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Introduction/Objective DMAIC (an acronym for Define, Measure, Analyze, Improve and Control) refers to a data- driven improvement cycle used for improving, optimizing, and stabilizing business processes and designs. Our goal was to utilize DMAIC principle of six sigma quality to improve histology slide quality. Methods/Case Report We “defined” the problem as suboptimal quality in endometrial biopsy slides (defects). Utilizing the DMAIC principle and adhering to a strict timeline, the defects found during baseline slide quality review were “measured” by linking the defects to specific histology competencies, which were addressed systematically for process improvement (PI). After PI, a follow up review (“improve” and “control” phases) was carried out to identify measurable outcomes as a testament to quality. Results (if a Case Study enter NA) During the problem “measurement” phase, the defects found in the baseline review of 175 slides were linked to four specific histology competencies (fixation, embedding, cutting, and staining). Processing was excluded as it is completely automated and standardized. Our analysis showed that 83.3 % of defects were linked to embedding (“tissue too dispersed”). As embedding competency depends on the size and nature of the tissue (e.g. mucus and blood admixed with tissue), grossing competency was also addressed along with embedding at the respective workstations. Recommendations were offered to the grosser, embedder, and cutter to reduce variables during the “improvement” phase. Follow up review was done on 196 slides. The number of defective slides decreased and the defects that linked to “tissue too dispersed” had an overall improvement of 91.3%. Once the PI is proven to be effective, in service to histotechnology personnel biannually were also offered during “control” phase. Conclusion We have demonstrated successful methods for improving histology slide quality utilizing DMAIC principle of quality improvement by six sigma methodology DMAIC principle can be creatively adapted in laboratory practice management to enhance quality.

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Introduction/Objective Leukostasis/symptomatic hyperleukocytosis is commonly seen in acute leukemias and is characterized by high blast counts and symptoms of decreased tissue perfusion with a one-week mortality of 20-40%, if left untreated. It is a rare complication in chronic lymphocytic leukemia (CLL) and is seen in CLL patients with white blood cell (WBC) counts > 500x10^9/L. Studies have shown that transfusion of blood products prior to decreasing the WBC count may lead to increased blood viscosity and worsen leukostasis. We report a CLL patient with a lower WBC count presenting with symptoms of leukostasis, further worsened by a red blood cell (RBC) transfusion prior to leukapheresis. Methods/Case Report A 73-year-old male with history of CLL for 5 years, hypertension and chronic kidney disease presented with acute dyspnea for 1 day. The WBC count was 208x10^9/L, hemoglobin was 6.5 g/dL, troponin I was 1.554 ng/mL, creatinine was 1.68 mg/dL and chest x-ray showed bilateral interstitial lung edema. The patient was diagnosed with acute hypoxic respiratory failure, acute kidney injury and myocardial infarction due to leukostasis. He received RBC transfusion, shortly after which his dyspnea worsened. There were no other signs or symptoms that could suggest a transfusion reaction. A single leukapheresis was performed following which there was a significant improvement in symptoms with a drop in WBC count to 123.1x10^9/L and creatinine to 1.3 mg/dL. Results (if a Case Study enter NA) NA Conclusion CLL may present with symptomatic hyperleukocytosis at lower leukocyte counts than has been described in the literature. Symptoms due to leukostasis can be precipitated/worsened by transfusion of blood products due to increased blood viscosity. It is critical to identify the signs and symptoms of this medical emergency as prompt diagnosis and management with leukapheresis significantly reduces the leukocyte count and blood products should be transfused slowly during or after leukapheresis.