it? Tomorrow!!! Suzanne Williams, NZBS­ Christchurch A description of the requirements and work involved in validating new equ ipment before it can be placed into routine use. HSIG journal based learning questionnaire: "Differential diagno­ Prions- the last frontier. Ingrid Christiaans, NZBS- Otago sis of microcytic anaemias" What are they? How do they work? W ill we ever be free of them? Laboratory Medicine, Vol. 30, No.8, Aug. 1999, p 538-542. Answers The advantages of being Le(a+b). Bevan Lockwood 1. True 12. Fa lse The association of being Leb+ allowing ~ receptor for Helicobacter 2. False 13. Fa lse pylori infection in the stomach and duodenum. 3. Tru e 14. True 4. Fa lse 15. Tru e Shift Work, the 24-Hour Society. Darryn Knight, NZBS- Auckland 5. Fa lse 16. True In the 24 hour society people engage in rotating night sh ift work, the 6. True 17. True ci rcad ian rhythms are unable to quickly adapt to a rapidly changing 7. False 18. False activity schedule. This res ults in de-synchronosis of many physiolog ic 8. False 19. False systems, including those w it h circad ian timing. Diet, sleep hygiene, car­ 9. True 20. False diovasc ular hea lth, and t he need to address social and domestic ten­ 10. Tru e 21 . Tru e sions will be discussed. 11 . Tru e

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NZ J Med Lab Science 2001 66 Obituary

John Case

It is thirty years since John Case left New Zealand for a new post in Sydney, but his name will still be recalled by older members for his keen interest and support for the NZIMLT. He undertook many tasks to this end. He was editor of the New Zealand Journal of Medical Laboratory Technology and Newsletter for seven yeas from 1963- 1970 and transformed the Journal into a publication of merit with an international circulation. He was a promi­ nent member of the staff side which in those days negotiated our salaries and conditions of service with the State Services Commission and was a fearless negotiator with a detailed knowledge of the requisite regulation who saw that justice was done. He was also an examiner and an excellent speaker but his influence transcended all these roles. From a personal point of view I shall greatly miss the correspondence we have kept up over the years particu­ larly the twenty page Christmas letters. Derek Ford, who worked with John in Dunedin, has written an obituary for his Australian colleagues, which succinctly records the details of John's career, and has kindly given permission to reproduce it herewith. Bob Allan lmmunohaematology lost a renowned medical scientist with the recent death of John Case in Houston. John inspired many medical scientists to specialise in blood group serology by his very individual form of enthusiasm and dedication. I was just one of those who John inspired and he was my mentor, teacher and friend throughout my entire career. John commenced his medical scientist training at the Public Health Laboratory in Poole, Dorset. Following his two years in the army, from 1945, John held posts in Whipps Cross Hospital and the South London Blood Transfusion Service (where Laurie Marsh was also employed), before emigrating to New Zealand in 1959 to take the position as Chief Technologist in Haematology and Blood Transfusion at the Otago Medical school. It was in 1961 that I first met John, when I joined him as Senior Technologist; from that point on, John was the leading influence in my career as he encouraged me to specialise in immunohaematology. In 1971 , John moved from Dunedin to Melbourne, Australia, to take the post of Consultant Serologist at the Commonwealth Serum Laboratories (CSL) and to head the National Blood Group Reference Laboratory. Whilst there, he quickly expanded and improved the range of blood group reagents that were produced by CSL and was a leading force in assisting the growth of the blood transfusion service in Malaysia. Within only a few years, John was well known throughout the blood banking international scene and, only five years after joining CSL, he was headhunted by Gamma Biologicals of Houston, Texas to become Vice-President of Regulatory affairs. From that time, John played a leading role in the "English Mafia" of USA blood banking and became a well-respected teacher, adviser and consultant. In 1990, John was honoured by the AABB by being awarded the lvor Dunsford Prize for that year and in 1997 he was given the Ruth Sanger Oration Award by the ASBT. John's forthright man­ ner sometimes rankled a few feathers, but he never hesitated to openly state his opinion- which was always based on his extraordinary theoretical and practical knowledge. Over the last few years of his career, John's exchanges with John Judd in the discussion pages of the AABB web site kept many amused, but never failed to educate at the same time. John's love for immunohaematology can be gauged by the fact that he did not retire at 65, but continued until his 73rd year; only two years before his untimely death following a stroke. John's sudden passing came as a shock to many immunohaematologists, both medical and scientific, throughout the world and leaves a gap that can never be filled. He is survived by his wife, Ellen and children, Edward, Jackie and Adrienne, and granddaughters Kelsey and Landa, to whom we offer our sincere condolences. Derek Ford

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