Lagos State University Teaching Hospital Ikeja (Lasuth)Lagos

LAGOS STATE UNIVERSITY TEACHING HOSPITAL IKEJA (LASUTH)LAGOS

RESIDENCY TRAINING PROGRAMME CURRICULUM

FOR

HAEMATOLOGY AND BLOOD TRANSFUSION

SEPTEMBER 2015

This curriculum is available on LASUTH website

INDEX Page

General Information3

Aims and Objectives5

Specific Objectives6

Rotation Programme9

Curriculum A. Technical skills 10

B. Clinical Haematology 11

C. Sub-speciality training 12

D General Aspects of Haematology 13

E Research and Dissertation 13

F Attendance at Conferences etc 14

G Outside Postings 14

Seminars in Haematology14

Weekly Seminars16

Teaching and learning methods17

Assessment methods 18

Junior Residency Training 21

Senior Residency Training 30

References 35

General Information

Introduction

Haematology Residency training in the department encompasses both clinical and laboratory aspects of the speciality. Award of the degree FMCPath or FWACP (Laboratory Medicine)by National Postgraduate Medical College and West African College of Physicians respectively require evidence of satisfactory completion of training in both of these aspects.

Entry Requirements

A Medically qualified graduate with a current practicing license of Medical and Dental Council of Nigeria.
Possess evidence of passing Primary examination of either the West African College of Physician or National Postgraduate Medical College.
Possess certificate of National Youth Service Corps (NYSC) orExemption from NYSC (Nigerian candidates only).
Pass LASUTH residency training entry examination in Haematology

Registration of Associate Fellows of the Colleges

Residents admitted for training are associate fellows of either or both Colleges and must apply to be so registered by the two colleges. Candidates not registered as associate fellows of the colleges will not be allowed to sit for the Part 1 or II Fellowship Examinations.

Examination Requirements

PART 1: Candidates will be qualified to sit for Part 1 examination after the initial two years of training (i.e.Junior residency programme).Only candidates that complete the initial 24 months of training (without interruptions other than the normal annual leave periods) are eligible to write Part 1 examination.

PART II: This is taken at least 2 years post part 1 (senior residency programme)

Duration of Examinations Passed.

A pass in the primary examination stands for 5 years while a pass in the Part 1 Examination will be for four years. Candidates will be required to retake the part 1 fellowship examination after repeating their pre-part 1 postings if they fail to attempt the examinations 4 years after passing.

Temporary Suspension of Training

Candidates intending to take an extended leave or suspend training for any reason must inform the Faculty Secretaries of either or both Colleges in writing, providing details of the anticipated duration of leave or suspension.This exclude period of standard annual leave.

The trainee will be required to undertake additional training time up to the period of additional leave.Where this training suspension exceeds two years and activity during this period is outside Haematology Department, the Period of Training already undertaken shall be deemed to have lapsed. The trainee therefore starts afresh (junior or senior residency postings) provided that no examination already passed has lapsed (primaries -5 years, part 1 ---4 years)

Aimand Objectives

The aim of this curriculum is to provide the trainee the skills and knowledge required for clinical and laboratory haematology service.

General Objectivesofthe Residency Trainingin Pathology (NPMCN)

To organise and manage a pathology laboratory, including being conversant with the requisite safety procedures at the laboratory in question
To learn the basic principles underlying all the laboratory, diagnostic techniques as well as practically carrying them out
To prepare laboratory reagents as may be required in the relevant areas of the laboratory
To undertake accurate statistics and periodic clinical audit in the laboratory
To interpret laboratory results and situate them in the appropriate context and sign-out or authorize the reports of these results on the appropriate forms
To make diagnosis or summaries, based on the results of the laboratory tests or procedures, which may impinge on or be contributory to the management of disease processes
To organise and supervise the primary and secondary health care laboratories
To advise on antibiotic use for communicable diseases based on the results of the appropriate laboratory procedures
Clinical management of infectious, metabolic and haematological disorders
The acquisition of communication skills required for the practice of clinical haematology.
The acquisition of some management skills required in the running of the haematology laboratory.
Understanding of research, audit and team working, which underpin haematology practice.

