Coagulation Pathology Fellowship

Training Objectives and Duties

The goals and objectives for Transfusion Service/ Coagulation Rotation are:

Coagulation

  1. Develop familiarity with interpreting coagulation profiles in liver disease, vitamin K deficiency heparin effect, DIC, lupus anticoagulant, von Willebrand's disease, hemophilia, blocking inhibitors, and hypercoagulable states. Develop familiarity with the management of patients with active DIC or other coagulopathies.
  2. Obtain medical histories for interpretation of coagulation studies. Fellows are expected to provide guidance to the residents and medical students.
  3. Understand the diagnosis and significance of Factor V Leiden, Prothrombin variant mutations, deficiencies of protein C, S, and antithrombin III and patient management of these hypercoagulable conditions.
  4. Develop familiarity with the interpretation of platelet aggregation studies and bleeding times and their role in the diagnosis of acquired and inherited platelet dysfunction disorders.
  5. Understand the appropriate use and interpretation of coagulation testing. Understand the coagulation mechanisms evaluated by the various tests.
  6. Be familiar with the various testing methods used in coagulation, i.e., clotting endpoint, chromogenic assays, ELISA and molecular assays.

Hemophilia

  1. Understand the diagnosis, natural history, and management of patients with hemophilia A, B and C.
  2. Recognize the presentation, symptomatology, and appropriate management of hemorrhagic problems of hemophilia: hemarthroses, hematomas, retroperitoneal hematomas, CNS hemorrhage, GI bleeding.
  3. Understand the incidence, natural history, and management of the complications including hepatitis, HIV infection, inhibitors, and orthopedic disabilities.
  4. Understand the diagnosis, natural history, and management of patients with von Willebrand's Disease.
  5. Develop a working knowledge of the replacement therapy indicated for hemophilia and von Willebrand's management, including calculations and appropriate treatment doses and safety of each product. Fellows will be able to provide initial therapeutic recommendations for outpatient and emergency factor replacement.
  6. Understand the genetics of hemophilia and von Willebrand's disease, diagnostic tests available, and appropriate counseling for family members.
  7. Understand treatment modalities for von Willebrand's disease and indications for treatment including prophylaxis.
  8. Be familiar with gene therapy and its potential role in future patient management.

Transfusion Medicine

The fellow will master basic blood group serology and develop familiarity with techniques to perform ABO & Rh typing, antibody screen, antibody identification, crossmatching and direct antiglobulin testing.

  1. Perform clinical investigation and laboratory interpretation of transfusion reactions.
  2. Know the indications for each blood component, its content and potential adverse effects.
  3. Know indications for CMV-negative/safe, irradiated, and leukocyte-reduced blood products.
  4. Become familiar with the principles of transfusion support of organ transplantation and bone marrow transplantation.
  5. Become familiar with the regulatory agencies that oversee transfusion services (AABB, FDA, CLIA, State, CAP). The fellow is expected to participate in activities involving the department of Quality Assurance.
  6. Know the acute, delayed, and chronic complications of transfusion, their pathogenesis, diagnosis, treatment, and prevention including: acute and delayed hemolysis, fever chill reactions, allergic reactions, anaphylaxis, TRALI, TAGVHD and septic transfusion reactions
  7. Understand the role of cytokines in mediating acute transfusion reactions
  8. Be familiar with the laboratory evaluation of transfusion reactions
  9. Be familiar with transfusion transmitted infections including HIV, hepatitis, HTLV, bacteria, CJD, syphilis, malaria, babesia, and Chagas disease.
  10. Know the pathogenesis, management, and diagnosis of hemolytic disease of the newborn.
  11. Be familiar with blood component support for the fetus and the newborn.
  12. Be familiar with blood component support during pregnancy.
  13. Be familiar with major clinically significant red cell antigen systems (ABO, Rh, Kell, Kidd, Duffy, MNSS), their frequency, and frequency of antibodies to these antigens, clinical significance and transfusion management. Be familiar with the commonly encountered clinically insignificant antibodies, including Lewis, P, I, and HTLA, and their transfusion management.
  14. Be familiar with the laboratory investigation of warm, cold, and drug-induced hemolytic anemia, their clinical features, laboratory investigation, and management.

The fellow will also act as a consultant for clinicians in the area of coagulation and serve as a teaching and clinical resource for residents and students.

Apheresis Rotation

  1. Review the various apheresis instruments with the nurses.
  2. Observe the performance of therapeutic plasmaphereis and cytopheresis procedures with the nurses.
  3. Fellows discuss with the nurses and attendings the indications for therapeutic apheresis, complications, fluid replacement and treatment course. Particular focus on management and treatment of TTP patients.
  4. Fellows follow all patients on the service either by attending the procedure or discussing the case with the nurse. Fellows report to the attending any changes in clinical status and the progress of therapy.
  5. Fellows observe the collection of stem cells by apheresis and follow patients who are undergoing multiple collections.
  6. Fellows will observe a therapeutic phlebotomy

Goals and Objectives

  1. Understand the principles of apheresis technology.
  2. Know the complications associated with apheresis and their management.
  3. Know which disease can be effectively treated with therapeutic plasmapheresis and the appropriate replacement fluids.
  4. Know the indications for therapeutic leukopheresis, plateletpheresis and erythrocytapheresis.
  5. Become familiar with apheresis techniques for hematopoietic stem cell collection.
  6. Understand the indications and techniques used for therapeutic phlebotomy.

Conferences and Meetings

Teaching Responsibilities

The Fellow is expected to conduct daily morning rounds with the trainees and attendings. These rounds involve evaluation of difficult red cell serologic studies, discussion of transfusion reactions and consultations on blood product usage from the clinical staff. The fellow provides didactic lectures for trainees that will cover: ABO and Rh serology, component therapy, transfusion reactions, use of specialized blood products, hemolytic disease of the newborn, and hemolytic anemias. Fellows also serve as a continuing medical education resource for the Blood Bank technical staff.