A short report on the impact of the American Society for Hematology (ASH) Visitor Training Program (VTP) on the diagnosis of malignant hematology at the Port Moresby General Hospital, Papua New Guinea.

The challenge

Port Moresby General Hospital (PMGH) is the only teaching hospital in Papua New Guinea. Laboratory diagnosis of malignant and benign hematopathological conditions is based on cytomorphological analysis. Sometime in 2015 a multi-color flowcytometry analyzer was purchased to allow greater accuracy in diagnosis. However, there was no trained medical scientist to operate the machine nor was there a trained physician to interpret and report on the flowcytometry analyzer results. As a result of these limitations hematopathology training for registrars (residents)  is focused on cytomorphology using the FAB classification system, a system obsolete in most settings except in resource limited laboratories.

The opportunity

I was very fortunate to be supported by the American Society of Hematology to undergo 6 weeks of training at the Maryland Medical Center in Baltimore under the supervision of Associate Professor Zeba Singh. My training was focused on interpretation of peripheral smears, bone marrow aspirates and flowcytometry. My personal training goals were to (1) improve Bone Marrow Aspirate  & Core Biopsy Interpretation and Reporting Skills and (2) understand and be able interpret and report flowcytometry for leukemia diagnosis.

Meeting the challenge at PMGH: Focusing on leukemia diagnosis.

Transfer of skills

A key outcome of my training that I wanted to achieve was to teach other residents in pathology what I have learnt. So I developed a training program and implemented it at my hospital. The program consisted of tutorials where I would teach 4 residents on how to report on peripheral blood smears, bone marrow biopsies and bone marrow aspirates. We also had tutorial sessions on interpreting and reporting flowcytometry results.

Introducing flowcytometry services for the diagnosis of leukemia at PMGH

My supervisor asked me develop the flowcytometry services at PMGH so I did a gap analysis and identified training needs. After that I conducted bench top refresher training for medical laboratory scientist on how to do proper gating when operating the flowcytometry analyzer. The gap analysis also showed me what antibody panels we had and what we could afford to sustain the service. I produced a report to my supervisor who used the recommendations to purchase added antibody panels. I also established communications with the technical support group of the flowcytometer supplier – BD Diagnostics office in Australia, who provided added technical advice to screening protocols.

Gly ACD33CD23
CD38CD117CD10
CD25CD45CD56
TCR g/dCD13CD8
CD103CD14CD22
TdtCD41aCD5
TCR a/bCD13CD45
CD138CD33CD20
FMC7CD3CD19
CD57CD34CD64
CD1aCD7CD4
CD2CD61K/L
CD11cHLA-DR 
 CD71 
Table1.0. Antibodies at the PMGH Pathology Laboratory for flowcytometry analysis.

I continued to communicate with Professor Singh via email and we developed testing protocols for use at PMGH.

The leukemia screening antibody protocol we developed is shown below:

  • cMPO, cCD79a, CD34, CD19, CD7, cCD3, CD45, sCD3 [AML vs T ALL]
    • Any 3 antibodies + CD45
  • CD15, CD56, CD34, CD117, CD33, HLA-DR, CD38, CD45 [AML vs B ALL vs NK Cell leukemia]
    • Any 3 antibodies + CD45
  • Minimum Panels
    • CD45/cMPO/CD34/CD117 (AML)
    • CD45/CD19/CD34/CD10 (B ALL)
    • CD45/sCD3/sCD3/Tdt (T ALL)

Feedback from residents and medical scientists

Unfortunately I was not able to quantitatively or qualitatively measure the impact of the programs we instituted in the laboratory at PMGH. But I observed the following changes:

  1. Residents were more confident in their cytomorphological diagnosis of malignant hematological conditions using the FAB classification system.
  2. Residents had a working knowledge of multicolor flowcytometry and the training increased their enthusiasm to know more in this area.
  3. The ability of residents to report bone marrow aspirates and biopsies increased dramatically compared to before the training sessions. Reports were more detailed giving more information to treating physicians resulting in improved care of patients.
  4. Medical scientists were able to do gating properly and accurately when conducting experiments on the flowcytometer.
  5. Medical scientists were able to properly set up antibody panels.
  6. Residents were able to understand the CD system for cell antigens which enabled them to order the correct antibody panels for leukemia screening or diagnosis.

Attending my first ever ASH conference in Orlando, Florida.

I was very surprised when I received an email informing of me being chosen to attend the 2019 ASH conference in Orlando. In fact I thought it may be a scam and had to verify its genuineness. I did not expect it at all.

My experience at the ASH conference in Orlando, Florida in 2019 will be a key highlight of my career. Although my travel was very long and tiring, I would remember the trip for a long time to come. My mentor at the conference – Professor Daisy Alapat was very kind and patient with me. She showed me how to navigate the different education sessions and choose only those that were relevant for me. One of the great things for me was that I was able to earn CME points which I needed. A key highlight of the conference for me was observing world leaders in the various fields of hematology debate and discusses diagnostic, treatment and research issues.

The research presentations tweaked my interest in hematopathological research and prompted me to consider doing research full-time. I am now 45 years of age so I don’t know if I would have the time and energy to do that but certainly the conference opened my mind to the level of research that is conducted in the United States. I am hoping that I will be able attend another ASH conference again before I retire.

Final comments

Pathology trainees in PNG would not have benefited from this specialized training without the support of ASH and I extend my sincere gratitude to ASH international committee and for supporting me and help build the capacity of our laboratory at PMGH, PNG. I also want to express my sincere gratitude for supporting me to attend the ASH annual conference in Orlando, Florida in 2019. I am also grateful to my mentors, Professors Zeba Singh and Daisy Alapat.

About rodney itaki

A physician trying to become a writer.
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