Specific Objectives

HaematologyandBlood Transfusion

Part 1 Level

Technical Skills

Understand basic scientific principles of the techniques used in Haematology laboratory
Be able to carry outbasic techniques e.g. estimation of Hb, PCV, WBC (total and differentials), platelet, ESR, Sickling, Solubility tests, Hb electrophoresis, reading of peripheral blood films, coagulation screening tests (prothrombin time, partial thromboplastin time, thrombin time), basic serology tests, e.g. grouping and cross matching, antibody screening and identification
Prepare basic routine reagents.
Understand and master the principles and use of microscope, centrifuges and electrophoretic equipment.
Have knowledge of specimen bottles, anti-coagulants and their uses
Understand the principles and use of automated equipment

Clinical Skills

Be able to describe and investigate simple haematological disorders e.g. anaemia, leukaemia etc. and principles of their management

Donation Drive

Understand the principles of donor recruitment and bleeding and care of donors

Part II

Technical Skills

Understand and be able to take responsibility for organization, management and supervision of the laboratories e.g.

-Routine haematology laboratory

-Coagulation laboratory

-Blood transfusion/serology laboratory

-Disposal and decoagulation of expires blood, washing up techniques etc.

-Quality assurance of reagents and techniques

-Management of staff

Understand and be technically sound in the principles of instrumentation
Be able to carry out special tests e.g. Bone Marrow Aspiration/biopsy preparation and reporting, haemoglobin electrophoresis, L.E> cell preparation and identification
Be able to carry out fine needle aspiration of superficial lymph nodes and masses

Clinical Skills, Responsibilityand Decision Making

Be well grounded in the diagnosis and management of haematological diseases e.g.anaemias, leukaemias, lymphomas, bleeding disorders etc.
Be able to handle clinical consultations
Understand and master the principles of oncology

Blood Products

Be able to prepare and preserve blood products

Signing Reports

Must report and sign reports with consultants

Rotation

Must spend at least 3 months each in the Departments of Paediatrics and Internal Medicine

Numberof Residents Needed

For each consultant unit,-1 senior resident and 2 junior residents are desirable

Pre-primary Examination

The resident is encouraged to attend the undergraduate lectures in Haematology and Blood Transfusion, Medical microbiology and Parasitology, Morbid anatomy and Chemical Pathology to refresh his memory

Rotation Programme

Within the first 18months, the resident must rotate through the other three sub-specialities of pathology. During the rotation, he will take full part in the residency programme of that department in technical and clinical skills

Rotation Schedule (Table 1)

Year 1 / Haematology / Rotation / Rotation / Formal instructions, Lab. Experience, Clin. Management
Year 2 / Rotation / Haematology / Above plus Blood Trans. Course, Seminars, Eligible for part 1
Year 3 / Haematology, Oncology, Cytology, Paediatric Haematology(3months), Haematology and blood transfusion services, Research project for dissertation / Specific instr. in subspecialities , sound theoretical and practical knowledge
Year 4 / Internal Medicine (3months), Haematology / As above plus demonstrator. Eligible for FMC Path Part II exams

Technical Skills

Making and reading of peripheral blood films, Differential counts
Reporting and recognition of malaria parasites, abnormal red blood cell, white blood cells and platelets
Performance of Hb, PCV, WBC and platelet counts. Reticulocyte count
Automated blood counts
Sickle cell tests and electrophoresis
Blood grouping and cross-matching
DAT, IDAT
Antenatal serology
Assessment and counselling of blood donors
Bleeding and care of donors
Collection and preservation of blood inventories
Rapid test for HIV, ELISA tests
CD4 counts, manual and by flow cytometry
PCR participation and knowledge of general principles
Preparation of blood products
Bone marrow aspiration, staining and reports
PT, INR, PTTK, TT and their interpretation
Enumeration of platelets, platelet function tests
Cytochemistry
Immunophenotyping
Molecular tests in haematology
Documentation of tests, registers
Good laboratory practice
Quality control and SOPs
Audit

Clinical Haematology

General haematology

-Supervised participation in in-patient and out-patient management of haematological disorders

-Haematology day clinic management and care of acute cases

-Comprehensive care of HIV-AIDS patients including use of HAART and treatment of opportunistic infections

-Counselling activities

Specialist haematology

-Anaemias—diagnosis and investigations of nutritional and haemolytic anaemias, malaria anaemia, management and prevention strategies

-Diagnosis of haematology treatment and follow up of patients with haemoglobinopathy particularly HbSS

HbSS antenatal screening methods in conjunction with other laboratories. Counselling activities

-Acute leukaemias- classification and chemotherapy regimens and their side effects

-Chronic leukaemia- diagnosis, classification, staging and management. Pathogenesis, molecular biology

-Myeloma and lymphoma- morphological diagnosis,classification, staging and treatment protocols

-Haemophilia- diagnosis, management of Haemophilia A and B, Von Willebrand’s disease. Use of coagulation factor concentrates

-Acquired bleeding disorders. DIC, massive transfusion, renal, hepatic and obstetric complications.

-Clinical and laboratory aspects of platelet disorders, numerical and functional platelet disorders, mechanism and use of antiplatelet drugs

-Thrombophilia. Instruction in diagnosis and management of thrombophilic conditions. Anticoagulation and control

-Bone marrow failure syndromes. Diagnosis and long term management

-Appropriate use of blood and blood products. Protocols for transfusion and management complications. Alternative strategies to blood transfusion

Sub-speciality Training

-Blood transfusion

The resident will spend a period of time in blood transfusion centre where active donor recruitment, deferral and retention is taking place. Understand the principles of management of resources in a blood bank. Equipment use and maintenance. Quality assurance in blood banking. Audit

-Paediatric haematology

In conjunction with the paediatric departments and neonatal unit, instructions while on posting will be given on haematologic problems in children.

Neonatal haematology, normal values, anaemias, haematological aspects of sepsis, coagulation
Management of haemoglobinopathies in children
Congenital bleeding disorders
Transfusion in neonates and children

-Oncology

There will be regular tuition meetings, seminars and practical management with the oncology unit in the department of radiotherapy in order to strengthen knowledge in the use of chemotherapy agents

-Cytology

Some experience in aspiration biopsy of tumours, staining and interpretation

-Stem cell transplantation

Formal and informal instructions in hematopoietic progenitor cell transplantation
Indication, sources, harvesting
Problems of allogeneic and autologous transplantation

Generalaspects of Haematology

Communication skills- formal presentation of casesand seminars with the use of IT

Learn the problems of communication of bad news, care of the dying and counselling on the use of chemotherapy

Counselling in haemoglobinopathy

Researchand Dissertation

An approved research project may beundertaken in the 3rd and 4th yearsof training and residents will be encouraged to present their finding at conferences and workshops and also publish them in scientific journals

There is ample opportunity for research in the Haematology laboratory at the medical research centre

The resident will work on his dissertation for the FMC Path Part II examination

Attendanceat Conferencesand Workshops

Continuing education programmes, grandrounds, mortality reviews are ongoing in the hospital once a month

Residents are nominated to attend training programmes of benefit to their course within and outside Lagos. Sponsorship is available for many of these

Outside Postings

Lagos State Blood Transfusion Service (LSBTS)

Nigerian Institute of Medical Research (NIMR)

Lagos University Teaching Hospital, Idi-Araba (LUTH)

Seminarsin Haematologyand Blood Transfusion

Weekly Topics

Multiple myeloma
Markers of lymphoma and their classification
Iron metabolism
Investigation of autoimmune haemolytic anaemias
Diagnosis and treatment of acute lymphoblastic leukaemias
Platelet structure and functions
Normal and abnormal haemoglobins
Chronic myeloid leukaemias: prognosis and treatment
Red cell enzymopathy: pathology and investigation
Platelet concentrate: preparation, storage and utilization
Spherocytic haemolytic anaemias
Red cell in-vitro preservation and utilization
Management of aplastic anaemia
Cryoprecipitate: composition, preparation, preservation and utilization
Thrombosis, antithrombotic agents and their monitors
Myelodysplastic syndrome
Inherited bleeding disorders: platelet and vascular disorders
Inherited bleeding disorders: coagulation disorders and vWD
Stem cells and boneu marrow transplantation
Acquired bleeding disorders
Polycythaemia
Management of lymphomas
Management of acute leukaemias
Management of chronic leukaemias
Inherited immune deficiencies
Syndromic management of HIV/AIDS
Antiretroviral therapy: guidelines and side effects
Quality control and organisation of blood transfusion service
Quality assurance in haematology
Exchange blood transfusion and plasmapheresis: modalities and indications

Weekly Activitiesof the Department OF Haematologyand Blood Transfusion

Weekly clinical programme of activities (Table 2)

Day / 8.00am-5.00pm / BLOOD BANK CALLS IN THE 1ST WEEK OF EACH MONTH
Monday / Clinic / Unit ward round / Day care/ward call
Tuesday / Clinic / Unit ward round / Day care/ward call
Wednesday / Case presentation, presentation of short topics in haematology / Slide review/ Special investigation/ Bench work / Day care/ward call
Thursday / Clinic / Unit ward round / Day care/ward call
Friday / Seminar/dept. meeting/journal review/ / Consultant ward round / Day care/ward call
Saturday / Ward Calls
Sunday / Ward Calls

Teachingand Learning Methods

Observation of assisting and discussing with consultants
Task specific on the job training
Observation of laboratory methods
Practical bench work
Personal study
Postgraduate education courses
Clinical experience
Laboratory meetings
Clinical team meetings

Assessment Methods

Continuous assessment

Mini tests
Case presentation
Slide reviews
Seminar presentation

Annual review

Detailed and reliable history taking and clinical examination
Accurate and timely diagnosis and formulation of a treatment plan
Good follow up notes
Sound knowledge of laboratory methods, limitations and interpretation of results
Ability to present and discuss cases

Assessment of Resident’s Performance

Laboratoryand Practical Haematology

Objective: to understand basic scientific principles of the techniques used in haematology and carry out basic techniques and apply the laboratory results to patient care.

(Table 3)

Activity / Assessment / Signature of consultant

Preparation:

Reagents
Buffers
Dilution fluids
Stains

Making and staining of

Peripheral films
Leishman
Supravital stains

Manual tests

Haemoglobin
PCV
Rbc count
Rbc indices

WBC COUNT

Differential count
Absolute count

Use of automated machines

Perform bone marrow

Aspiration
Biopsy
Preparation and staining
Reports on BM

Blood transfusion techniques

Blood grouping
Cross-matching methods
Investigation of transfusion reactions

Coagulation tests

PT
INR
PTTK
Thrombin time
Fibrinogen assay FDPs
Automated methods

Platelets

Counts
Function tests

LE preparation

Cytochemical staining

Immunophenotyping
Cytogenetics

Haemoglobinopathy

Sickling test
Solubility test
Hb electrophoresis
Kleihauer technique

Blood products

Preparation of red cell conc.
‘’ ‘’ ‘’cryoprecipitate
‘’ ‘’ ‘’ FFP
‘’ ‘’ ‘’ platelets

Lymph node histology and classification of lymphomas

Performance of lumber puncture

Interpretation of CSF cytology

Interpret peripheral blood films and relate to the clinical picture

Principles of laboratory management
Q.C.
Staff performance and appraisal
Laboratory statistics

Junior ResidencyTraining (Table 4)

A formalintroduction to laboratory haematology is required during the first three months of residency training programme, this will be followed by rotation through the major laboratories, in and out-patient managements of patients, emergency bench calls from 4pm to 8pm; and all day during theweek ends and public holidays. Clinical calls are also compulsory for all residents during the call periods as for emergency bench calls, except that they are not run concurrently by the same individual. Laboratory haematology will include instruction and hands on experience in routine haematology/heamato-oncology, blood transfusion medicine, haemostasis and coagulation and special tests, laboratories.

The trainee in haematology will spend the first 3 months as introduction to laboratory and clinical haematology. He/she will spend a minimum of 2 weeks in blood transfusion, four weeks in general haematology (for stain preparation, diagnostic blood counting, peripheral blood film and bone marrow slides reporting) and one week in coagulation. The remaining five weeks will be for clinical exposure

The trainee will be instructed in methods for obtaining bone marrow by aspiration and trephine, making slides from the aspirate and touch or roll preparations from the trephine. Resident must be conversant with preparation of basic stains.

Trainee will be exposed to fine needle aspiration biopsy techniques.

Clinical training during this induction period will include supervised participation in in-patient and out-patient management of haematological disorders including clinical on-call as appropriate

There will be an assessment at the endof the 3-month rotation

Following the introduction period, the trainee will receive instruction and practical experience in further aspects of haematology and rotate through other specialities in pathology, for the rest of the 1st year of training and through the 2nd. Part 1 FMCPath examination will be written after the 1st two years of posting (Table 2).

Junior residents will also start formal academic and clinical components of the training, as indicated in the tables

Table 4: Schedules for junior resident postings, first 24 months

Module / Programme / Duration in months / Contact academic Hrs/wks / Contact bench work Hrs/wks / Contact clinical rounds Hrs/wks / Total credit units/ module earned
1 / Haematopoiesis, blood cells and functions; introduction to clin. Haemato / 1 / 4 / 12 / 16 / 4
2 / Non-haemolytic anaemias (nutritional deficiencies, marrow failure, others) / 2 / 4 / 12 / 16 / 8
3 / Transfusion medicine and haemolytic disease of the new born / 2 / 4 / 12 / 16 / 8
4 / Haemolytic anaemias (acquired &inherited) / 2 / 4 / 12 / 16 / 8
5 / Haemostasis and bleeding disorders, AIDS / 2 / 4 / 12 / 16 / 8
6 / Haematologic malignancies: lymphoproliferativemyeloproliferative disorders, plasma cell neoplasm / 3 / 4 / 12 / 16 / 12
Chemical pathology / 3 / Outside postings
Histopathology / 3
Medical microbiology &parasitology / 3
Leave period / 3
Total for the 4 semesters of 3months each / 24 / 192 / 576 / 960 / 48

Note: