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Body Information and Courses from MediaLab, Inc.

These are the MediaLab courses that cover Body and links to relevant pages within the course.

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Antibody Detection and Identification
Naturally Occurring Antibodies

Antibodies are immunoglobulin proteins secreted by B-lymphocytes after stimulation by a specific antigen. The antibody formed binds to the specific antigen in order to mark the antigen for destruction.The type of antigenic exposure occurring in the body determines if the antibody is a naturally occurring or immune antibody.Naturally occurring antibodies can be formed after exposure to environmental agents that are similar to red cell antigens, such as bacteria, dust or pollen. Sensitization through previous transfusions, pregnancy or injections is not necessary. These antibodies are usually IgM and react best at room temperature or lower. Most of these antibodies are not clinically significant with the exception of ABO antibodies. Examples of naturally occurring antibodies include anti-A, anti-B, anti-Cw, anti-M, and antibodies in the Lewis and P system.

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Antinuclear Antibody Testing: Methods and Pattern Interpretation
Autoimmune Diseases

Autoimmune diseases are a group of disorders where the body's immune system malfunctions and attacks its own tissues. One aspect of these diseases is the formation of antibodies that are directed to self-antigens (autoantibodies). Autoimmune diseases can be divided into two general groups: Organ specific, where the autoantibodies attack a specific organ, and Non-organ specific (or systemic), where the autoantibodies attack multiple organ systems. An example of an organ specific autoimmune disease is Hashimoto thyroiditis where autoantibodies damage the thyroid gland. An example of a systemic autoimmune disease is systemic lupus erythematosus (SLE) where the autoantibodies may attack any organ in the body.

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Autoimmune Disease (continued)

Why our immune system malfunctions is not completely understood. One current hypothesis is that the following series of events occurs resulting in the initiation of an autoimmune reaction. Gender and Genetic PredispositionA predisposition is usually the first step toward the development of an autoimmune reaction. Women are more likely to develop a systemic autoimmune disease than men. For example in SLE the female to male ratio is 9:1. The genotype of some individuals predetermines that their immune system will be more prone to a break in tolerance. This genetic susceptibility appears to be linked to multiple genes rather than a single gene. This is supported by evidence that some autoimmune diseases are more frequently encountered in certain ethnic groups compared to others. For example in American women between the ages of 15 and 64, the prevalence of SLE is 1 in 700 for Caucasians while it is 1 in 245 for African-American women.(Ref1) Evidence in one recent study suggests that the genes that impart an increased resistance to malaria unfortunately produce an increased susceptibility to the systemic autoimmune rheumatic diseases.(Ref2)Triggering eventThe second step is the occurrence of a triggering event that leads to a break in tolerance. For some very susceptible individuals this event might be exposure to an environmental trigger. These environmental triggers could be ubiquitous such as exposure to the Epstein Barr virus (EBV), or very limited, such as the exposure to leaking silicon from a breast implant. In others, the triggering event might be a change in hormonal balance. Whatever the case, the triggering event initiates the break in tolerance and the cascade of immunological events that eventually lead to the formation of an autoimmune disease begins.Development of autoantibodiesThe third step is the development of autoantibodies and subsequent development of clinical symptoms. Studies have shown that this process can take 3 years or longer and unfortunately, by the time the diagnosis is made, substantial damage to the body may have already occurred.

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Which of these is NOT considered one of the systemic autoimmune rheumatic diseases?View Page
Which of these may contribute to the development of an autoimmune disease? (Choose all that apply)View Page

Basic Tissue Orientation and Paraffin Embedding Technique
The terms "superior" and "inferior" are used to indicate a position or relationship and can be translated to mean the same as:View Page
Commonly Used Anatomic Direction Terms

TermMeaningSagittal A longitudinal, vertical plane that divides into right and left sides.Mid-sagittalA plane which divides the body into anterior and posterior.InferiorThe bottom half, toward the feet.CaudalLocated at or near the hind or posterior of the body. Means the same as "dorsal" and "posterior."InferiorBeneath. Used to reference an under-structure or something below another referenced structure.SuperiorThe top half, toward the head.DistalAway from the center.Cross-sectionA plane formed by cutting though an object at right angles to an axis, which provides a representative sample of most parts contained within the whole.ProximalNearest to a point of reference, such as a point of origin.Horizontal (transverse)A plane that is parallel to the ground.

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Which of the following is NOT a purpose of the embedding process in routine histology? View Page
Uncomplicated Specimens

For larger tissue specimens without complicated margins or stratified layers, the orientation is simply to find the cut surface. Most of these types of specimens will be embedded flat on this cut surface so that the cut surface is placed flat against the block face (bottom, most recessed surface of the mold). Your main concerns will be with getting the specimen as flat as possible and leaving a border of paraffin surrounding the outside edge of the tissue. It is helpful to place at a slight angle, any tissue which is dense or rigid in the block face, as this will aid microtomy. Examples of tissue types which might be easiest to cut at a slight angle are uterus body, thyroid, and prostate gland wedges. Large fatty pieces, such as large sections of breast tissue or lipomas, may not have a distinct cut edge, but should be embedded to show the greatest surface area. It is important to also be sure to leave a heavy border of paraffin to help contain the fatty tissue and hold the section together on the water bath during microtomy.

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Elliptical Skin Specimens

Many skin excisions are submitted in an elliptical shape. This is because it creates wounds that lie parallel to the skin tension lines, so the wounds tend to heal with less scaring. Frequently, elliptical skin specimens will have sutures to indicate how the specimen was oriented on the body. Embed these skin shapes so that the cut surface of the tip (broadest surface of the triangle) is down in the block face. This results in successive sections that progress towards the tip and become smaller over multiple sections. This orientation allows the residual tumor, if present, to be traced out to the tiniest point of the tip. The body, or mid sections, of the specimen will be placed on the cut surface to be serially sectioned at an angle perpendicular to the epidermis.

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Blood Banking Question Bank - Review Mode (no CE)
Which of the following activities will put an employee at risk for exposure to a Bloodborne Pathogen (BBP)?View Page
Therapeutic hemapheresis may be used to treat all of the following except:View Page

Body Fluid Differential Tutorial
Infectious Organisms in Body Fluids

Under normal circumstances, fluids collected from any enclosed body space such as a cerebrospinal fluid (CSF), pleural, peritoneal, pericardial or synovial fluids, should be sterile. When an infection occurs within a body cavity, the fluid that is collected from that site for diagnostic purposes will potentially have infectious organisms present on the cytospin. There can be several types of organisms demonstrated on the Wright stained preparation.Bacteria and fungus are the most common but it is possible to demonstrate the presence of protozoan parasites as well.Spirochetes and acid fast bacilli (AFB) such as mycobacteria will not stain with Wright stain so they will not be detected even if they are present.Since bronchial alveolar lavages, or BALs, are collected through an open airway it is normal to observe respiratory flora, however yeast and hyphae are never normal in a BAL.It is standard practice before reporting the presence of bacteria in a fluid to correlate/confirm the findings with the microbiology lab.

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Neuroblastoma in Pleural Fluid (NBL)

Neuroblastoma is a tumor that arises from embryonic neural crest tissue. It is the most common tumor diagnosed in children under the age of five. Since it arises from nerve tissue, it can be found in many locations throughout the body and therefor can be found in several body fluids.This image shows a tumor clump in the pleural fluid of a patient with stage IV neuroblastoma. Like many of the other metastatic tumors shown in this section, the cells are large in size with a large nucleus and a soft, fine chromatin pattern with prominent nucleoli. The cytoplasm is basophilic with little distinction between individual tumor cells. Since the nuclei are so close to one another, the cytoplasm is much more scant; indicating that this is tumor is not a mesothelial clump.

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Metastatic Tumors in Fluid Cytospins.

There are a wide variety of solid tumors that can metastasize and spread into body fluids. As with cytospins positive for leukemia or lymphoma, any smear with tumor or suspected tumor should be sent for pathology or hematologist review.Body fluids tend to be a good growth medium for metastatic tumors. These tumor cells tend to be present in sheets and clumps. Frequently there will be reactive changes with increased mesothelial cells and macrophages associated with metastatic tumors as well.Tumor cells, in general, typically appear large with fine/open chromatin patterns, dismorphic or dysplastic nuclei and prominent nucleoli. They will have varying amounts of basophilic cytoplasm depending on the tissue of origin.

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Peripheral Morphology vs Cytospin Morphology

Most technologists working in the clinical hematology setting are familiar with the morphology of blood cells found in peripheral blood smears. Many of the same blood cells found in the peripheral blood are also found on cytospin preparations of body fluids. While the morphologies are similar between the two sources, there are changes to the "comfortable/familiar" peripheral blood morphology that are introduced by the cytospin technique. It is paramount to fully conceptualize the appearance of both normal and abnormal blood cell morphologies in body fluids in order to accurately perform fluid differentials.The cytopsin process works by wicking fluid into a filter while fluids samples are spun into a central column and deposited in a mono-layer onto a defined area of a slide. This allows the cells to be concentrated for appropriate identification. This technique can cause pronounced changes to morphology and staining characteristics, as well as cellular destruction if the cytospin malfunctions.The cytospin technique is known to stretch and distort cellular and nuclear morphology and allow nucleoli to appear more prominent than what one would normally see in peripheral smears. Cytospinning, however, does not change nuclear:cytoplasmic ratios nor does it alter relative chromatin textures or clumping patterns. Though this technique can make cells appear larger that on the peripheral blood smear, it can not change cytoplasmic textures and granulation. Focusing on these steadfast features can make cytospin morphology less intimidating.

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References

Carr JH, Rodak BF. Body Fluids. In: Clinical Hematology Atlas, 3rd ed. St. Louis, Missouri: Saunders Elsevier; 2009: 231-253.Galagan KA, Blomberg D, Cornbleet PJ, Glassy EF. Color Atlas of Body Fluids: An Illustrated Field Guide Based on Proficiency Testing. Northfield, IL: College of American Pathologists; 2006.Kjeldsberg CR, Knight JA. Body fluids: laboratory examination of amniotic, cerebrospinal, seminal, serous & synovial fluids. Chicago, Illinois: ASCP Press; 1993.McKenzie SB, Williams JL. Morphologic Analysis of Body Fluids in the Hematology Laboratory. In: Clinical Laboratory Hematology, 2nd ed. Upper Sadle River, New Jersey: Pearson Education, Inc.; 2010: 583-611.

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Monocytes and Macrophages

Monocytes and macrophages are frequently found together in body fluids. In fact, macrophages are actually monocytes that have arrived in the fluid earlier, and become more active than their more recently arrived brethren. The function of a monocyte or macrophage is to remove and recycle dead or dying cells so they do not become an irritant to the body. Macrophages (see arrows) are larger with much more cytoplasm which is frequently heavily vacuolated. The nucleus tends to be pushed to the edge of the cell and the cytoplasm may have ingested materials present. You may see ingested RBC's or WBC's, lipid droplets, hemosiderin and even ingested crystals.

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Macrophages are actually lymphocytes that have entered the tissues and body fluids via diapedesis.View Page
Select the specific cells listed below that can be found in all types of body fluid.View Page
Prominent vacuolation involving the cytoplasm of abnormal lymphoblast-like cells seen in a body fluid preparation is a distinctive feature of Burkitt Lymphoma.View Page
Identification of tuberculosis can be performed by examination of Wright stained cytospin slides of infected body fluids.View Page
Yeast

Fungal infections can also be identified in the cytospin preparations from various body fluids. The next series of photos shows the peritoneal fluid from an immunosuppressed patient in renal failure requiring peritoneal dialysis.Note the cluster of yeast cells in the center of the photo. This was eventually identified as Candida albicans.

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Intracellular Diplococci

When intracellular bacteria are present in a body fluid cytospin, they classically appear within neutrophils (see arrows). When the bacterial burden is high, they may also be found in monocytes/histiocytes. It is important to note that monocytes are the less effective phagocytes of these two cell types, so they will never contain intracellular organisms if the neutrophils do not do so as well. If you think you are seeing bacteria in a monocyte/macrophage, and the neutrophils do not display intracellular bacteria, you may actually be observing granules of hemosiderin within the macrophages. Hemosiderin usually stains more green-blue or black than bacteria, and the granules are less regular in size than ingested bacteria. Comparing the Wright stain to the Gram stain, and performing an iron stain, will help with this distinction.

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Match the following blood cell types to the respective body fluids where they may reside.View Page
Mesothelial Cells

The mesothelium is the name given to the membrane that lines most body cavities and surrounds the internal organs. Cells that shed from these membranes are commonly found in pleural, peritoneal and pericardial fluids. Mesothelial cells are large cells that may be found as single cells or in clusters and clumps. They tend to have a large round centrally placed nucleus with a generous amount of basophilic cytoplasm which can appear frayed at the edges. They will have one ore two small, well-defined, deeply staining nucleoli. While they may have small pinpoint vacuoles, they will not have the larger "foamy" vacuoles seen in macrophages or histocytes.There are two mesothelial cells in the image below (see arrows). While they are different in size, they are definitely larger than the background lymphocytes and plasmacytoid lymphocytes. Notice the irregular frayed edge to the cytoplasmic membrane.

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Reactive Mesothelial Cells

Reactive mesothelial cells can be found when there is an infection or an inflammatory response present in a body cavity. This condition can be due to the presence of a bacterial, viral or fungal infection. It can also be the result of trauma or the presence of metastatic tumor.Reactive mesothelial cells tend to come in clusters and clumps and have a more washed out cytoplasm in body fluids. Notice in the image on the right, how indistinct the cytoplasmic borders are in this clump compared to normal mesothelial cells. The wide separation of the nuclei and the well defined nucleoli help to identify these as reactive mesothelial cells. However if there is any doubt, the smear should be sent for hematology or pathology review.Note: It is not uncommon for macrophages to be mixed into a reactive mesothelial clump.

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Bone Marrow Aspiration Part I: Normal Hematopoiesis and Basic Interpretive Procedures
Bone Marrow Biopsy

A bone marrow biopsy is obtained by a similar technique but rather than aspirating liquid marrow, a core of bone is allowed to enter the biopsy needle and is then removed within the needle. The image* illustrates the body site where the bone marrow is normally obtained.The core can be rolled between two slides to make touch preparatons (touch preps), which are then stained and reviewed. The bony core is fixed and sent to pathology, where it will be decalcified and prepared for sectioning and staining.Reference: Bone marrow biopsy. National Cancer Institute. Available at: http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46506&version=Patient&language=English. Accessed July 3, 2011.

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Rules for Bone Marrow Differentials

Bone marrow differentials have significant differences from peripheral blood differentials that need to be considered as they are reviewed and counted.One of the most important facts to consider is the large variability in cellularity and cell distribution depending on the type of preparation that is used. Choosing where to count and when to use which of the smear types available to you, takes time and experience and can be directed by a pathologist's preference.Regardless of how many, or what types of smears you have available to choose from, you will always start with a simple visual inspection of your smears. Begin by recording the patient identification information as well as date of sample, and any other mandatory patient identifying information necessary for your laboratory. Record aspiration site information when provided. Many patients will have bilateral bone marrow aspirates performed as part of a diagnostic or staging workup. Standard aspiration sites are: posterior iliac crest (PIC), anterior iliac Crest (ANT), sternum (S), spinous process (SP) and sometimes in very young children, bone marrow is obtained from the tibia (T). Be aware, that while a bilateral bone marrow aspirate usually involves an aspirate of the same site from opposite sides of the body, e.g., L-PIC and R-PIC, in some situations, a bilateral staging aspirate will be from two different compartments on the same side, e.g. R-AIC, R-PIC. Observe the appearance of the bone marrow smears. Do any have feather edges? Are there fragments or spicules present on any of the smears available? If so, they should be your first choice to view, since they are more representative of what the biopsy will show if one was obtained. Once you select your smears, scan using 10X magnification on the microscope. Are some of the fragments/smears so thick that you cannot see good morphology? If so, reject these areas/slides. Are some of the fragments/smears so thin that everything is smashed? These areas/smears cannot be used either. Are there areas in the vicinity of any of the fragments that have good staining characteristics as well as readable morphology? This is where you should begin your differential.

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Cardiac Biomarkers
The Human Heart

The human heart is a muscular organ that is formed into four chambers with an interconnecting vascular system. Venous blood from the body enters the right atrium, is pumped into the right ventricle and from there is pumped to the lungs for reoxygenation. Oxygenated blood from the lungs accumulates in the left atrium and is pumped into the left ventricle and out to the body. Myocytes (muscle cells) require large amounts of energy and oxygen to accomplish this. The capacity of the heart to pump adequately is regulated by the volume of blood, systemic blood pressure, and the force of contraction achieved in the left ventricular wall.

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Which heart chamber pumps oxygenated blood out to the body?View Page
Congestive heart failure (CHF) ordinarily results when the left ventricular myocardium is weakened.View Page
Terminology Describing Ischemic Heart Disease and Heart Failure

Descriptions of cardiac biomarkers and their use require knowledge of several terms. These terms and their definitions follow.Acute Coronary Syndrome (ACS) Includes all the ischemic events that can occur in the heart. These events range from angina (where there is no cell death or reversible cell injury) to an AMI with large areas of cell necrosis. A continuum of events that are involved in ACS is illustrated on the page that follows this glossary of terms.Acute Myocardial Infarction (AMI) Commonly referred to as a heart attack. A sudden loss of circulating blood and oxygen that causes necrosis of myocardial tissue. It is most often caused by the narrowing of coronary arteries by atherosclerosis, a thrombus, or dislodged plaque material.Angina Chest pain caused by inadequate supply of oxygen to heart myocardium. It is synonymous with angina pectoris, pectoris meaning chest.Congestive Heart Failure (CHF) Usually, a left ventricular dysfunction resulting from aging, hypertension, atherosclerosis or muscle damage from an AMI or repeated AMIs. In CHF, the heart is not able to effectively pump blood through its chambers and to the body. Fluid accumulates in the lungs and tissues causing edema because less blood leaves through the arteries than what entered the heart from the veins. Electrocardiogram (ECG or EKG) The tracings of the electrical current that passes through the myocardium. The heart contractions are stimulated by this current. In areas of myocyte necrosis, the current does not pass and the tracings display abnormal patterns.Infarction An area of tissue death that occurs due to lack of oxygen. Clogging of an artery will cause dead muscle tissue or infarction.IschemiaAn inadequate blood supply that decreases availability of oxygen. Atherosclerosis is the main cause of myocardial ischemia.

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Case Studies in Clinical Microbiology
Minimum inhibitory concentration (MIC) susceptibility tests should be performed against other beta lactam antibiotics on important S. pneumoniae isolates from blood cultures and other sterile body fluids when a MIC for penicillin is performed.View Page
Isolates of Escherichia coli, Klebsiella pneumoniae, K. oxytoca and clinically significant isolates of Proteus mirabilis may possess extended-spectrum beta-lactamase (ESBL) activity.View Page
Case History

A 63-year-old man was seen in the emergency room with the complaints of sudden onset of fever, chills, and abdominal pain, accompanied by mild diarrhea. The blood pressure was 140/84, the pulse rate 82/minute, and the body temperature 39.8C. A blood sample was drawn for a complete blood count, and a blood culture. A second blood culture was drawn from the opposite arm, with 10 mL of blood being placed into each an aerobic and an anaerobic bottle, following customary practice. The complete blood count revealed a hemoglobin of 15.8 mg/dL, a hematocrit of 45%, and a white blood count of 4.2/L. The neutrophils were 39%, lymphocytes 45%, monocytes 10%, eosinophils 4% and basophils 2%. The platelet count was 255/L. The patient was admitted to the hospital for further work-up and empiric antibiotic therapy. Within 24 hours after admission, the body temperature had decreased to 38.2C, although the mild diarrhea persisted. A stool toxin test for Clostridium difficile was negative and neither enteric pathogens nor Campylobacter species were recovered in stool culture after 24 hours incubation. Fecal neutrophils were not seen on direct examination. The anaerobic blood culture became positive 36 hours after inoculation.

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Review 1

Francois P. Vaudaux P. Foster TJ. Lew DP.: Host-bacteria interactions in foreign body infections. Infection Control & Hospital Epidemiology. 17:514-20, 1996 Persistent staphylococcal infections are a major medical problem, especially when they occur on implanted materials or intravascular catheters. This review describes some of the recently discovered molecular mechanisms of Staphylococcus aureus attachment to host proteins coating biomedical implants. These interactions involve specific surface proteins, called bacterial adhesins, that recognize specific domains of host proteins deposited on indwelling devices, such as fibronectin, fibrinogen, or fibrin. Elucidation of molecular mechanisms of S. aureus adhesion to the different host proteins may lead to the development of specific inhibitors blocking attachment of S. aureus, which may decrease the risk of bacterial colonization of indwelling devices.

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Review 3

Ladhani S. Joannou CL. Lochrie DP. Evans RW. Poston SM.: Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome. Clinical Microbiology Reviews. 12:224-242, 1999 The exfoliative (epidermolytic) toxins of Staphylococcus aureus are the causative agents of the staphylococcal scalded-skin syndrome (SSSS), a blistering skin disorder that predominantly affects children. Clinical features of SSSS vary along a spectrum, ranging from a few localized blisters to generalized exfoliation covering almost the entire body. The toxins act specifically at the zona granulosa of the epidermis to produce the characteristic exfoliation, although the mechanism by which this is achieved is still poorly understood. Despite the availability of antibiotics, SSSS carries a significant mortality rate, particularly among neonates with secondary complications of epidermal loss and among adults with underlying diseases.

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Cerebrospinal Fluid (retired 7/17/2012)
Malignant Cells

Malignant cells that have broken away from tumors located in other areas of the body may be seen in spinal fluid. All of the cells in this field are tumor cells. The cells in this slide are characterized by an open, loose chromatin pattern, nucleoli and vacuoles. Notice that the vacuoles are present in both the nucleus and the cytoplasm. Vacuoles in the nucleus are an unusual finding even in tumor cells. Tumor cells are often found in clumps and may have more than one nucleus due to their erratic mitotic patterns. Malignant cells sometimes have an irregular nuclear shape. Bizarre granules may be found in malignant cells but are absent in mesothelial cells.

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Chemical Screening of Urine by Reagent Strip
Ketones Overview

When the body breaks down fat for energy, three intermediate products are formed. These products, collectively referred to as ketones, include acetone, acetoacetic acid, and beta-hydroxybutyric acid. Normally, the body gets the energy it needs from carbohydrates in the diet. However, stored fat is broken down and ketones are produced and appear in the urine if the diet does not contain enough carbohydrate to supply the body with glucose for energy or if the body cannot use glucose properly.

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Clinical Significance of Positive Urine Ketones

Ketone bodies are usually absent in urine. The presence of ketones in the urine most likely indicates that the body is using fats rather than carbohydrates for energy. For example, high levels of ketones may be present in the urine of individuals with uncontrolled diabetes because the body's ability to metabolize carbohydrates is defective. Detecting the presence of ketones in the urine is a valuable aid to managing and monitoring individuals with diabetes mellitus. Ketonuria is an indication that the insulin dose needs to be increased. Electrolyte imbalance and dehydration may occur when ketones accumulate in the blood. If these conditions are not corrected by adjusting the dose of insulin, the patient may develop ketoacidosis and ultimately diabetic coma. Low levels of ketones may also be detected in the urine during conditions of physiological stress such as fasting, rapid weight loss, frequent strenuous exercise or prolonged vomiting. The presence of ketones in these situations is due to either inadequate intake of carbohydrates or increased loss of carbohydrates.

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Chemical Screening of Urine by Reagent Strip (retired March 2012)
Clinical Significance

In the healthy individual, almost all of the glucose filtered by the renal glomerulus is reabsorbed in the proximal convoluted tubule. The amount of glucose reabsorbed by the proximal tubule is determined by the body's need to maintain a sufficient level of glucose in the blood. If the concentration of blood glucose becomes too high (160-180 mg/dL), the tubules no longer reabsorb glucose, allowing it to pass through into the urine. It is important to note that glucose may appear in the urine of healthy individuals after consuming a meal that is high in glucose. Fasting prior to providing a sample for screening eliminates this problem.

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Three Kinds of Ketones

When the body breaks down fat for energy, three intermediate products are formed. These products, collectively referred to as ketones, are acetone, acetoacetic acid, and beta-hydroxybutyric acid. Normally, the body gets the energy it needs from carbohydrates in the diet. However, stored fat is broken down and ketones are produced and appear in the urine if the diet does not contain enough carbohydrate to supply the body with glucose for energy or if the body cannot use glucose properly.

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Ketone Bodies

Ketone bodies are usually absent in urine, but low levels may be detected during conditions of physiological stress such as fasting, rapid weight loss, frequent strenuous exercise or prolonged vomiting. The presence of ketones in these situations is due to either inadequate intake or increased loss of carbohydrates. High levels of ketones are present in the urine of individuals with uncontrolled diabetes. In diabetes the ketones are present because the body's ability to metabolize carbohydrates is defective.

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Clinical Significance of Positive Urine Ketone Result

Ketone bodies are usually absent in urine. The presence of ketones in the urine probably indicates that the body is using fats rather than carbohydrates for energy. High levels of ketones may be present in the urine of individuals with uncontrolled diabetes because the body's ability to metabolize carbohydrates is defective. Detecting the presence of ketones in the urine is a valuable aid to managing and monitoring individuals with diabetes mellitus. Ketonuria is an indication that the insulin dose needs to be increased. Electrolyte imbalance and dehydration occur when ketones accumulate in the blood. If these conditions are not corrected by adjusting the dose of insulin, the patient may develop ketoacidosis and ultimately diabetic coma. Low levels of ketones may be detected during conditions of physiological stress such as fasting, rapid weight loss, frequent strenuous exercise or prolonged vomiting. The presence of ketones in these situations is due to either inadequate intake of carbohydrates or increased loss of carbohydrates.

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Chemistry / Urinalysis Question Bank - Review Mode (no CE)
Creatinine excretion correlates best with which of the following parameters:View Page
Metabolic acidosis is characterized by:View Page
Chylomicrons are primarily composed of:View Page

Confirmatory and Secondary Urinalysis Screening Tests
Other Causes of Ketonuria

Ketonuria can also be found in conditions associated with a decreased intake of carbohydrates (starvation), digestive disturbances, dietary imbalance (high fat/low carbohydrate diet), eclampsia, prolonged vomiting and diarrhea, glycogen storage diseases, vigorous exercise, fever, and following administration of anesthesia. Ketone bodies are mildly toxic to the body, tending to interfere with the excretion of uric acid, produce mild depression of the central nervous system, and cause acidosis.

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Department of Transportation (DOT) Federally Regulated Urine Specimen Collection Training
Observed collection

The last type of collection is the observed collection. In this type of collection both the donor and "observer" enter the collection stall. Observed collections afford less privacy in order to guard against the donor using items which are designed specifically to beat the testing process. Under the Department of Health and Human Services mandatory guidelines for Federal workplace drug testing the observer must directly watch the urine go from the donor's body into the collection container. The use of mirrors or video cameras is not permitted.The observed collection is expanded under the Department of Transportation's 49 CFR § 40. After entering the stall the observer requests the donor to: Raise shirt, blouse, dress / skirt as appropriate, above the waist, just above the navel, Lower clothing and underwear to mid-thigh, and, Then turn around to show the observer that the donor does not have a prosthetic device. After the observer has determined that the donor does not have a prosthetic device, the donor is permitted to return clothing to proper position. The observer must personally watch the urine go from the donor's body into the collection container. The use of mirrors or video cameras is not permitted.

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Dermal Puncture and Capillary Blood Collection
Miscellaneous Equipment

In addition to the puncture device, additional equipment may be required when performing a successful dermal puncture.Plastic microcollection devices: Plastic microcollection devices are small plastic tubes designed to collect capillary blood from a dermal puncture wound. Each small collection tube is color-coded in the same manner as blood collection tubes used for venipuncture. The color of the cap of each container tube corresponds to the type of additive inside the tube, most often an anticoagulant. The additive coats the inside of the tube. Examples of microcollection devices are shown below. Heel warmer: It is best practice to warm the heel of an infant with a warming device known as a heel warmer. The heel warmer, when activated, is designed to warm its contents to a standardized temperature. This temperature will be hot enough to effectively warm the heel and facilitate blood flow to the area without causing heat injury to the patient. It is unacceptable to warm a cloth using a microwave. There may be "hot spots" on the cloth that could potentially burn the patient. Keep in mind, what may feel warm to you, the phlebotomist, may feel hot to your patient!Plastic or Mylar-wrapped capillary tube: In some facilities blood from a capillary puncture is collected directly into a capillary tube. These tubes are very delicate and must be used with great caution. As soon as the tube is two thirds to three-fourths filled, one end is sealed to prevent blood from leaking out.Glass microscope slides: In some facilities, the person collecting the capillary specimen may also be required to prepare a blood smear for laboratory examination. A drop of blood is placed directly on a glass slide and spread to create an area for cell examination. If you are required to prepare blood smears, remember that the slide is considered infectious until fixed or stained. It is also important to remember that glass is a sharps hazard. If not used correctly, the glass may cause injury to both the patient and the phlebotomist. Be as cautious with a glass slide containing blood as you are with a contaminated needle. Dispose of glass slides that will not be used for testing in approved sharps containers.Alcohol and gauze pads: Alcohol is the disinfectant of choice for dermal puncture. The alcohol must be allowed to air dry, which will prevent hemolysis of the specimen and discomfort for the patient. A piece of clean or sterile gauze is used to wipe away the first drop of blood. Gauze is also used to apply pressure to the wound after the specimen collection is complete to stop the wound from bleeding.Iodine or other approved cleaning agents may be used as an alternative to alcohol.Bandage: It may be necessary to apply a bandage to the puncture wound on a finger or heel if the site continues to bleed. However, it is NOT recommended to bandage the finger of a child who is 2-years-old or younger since the bandage may become a choking hazard if the child puts that finger in his/her mouth.Personal protective equipment (PPE): All healthcare professionals that may come in contact with blood and/or body fluids while performing a laboratory procedure are required to wear intact gloves. It is against safety guidelines to alter gloves in any way that may compromise the integrity of the gloves. Eye protection, such as safety goggles, is recommended if there is the possibility of a splash of blood while collecting a capillary blood specimen. In many facilities, special gowns are required in some patient areas such as special-care nurseries. Always follow the policies of your facility in regard to PPE.

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Inappropriate Sites/Patients for Capillary Puncture

There are some instances where a dermal puncture is prohibited or not recommended.Mastectomy patientsAs a general rule, a dermal puncture, or a venipuncture, should not be performed on the side affected by a mastectomy. The body's ability to fight infection is compromised if lymph nodes were removed. A physician's permission must be obtained before performing a blood collection procedure on the same side as a mastectomy. Edematous siteDermal punctures should not be performed on previously punctured sites or swollen sites. Excess tissue fluid may contaminate the specimen.Dehydrated patientIf the patient is dehydrated or has poor circulation, it may be impossible to get a quality specimen. Fingerstick on a newborn or young infant Dermal punctures must never be performed on the fingers of a newborn or very young infant (usually defined as under 12-months-old). There is very little distance between the skin and the bone. Therefore, the bone could be easily pierced during the puncture, causing injury to the bone, infection, or gangrene.

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Detecting and Evaluating Coagulation Inhibitors and Factor Deficiencies
Introduction: Factor Deficiencies

A deficiency in one or more coagulation factor will also cause abnormalities in hemostasis. The image to the right depicts the coagulation cascade. Notice how one factor acts upon another to eventually form a stabilized fibrin clot, the end product of the coagulation cascade. Having an abnormally low level, or a complete lack, of a coagulation factor can cause the extrinsic, intrinsic, or common pathways to malfunction, resulting in dangerous hemorrhagic issues including spontaneous bleeding. Two of the most common factor deficiencies are factor VIII (hemophilia A) and factor IX (hemophilia B). Hemophilia A comes in two forms: congenital (inherited) or acquired. Congenital hemophilia A represents the condition where an individual is born defecient (to various degrees) of factor VIII. Acquired hemophilia A is a condition in which an individual spontaneously produced an autoantibody to factor VIII, leaving the body unable to use the factor VIII that may be present. Hemophilia B is an inherited condition where the individual has a mutation of the factor IX gene and is unable to produce adequate levels of this coagulation factor.In some cases, patients have multiple factor deficiencies that are secondary to a primary condition such as vitamin K deficiency, disseminated intravascular coagulation (DIC), and liver disease. With vitamin K deficiency, the liver is unable to produce the coagulation factors that are vitamin K-dependent. During liver disease, the liver may be unable to produce coagulation factors effectively. In DIC, the clotting processes are in overdrive and will consume the coagulation factors that are being produced, leading to low levels of circulating coagulation factors.

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Diabetes and the Current American Diabetes Association Guidelines
Diabetes - A Metabolic Disorder

Diabetes results when insulin concentrations are absent, reduced, or when insulin action is impaired (referred to as insulin resistance). Without cellular uptake of blood glucose for energy, the balance of metabolizing carbohydrates, fats, and proteins for energy is lost. Hyperglycemia and excess use of fats and proteins for energy result. The latter causes excess acetyl-CoA which is converted to ketone bodies or to cholesterol.Polydipsia, polyuria, and unexplained weight loss are symptoms of diabetes. Polydipsia and polyuria occur as the body tries to lower blood glucose concentrations with increased urinary excretion of glucose. Weight loss results from increased utilization of proteins and fats for energy. The image on the right represents impaired metabolism in diabetes. The thicker arrows represent the pathways that are imbalanced. In normal carbohydrate metabolism, the opposing arrows would be of the same size, representing a normal pathway and a balanced metabolism.

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Type 2 Diabetes

The cause of type 2 diabetes is more complicated. The hyperglycemia can result from insulin resistance, insulin deficiency, or a defect in insulin secretion. Insulin resistance is probably the primary dysfunction. The insulin is present; however, due to other metabolic processes, it is unable to act on peripheral cells and tissue. The pancreas is unable to increase insulin production to compensate for the resistance and therefore, insulin activity is deficient.The insulin resistance and deficiency result from a combination of genetic and environmental factors. Common among these are obesity, family history, and distribution of body fat. Truncal obesity is associated with insulin resistance. Increased calorie intake, weight gain, duration of obesity, and decreased physical activity are other factors contributing to type 2 diabetes onset.

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Other Complications

Ketoacidosis is always a serious complication for type 1 diabetics. Due to lack of uptake of glucose into cells by insulin, proteins and fats are utilized as energy sources. This results in excess acetyl CoA which is converted to ketone bodies. A serious acidosis results and if untreated or not resolved by the body, coma and death can occur.Most often the acetyl CoA in a type 2 patient is converted to cholesterol and results in hyperlipidemia and heart disease in these patients.The elderly type 2 diabetic is at risk for a hyperosmolar nonketotic coma. The patient becomes dehydrated due to increased urine excretion to lower the blood glucose. If reduced renal or cardiac function is also present, glucose excretion is impaired and blood glucose concentrations can become extremely high. Ketones are not produced in excess, thus the patient remains nonketotic. Insufficient hydration, elevated blood glucose, and decreased renal excretion of waste products result in an increased osmolality and total concentration of all plasma components.

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Screening for Diabetes

The ADA guidelines include recommendations for screening for diabetes. It is recommended to screen asymptomatic persons for diabetes or their risk of diabetes. Screening is recommended for all individuals age 45 years and older; a negative screen should be repeated every three years. Screening is essential for individuals who are overweight, defined as a body mass index (BMI) > 25 kg/m2. The ADA also recommends earlier screening for many individuals. Among these are individuals who are overweight and have additional risk factors. Additional risk factors include: Physical inactivity Family history of diabetes A member of a high-risk ethnic group Women who have had a large birth weight baby or gestational diabetes diagnosis should have earlier screening. Also included for earlier screening are individuals who are hypertensive or have lipidemia, vascular disease, or other clinical conditions associated with insulin resistance. Individuals who in previous testing had impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or HbA1C in the range of 5.7-6.5% should be screened for diabetes regularly.

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Ketones

Acetyl CoA is converted to acetone, acetoacetate, and beta-hydroxybutyrate. These are acids and when dissolved in body fluids in excess lower the blood pH. Increased ketones can result in a metabolic acidosis referred to as ketosis, ketoacidosis or diabetic acidosis. Type 1 diabetic patients are especially at risk for ketoacidosis. Urine and serum ketones are measured semiquantitatively and a diabetic in ketosis is monitored for ketones and blood pH.

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Electrophoresis
Specimens

Serum and plasma are the most common clinical specimens used for electrophoresis applications. Urine and cerebrospinal fluids (CSF) are also suitable. Other body fluids such as pleural fluid and pericardial fluid are analyzed less frequently. Some specimens require pretreatment before electrophoresis. Low concentrations of proteins normally in urine and CSF are concentrated in order to have enough proteins for detectable separations. Some body fluids require removal of pigments, salts, and other compounds that interfere with electrophoresis or the detection of separated solutes. In molecular diagnostic testing of DNA and RNA, the nucleic acids must first be isolated from the specimen and then purified before separation with electrophoresis.

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Currently there has been a revitalization in the clinical usage of electrophoresis. Previously, methods were primarily used to separate proteins in blood and other body fluids. From the following statements, select the statements that correctly describe newer applications of electrophoresis.View Page
Electroendosmosis

With a pH 8.0-9.0 used for protein electrophoresis, proteins take on a negative charge, that is a negative ion cloud forms. As the negative ion cloud migrates to the anode, the proteins are pulled to the anode. Several gels used routinely for protein electrophoresis attract positive ions from the buffer and form a positive ion cloud. This ion cloud moves in the opposite direction to the cathode. This phenomenon is called electroendosmosis or endosmosis.The tension created by these oppositely moving ion clouds can affect the movement of sample macromolecules. The migration of some proteins can be slowed, some proteins can become immobile, and other proteins are pushed toward the cathode. Many protein electrophoresis methods take advantage of this tension and use it to achieve better separation of protein bands. The gamma globulin band in serum, urine, and other body fluids will separate more sharply by being pushed to the cathode and will appear behind the point of sample application.

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Resurgence of Electrophoresis

Traditionally, most clinical laboratory electrophoresis utilizes methods that separate and identify proteins in serum, urine, CSF, and some other body fluids. Most studies are designed to detect serum protein abnormalities and gathering more information about gammopathies.In recent years, there has been a resurgence in electrophoresis use and methods. Development of automated methods has enhanced this. The evolution of numerous molecular diagnostic investigations and research in proteomics have also augmented electrophoresis.Applications of two-dimensional electrophoresis discussed the use of electrophoresis in proteomics. Electrophoresis and molecular diagnostics, blotting techniques, and current uses of CE in molecular diagnostics will be discussed now.

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Emerging Cardiovascular Risk Markers
Atherosclerosis continued

If a plaque ruptures it will expose sub-endothelial tissue to blood cells and in so doing stimulate the formation of a clot. The clot is the body's attempt to seal off the crack but the clot itself can cause further obstruction to blood flow. This sudden increase in the blockage caused by the raised ruptured plaque and associated clot can transform a mild blockage into a critical one within a matter of hours. If it occurs within the blood vessels of the heart, the decrease in blood flow leads to severe and prolonged chest pain known as unstable angina. Such a patient is at obvious risk for a myocardial infarct should the blockage become any worse.Atherosclerosis typically begins in early adolescence, and is found in most major arteries but since it is asymptomatic during the early half of life we need cardiovascualr risk markers to help assess patient risk. If an at-risk patient is identified early, the hope is that medication, lifestyle changes or medical procedures can be used to avert a serious cardiovascular event. So, although the vast majority of us have some degree of atherosclerosis, risk markers can help identify those among us who are in more imminent danger or who have increased risk of an adverse cardiovascular event.

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Atherosclerosis

Atherosclerosis is a clogging, narrowing and hardening of the body's large and medium-sized blood vessels. Atherosclerosis can lead to hypertension, stroke, myocardial infarction (heart attack), renal problems, etc. Not surprisingly, cardiovascular risk markers tend to reflect a person's degree of atherosclerosis.Atherosclerosis is actually a chronic inflammatory response within the walls of arteries. Small lipoproteins like LDL are able to diffuse through the endothelial wall of blood vessels and accumulate. The inflammatory component of atherosclerosis results from the migration of leukocytes (mainly macrophages) that enter the blood vessel walls. These macrophages seek to remove the deposited LDL as well as intermediate-density lipoproteins (IDL). As macrophages phagocytose these lipoproteins, they become foam cells that get trapped in the endothelial space. This eventually leads to "hardening" or "furring" of the arteries and plaque formation. Arteriosclerosis is a general term describing any hardening (loss of elasticity) of medium or large arteries whereas atherosclerosis is a hardening of an artery specifically due to plaque. The risk to patients with significant atherosclerosis is that eventually a narrowing of the artery (stenosis) can cause a reduction in oxygen delivery to tissues and plaque rupture can lead to an acute coronary event.

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Transport of Lipophilic Substances

Many lipophilic substances, including fat-soluble vitamins, cholesterol, and triglycerides are essential for life. The body needs to be able to absorb and transport these substances. However, lipophilic substances are not water-soluble, and, since blood is aqueous, this presents a challenge. The body addresses this need by using 'carriers' which can bind or sequester lipophilic molecules to aqueous 'vehicles' and thus transport them through the aqueous environment of the blood. Small lipid-soluble hormone molecules like estrogen, testosterone or cortisone are carried through the blood by binding to carrier proteins. Cholesterol and triglycerides are carried through the body in small spherical particles which trap the lipophilic molecules in their centers. These particles have an outer shell that is polar on the surface so that the particles are soluble in the blood but they have a lipophilic core which can hold fat-soluble molecules.

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Apolipoproteins

Lipoproteins differ in size and density as well as in their content (what they tend to carry). They also can differ in their origination (where they are made). Another significant difference between lipoprotein molecules is the proteins they have on their surfaces. These proteins, known as apolipoproteins, are the major identifying characteristics of a lipoprotein. There are many different apolipoproteins and we are continually learning more about them. Apolipoproteins have multiple roles. One role is that these amphipathic (detergent-like) proteins increase the overall solubility of the lipid particle, helping it to dissolve in the aqueous environment of the blood. Apolipoproteins can also function as enzyme co-factors (receptor ligands) and facilitate the transfer of their lipid cargo to specific cells. Thus, the apoliproteins are the smart or working-end of the lipoprotein particle. The apolipoproteins dictate where the particles will dock and where they can bind, and in so doing the apolipoproteins regulate lipid metabolism in the body.

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ApoB and ApoA1

By measuring ApoB we can quantify the amount of all atherogenic or potentially atherogenic lipoproteins that carry this apolipoprotein. Although lipoprotein particles other than LDL can carry ApoB, LDL accounts for the vast majority of ApoB; therefore, it is a good index of LDL particle number. Furthermore, the other particles that can have ApoB (such as IDL and Lp(a)) are also atherogenic and so it is not problematic if they are counted along with LDL, since they also contribute to cardiovascular risk. What about ApoA1? HDL-C is known as 'good cholesterol'. The role for HDL in the body is to sequester excess cholesterol and bring it back to the liver. Since HDL can remove cholesterol and transport it back to the liver for excretion or re-utilization it is indeed good. HDL is a negative cardiovascular risk factor; as its concentration goes up, a person's cardiovascular risk decreases. A person with low cardiovascular risk would have low ApoB levels and high ApoA1 levels. If we measure both ApoB and ApoA1 and express them as a ratio of ApoB/ApoA1 we get a powerful cardiovascular risk marker. The ratio should be approximately 0.3-0.9. Patients with a higher ratio have elevated ApoB (LDL) and/or low ApoA1 (HDL) and are thus at increased risk. By combining these two markers in a ratio, we get synergy and enhanced predictive power.

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Erythrocyte Inclusions (retired 7/10/2012)
More on Howell-Jolly Bodies

Under normal conditions, Howell-Jolly bodies are thought to be remnants of nuclear fragments due to incomplete expulsion of the nucleus. In pathological conditions, they are aggregates of chromosomes which have separated from the mitotic spindle during abnormal mitosis. Single or multiple Howell-Jolly bodies may be found in a red cell. A single HJ body in a red cell may be seen in megaloblastic anemia, hemolytic anemia such as sickle cell anemia and after splenectomy. Megaloblastic anemia or abnormal erythropoiesis is usually present when multiple Howell-Jolly bodies are observed in a single cell.

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The inclusion seen in the red cell just above center in this field is a ___________ body.View Page
Comparison of Erythrocyte Inclusions

In section A of the image, the arrow points to an RBC with basophilic stippling.In section B, the arrows point to erythrocytes containing Pappenheimer bodies.The arrows are pointing to Howell-Jolly bodies in section C.By contrast, in section D the arrow is pointing to a platelet that is sitting on top of an RBC. This may be mistaken for an inclusion. One of the distinguishing characteristics that can alert you to the fact that it is not an inclusion is the halo around the platelet.

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Howell-Jolly Bodies contrasted with Pappenheimer Bodies.

Pappenheimer bodies are indicated with single arrows. A Howell Jolly body is shown at the double arrow.

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First Aid
Treatment of Third Degree

Third degree burns or second degree burns involving more than 20% of body surface area must receive immediate emergency medical attention.

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Fundamentals of Hemostasis
Introduction to the Fundamentals of Coagulation

The ability of the body to maintain a state of homeostasis, or physiological equilibrium, is absolutely essential for effective, efficient functionality of all body systems. Hemostasis is the cessation of free blood flow, external to the vascular system, when a vessel wall has been breached.With the maintenance of homeostasis in mind, it is vital that the body be able to rapidly repair vascular damage, arresting blood flow in the process, while simultaneously maintaining blood in a fluid state within the vascular compartment.

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Introduction to Primary Hemostasis

Primary hemostasis is considered the starting point for the hemostatic response. This process is initiated by the body, subsequent to vascular damage. Its activation serves as a trigger for ensuing hemostatic processes, as the mechanisms are all interrelated. Primary hemostasis consists of two key parts: The vascular systemPlatelets (thrombocytes)

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Summary of Primary Hemostasis

In summation, we have covered the following sequence of events, which comprise primary hemostasis. The process begins with damage to a vessel wall, as blood flows outside the vasculature. The body responds with vasoconstriction, decreasing blood flow to the affected area. Platelets begin sticking to the damaged vessel walls (platelet adhesion). As the platelets stick, they change their shape (platelet activation) and release chemicals which signal other platelets to respond (platelet secretion). As other platelets arrive, they begin sticking to one another, clumping together, forming a plug to fill in the breach (platelet aggregation). This plug, while strong, is a temporary fix, and must be reinforced with fibrin strands to effectively fill the breach during the vessel repair process (secondary hemostasis).

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Coagulation Disorders - Acquired

Disseminated Intravascular Coagulation (DIC) is best described as a disorder of consumption, because clotting factors are depleted from the blood. Basically, clotting occurs randomly throughout the body, as opposed to just in the localized areas where vascular damage has occurred, consuming clotting factors and other components such as platelets in the process. Symptoms may range from a mild bleed, to severe, profuse bleeding, primarily dependant upon the availability of clotting factors. As more and more coagulation factors and components are consumed, the disorder progresses and symptoms worsen. Most heavily impacted are the levels of factors I, V, and VIII as well as the number of available platelets. Clinically, DIC is detected via an elevated (positive) FDP, positive D-dimer test, a prolonged PT and APTT, plus the manifestation of hemorrhagic episodes. DIC is diagnosed as two primary types, acute and chronic. Acute DIC manifests in a few hours or a few days, has a high mortality rate, and is seen in infections, obstetric complications, liver disease, and tissue injury. Chronic DIC is a secondary condition to some other disease state. Once you treat the primary disease, this type of DIC will go away. Treatment is often factor replacement therapy through the use of fresh frozen plasma and/or cryoprecipitate.

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Coagulation Disorders and Liver Disease

The liver is the site of production for the vast majority of our clotting factors. Therefore, impaired liver function could adversely affect these hemostatic proteins. Some early indicators of a potential liver problem include:An increase in factor VIII. It is not produced in the liver and will be present in elevated numbers as the body attempts to compensate. The PT is sensitive to liver function, so an unexpected, prolonged PT should be evaluated. A lack of fibrinogen is often indicative of severe liver disease. It is difficult to treat liver disease, so therapy typically centers around replacing the missing factors by way of administration of fresh frozen plasma.

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Fundamentals of Molecular Diagnostics (retired 2/12/2013)
Targets

Molecular based clinical diagnostic test methodologies differ according to the target of interest. For example, patients suspected of having different diseases will require the identification of different targets. These targets might be found in different cells of the body and may therefore require different specimens to provide the answers. Patient A suspected of having Disease 1: Requires the identification of a target of missequenced DNA - might require specimen of whole blood Patient B suspected of having Disease 2: Requires identification of a target of antibody production -methodology might require specimen of serum Using this specific approach of disease diagnosis based on unique target identification, tests can provide answers that are more:Rapid Sensitive Specific

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Basis of Molecular Testing

The basis of molecular testing lies in the genetic material of a cell. Both prokaryotic and eukaryotic cells possess nucleic acid. The two types of nucleic acid include deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). The foundational building blocks of both DNA and RNA include nucleotide bases of purines and pyrimidines. The unique sequencing of these nucleotide bases found in each strand of DNA or RNA contribute significantly to the language of cells. This cellular based language is responsible for many complex activities within the human body, including the synthesis of proteins.

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Pharmacogenetics

Adverse drug reactions are a leading cause of morbidity and mortality in the United States. Drug metabolism is a process whereby drugs are delivered to the body, distributed, metabolized and then ultimately excreted. As there can be potentially significant differences between patient drug absorption, metabolism and excretion, molecular testing allows a physician to work with a patient's individual phenotype and/or genotype to deliver an optimum pharmaceutical selection and/or dosage.

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General Laboratory Question Bank - Review Mode (no CE)
Which of the following would not be considered a part of the body's cellular immune system:View Page
Identify the Body/or frame and Illuminator/diaphragmView Page

Hematology / Hemostasis Question Bank - Review Mode (no CE)
The cell indicated by the arrow in illustration is indicative of:View Page
Expected life span of a neutrophil in the peripheral blood of an adult is:View Page
Which one of the following statements about iron deficiency anemia is false:View Page
Match the following terms with the statement that best describes each:View Page

Hereditary Hemochromatosis
Overview

Because hereditary hemochromatosis (HH) is a disease of iron overload, a review of the basic principles of iron metabolism is helpful in understanding its pathophysiology. Iron is needed by all body cells and is crucial for oxygen transport, oxidative metabolism, and cell growth and proliferation. To serve these functions, iron must be bound to protein. Iron is potentially harmful when ionized or complexed to inorganic compounds. Iron must be present in amounts sufficient to carry out these normal functions, but not in excessive amounts which may be toxic.Two types of iron-containing compounds are normally found in the body: compounds that serve in metabolic or enzymatic functions and storage compounds. Hemoglobin, myoglobin, cytochromes and other proteins are involved in oxygen transport and utilization. Iron in hemoglobin comprises about 67% of total body iron, thus erythrocytes are rich in iron. Approximately 27% of iron is found in storage compounds. Myoglobin, other tissue iron, and transport iron comprise the remaining 6% of total body iron. (2)

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Which compound normally contains the majority of the body's total iron?View Page
Storage Iron

Storage forms normally comprise approximately 27% of total body iron. Stored iron provides a source of iron when physiologic demand is high, such as in blood loss, pregnancy, and periods of rapid growth. Storage compounds include ferritin and hemosiderin. Ferritin is a protein-bound, water-soluble, mobilizable storage compound and is the major source of stored iron. Hemosiderin is a water-insoluble form that is less readily available for use. When the amount of total body iron is relatively low, storage iron consists predominately of ferritin. When iron stores are increased, hemosiderin predominates. Unlike ferritin, hemosiderin stains with the Prussian blue stain (Perls reaction) and may be observed in tissues. The image on the right shows iron deposits in a liver section that was stained with Prussian blue.Image is courtesy of John Woosley, MD.

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Iron Intake and Recycling

The typical daily diet of most Americans contains approximately 10 to 15 mg of iron. Sources of dietary iron include heme iron from meats and nonheme iron from whole grains and vegetables. Many processed foods, such as breakfast cereal, are fortified with iron. However, the normal individual absorbs only 5% to 15% of dietary iron, or about 1 to 2 mg daily. Females may absorb slightly more iron than males as they require more iron to replace that lost through menstruation and to meet the increased need for iron in pregnancy.Absorption of iron occurs through the mucosal cells in the duodenum (proximal small intestine). Dietary iron that is not absorbed is excreted in the feces. Intestinal absorption provides the means for regulating the amount of iron in the body.The amount of Iron absorbed is normally low because iron is well conserved within the body. Heme iron from senescent erythrocytes is cycled back into the iron pool and reused for incorporation into developing erythrocytes. Furthermore, iron is normally lost from the body only in very small amounts, primarily through desquamation of mucosal cells in the gastrointestinal tract and losses through body secretions, including urine, sweat and feces. Therefore, under normal conditions, very little dietary iron needs to be absorbed to maintain iron homeostasis.(3)

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Serum Iron

Serum iron (SI) is a measure of circulating iron bound to transferrin and is reflective of total body iron. SI is elevated in hereditary hemochromatosis (HH) and acute hepatitis. SI is decreased in iron deficiency anemia and chronic inflammation. SI concentrations exhibit diurnal variation, with the lowest values occurring around midnight. In addition, specimens collected from the same individual at the same time of the day may exhibit day to day variations as high as 40%. SI determinations are also affected by diet, menstrual cycle, pregnancy, ingestion of iron supplements, and oral contraceptive use. SI levels alone are considered insensitive indicators of HH. SI is typically measured on automated analyzers using spectrophotometric methods. Iron in the sample is released from transferrin with an acid reagent, reduced to the ferrous state, and reacted with a chromogen such as bathophenanthroline or ferrozine. The intensity of the color change is proportional to the iron concentration. Interference can arise from the use of a hemolyzed sample and contamination of reagents and water with iron. A typical reference interval for SI is 60 - 150 micrograms/dL. SI is usually ordered along with its companion test, the total iron binding capacity (TIBC), or with transferrin (Tf).(2)

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Histology Special Stains: Carbohydrates
Mucopolysaccharides

Mucopolysaccharides also known as mucins are a group of glycoconjugates consisting of polysaccharides linked to proteins. Mucins are gel-like secretions from various epithelial cells and tissues in the body including the: tissues of the GI Tract Mast cells Cornea Cartilage Arterial walls Skin Heart valves Ovarian follicles

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PAS: Diagnostic Applications

The PAS staining procedure is most commonly used in the clinical histology laboratory to demonstrate glycogen deposits in the liver. Glycogen granules may also be visible in tumors of the bladder, kidney, ovary, pancreas, and lung. Basement membranes, which are present in various tissues in the body, may also be visualized through the PAS staining procedure. Several disorders can be identified through the demonstration of abnormal basement membranes. The PAS staining procedure can also demonstrate fungi in tissue samples due to the high carbohydrate content of the organisms cellular walls. Neutral mucins in the gastrointestinal tract and some epithelial mucins will also give a PAS-positive staining reaction.

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Histology Special Stains: Connective Tissue
What is Connective Tissue?

Connective tissue offers structural and metabolic support structure for organs and tissue. It is the most abundant tissue type in the body and can be found throughout. Cells and extracellular material called connective tissue matrix make up connective tissue. Fibroblasts, mast cells, macrophages, adipose cells, blood leukocytes, and plasma cells can all be found to some degree in connective tissue. In addition to cells, the matrix has 3 different fibers present:Reticular fibers - Support soft organs and the network around nerve fibers, fats cells, lymph nodes, and muscle fibers.Collagenous fibers - Found in ligaments, tendons, cartilage, and bone.Elastic fibers - Allow tissue to expand and are typically located in skin and blood vessel walls.

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Functions of Connective Tissue

The primary functions of connective tissues include:Transportation of nutrients and metabolites through direct diffusion between organs and connective tissue properImmunological defense (fights invading cells via inflammation)Structural supportTissue repair (after injury) Additional functions found in certain body sites include:Energy storage (fat)Heat generation (brown fat)Haematopoiesis/haemopoiesis (blood formation)

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Gordon and Sweet's Silver Staining - Diagnostic Applications

Reticular fibers support body organs like the liver, spleen, and kidney. The Gordon and Sweet's silver staining method is used to demonstrate abnormal reticular fiber patterns that may indicate cirrhosis or necrosis of the liver. This is why reticular stains are often requested on liver biopsies. Abnormal reticular fiber patterns may also indicate the presence of certain tumor types in the liver, spleen, or kidney.

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HIV Safety for Florida
HIV is known as a retrovirus because:View Page
Which of the following is not considered a potentially infectious body fluid for transmitting HIV?View Page
Mutations

Genetic mutations in HIV are well known and are very likely, considering the presence of two RNA molecules per virus. Either or both RNA molecules can mutate. These mutations potentially lead to drug resistance or encourage the virus to evade the body's immune response. Mutations have created three major groups of HIV - M, N, and O. M is found in 99% of all the HIV cases in the world. N and O are primarily found in West African countries. N, though, infects only a very small number of individuals. The M group has subgroups lettered A to J. Subgroup B predominates in North America.

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Introduction

Acquired Immunodeficiency syndrome (AIDS) is caused by the Human Immunodeficiency virus (HIV). When HIV enters a person's bloodstream, it attacks and kills the T-helper lymphocytes, which are essential to the body in fighting off infections. As these cells are lost, so is the body's ability to fight infection. Possibly months after the initial infecting episode, an infected person develops a mononucleosis-like illness lasting a week or two. A person may then be free of symptoms for years. But as the T-helper cells die, the person becomes vulnerable to many serious infections. The expected mortality is 100%, and there is no vaccine available to develop specific immunity.

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Occupational Exposures

HIV transmission, due to occupational exposure, occurs by: Percutaneous injury, such as a needlestick or a cut with a sharp object; Contact of mucous membrane or abraded skin with HIV-infected blood or body fluids. The risk of HIV transmission after a percutaneous exposure to HIV-infected blood is 0.3%.The risk of HIV transmission after a mucous membrane exposure to HIV-infected blood is .09%.The risk of HIV transmission after contact of abraded skin with HIV-infected blood is estimated to be less than .09%.

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Potentially infectious body fluids

These substances are considered potentially infectious for an occupational exposure: blood cerebrospinal fluid synovial fluid pleural fluid peritoneal fluid pericardial fluid amniotic fluid any body fluid visibly contaminated with blood semen or vaginal fluid tissues removed during surgery.

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Which of the following does not pose a significant risk for transmitting HIV?View Page
Overview

Prevention of HIV exposure is the best line of defense to prevent occupational transmission of HIV as there is no vaccine available to develop specific immunity and the postexposure prophylaxis is toxic. Following appropriate workplace practices in the laboratory focus on preventing needlesticks or other sharps injuries and exposure of mucous membranes and abraded skin to HIV-infected blood or body fluids.

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Gloves

Gloves must be worn: when there is a reasonable chance of exposure to blood, other infectious body fluids, mucous membranes, or nonintact skin. during vascular access procedures, including phlebotomy. when handling contaminated items or surfaces.Wear only flat rings under gloves as large rings may tear gloves.Replace gloves: Between patient contacts If they are damaged or contaminated Before leaving the work area. Wash hands after removing gloves.Never wash disposable gloves.

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HIV: Structure and Replication (retired 2/20/2013)
HIV is known as a retrovirus because:View Page
Mutations

Genetic mutations in HIV are well known and are very likely, considering the presence of two RNA molecules per virus. Either or both RNA molecules can mutate. These mutations potentially lead to drug resistance or encourage the virus to evade the body's immune response. Mutations have created three major groups of HIV - M, N, and O. M is found in 99% of all the HIV cases in the world. N and O are primarily found in West African countries. N, though, infects only a very small number of individuals. The M group has subgroups lettered A to J. Subgroup B predominates in North America.

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Infection of the Host Cell (2)

The DNA provirus continues to encode new HIV particles within the host cell. During this early stage the injured host cells, such as T-lymphocytes, are able to replace themselves, and the body remains able to launch a defensive response. Eventually, though, the number of viruses becomes overwhelming.

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Human Papillomavirus (HPV) and Molecular Diagnostic Testing
Most genital condolymas and cervical lesions caused by HPV resolve as a result of the immune response in the infected individual.View Page
Immune Mediated Regression

Abnormal cervical tissue is described using categories of cervical intraepithelial neoplasia (CIN). Categories are CIN 1, CIN 2, and CIN 3; increasing number designates the thickness of cervical lining with abnormal cells. CIN 3 is considered precancerous. Host immune response to the virus resolves most HPV lesions, especially genital condolymas and CIN 1 lesions. Neither of these is precancerous. Approximately half of CIN 2 spontaneously resolve and some CIN 3 may resolve. It is not known if the virus is cleared from the body or just suppressed.

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Introduction to Bioterrorism
Agent: Viral hemorrhagic fevers (Ebola, Marburg, Lassa and Argentine)

Most likely means of dissemination: Solid, liquid or aerosolPrimary route of entry: Absorption, inhalation, ingestionGeneral signs and symptoms: Vary by type of viral hemorrhagic fever (VHF), but initial signs and symptoms often include marked fever, fatigue, dizziness, muscle aches, loss of strength, and exhaustion. Severe cases of VHF often show signs of bleeding under the skin, in internal organs, or from body orifices like the mouth, eyes, or ears.  Photo courtesy of the CDC archives.

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In Case of a Dirty Bomb Attack

Stay inside or get inside quickly. Find a “Shelter-in-place”. To “shelter in” is a way to make the building you are in safe as possible to protect yourself until help arrives. You should not try to “shelter in” in a vehicle unless you have no other choice. The best room to use is one with as few windows and doors as possible. Be sure to close all windows and doors, and turn off the furnace, air conditioners, and exhaust systems. As best as possible, seal all openings in windows and doors. Monitor your radio for instructions from authorities. If you believe you’ve been exposed and you can’t get to a hospital, shed all your clothes as quickly as possible. Don’t take the clothes inside because you may spread contamination. Go straight to the shower and thoroughly wash all body parts with a coarse soap. It is important not to ingest radiation by eating contaminated food or even chewing on contaminated fingernails. Also, certain types of radioactivity can be flushed from the body by drinking large amounts of water. After an attack don’t travel through heavily contaminated areas. If you can get out of the general area through an uncontaminated route, do so—otherwise, stay indoors until assistance arrives.               

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Introduction to Bone Marrow
Advantages of a Biopsy Specimen

Examining the biopsy allows the structure of the marrow to be viewed as it exists in the body. It provides essential diagnostic information in conditions that disrupt the normal architecture, such as metastatic carcinoma, myelofibrosis, Hodgkin's lymphoma and granuloma. A biopsy may also be used to evaluate cellularity and identify acid-fast bacteria or fungi in less time than is needed for routine culture methods. One disadvantage of the tissue sections prepared from the biopsy sample is that morphologic detail is lost. For this reason, in many cases imprint slides or smears from the aspirated sample are also examined.

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Basic Structure and Function of Bone Marrow

Before learning to examine bone marrow microscopically, it is important to understand the basic structure and function of the bone marrow. The bone marrow is one of the largest organs in the body. The normal adult marrow on a daily basis produces approximately 2.5 billion red cells, 2.5 billion platelets and 1.5 billion granulocytes per kilogram of body weight. The main function of this organ is the formation and development of blood cells. Hematopoiesis begins in the yolk sac in the first weeks of embryonic life; stem cells from the yolk sac travel first to the liver and then to the spleen. These organs are the only blood forming sites during the first three months of fetal life. At the beginning of the fourth month the bone marrow begins its life-long function of cell production.

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The bone marrow is one of the largest organs in the body.View Page

Introduction to the ABO Blood Group System
Epitopes

In addition to red cells, ABO antigenic determinants (epitopes) are found in many tissues, body fluids, and other cells including endothelial cells and platelets. Because ABO antigens are so widely expressed, ABO antigens are also a major consideration in solid organ and bone marrow transplants.

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Laboratory Ergonomics
Scenario #1

Pam is seated at the workbench where she routinely prepares dilutions using an automated pipette. She leans to the right and stretches over her rack of tubes each time she needs to change a pipette tip. Pam is working in an awkward body position because the pipettes are not in a convenient location and the space is not well organized.By changing the location of the pipettes to within her routine work area, she can avoid overstretching to reach the pipettes and avoid contorting her body into an awkward position that could eventually result in an MSD. As shown in the image, regularly used items should be close to the worker to avoid leaning forward and over-extending reach radius. Adjust your work space so that you can reach tools and equipment without unusual bending or twisting; arrange the work area properly within the "work zone".Avoid reaching more than 10 inches (25 cm) in front of the body for frequently used materials or 20 inches (50 cm) for items that are used occasionally.

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Ergonomic Guidelines for Computer Users

A. Computer monitors should be approximately 18" - 24" away from the eyes. The top of the monitor is best set at eye level so that the eyes gravitate toward the center of the screen. B. Try to avoid glare from the light. C. Computer monitors should be set directly in front of the user D. Keep forearms 90° from your spine and keep elbows in close to the body. E. If seated, thighs should be parallel to the floor and about a 90° angle with the calves. F. Use an adjustable chair, preferably with padded arms. Adjust the chair or work surface (if possible) to the correct position. Avoid leaning forward or to the side. Do not lean on work surfaces. Do not lean on elbows or armrests. Keep neck and shoulders in a relaxed position.G. Place keyboard in a comfortable position (preferably on an adjustable keyboard tray) and use a wrist/palm rest. H. Place feet flat on the floor or on a footrest and do not crowd the legs or body into a cramped or cluttered work space. Use a document holder to keep working documents at eye level with the screen. To avoid eyestrain, follow the 20/20/20 rule. Every 20 minutes, take a 20 second break to focus on a spot 20 feet away.

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Body Position

Take frequent posture breaks; if standing, sit periodically. If sitting, stand about every 20 minutes and walk around. Shoulders and Arms Keep the shoulders relaxed, not shrugged-up or slumped-down. Keep your elbows close to your body Keep work at elbow height and directly in front of you as shown in the image below. Head and Neck Avoid situations that require prolonged or repetitive twisting, forward-bending, or backward-bending of the neck.Hands and Wrists Keep the hand in line with the forearm. Avoid repetitive twisting of the wrists. Avoid working with wrists pressed against hard surfaces or edges as shown in the image below. Feet and Legs Place a foot on a footrest for comfort Provide a toe space to allow work closer to counters and reduce reaching. Use mats on hard floors to reduce fatigue as shown in the image below.Back Stand straight. Avoid situations that require bending forward, backward, leaning side-to-side, or twisting. Use a stool to provide an occasional change in posture. If working seated, use a back rest/support to maintain proper posture. The chair that is shown in the image below offers neck, back, and lumbar support.

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Guidelines for Lifting, Lowering, and Carrying

Reduce the weight of an object whenever possible by reducing the container size/capacity. Reduce the hand distance from the body by changing the shape of the container or providing grips or handles enabling the load to be held closer to the body. Use carts, hand trucks, etc. to convert load lifting to a push or pull task. Reduce the carrying distance by moving the storage area closer to production areas. Assess an item before lifting it. Get help if the item is too heavy, large, or awkward. Store heavy objects on shelves below shoulder height and no lower than knee-height. Store materials that are frequently used on shelving units that are located no higher than shoulder height. Lifting a heavy objectTo pick up the item, secure it firmly in your hands, keep the item close to the body, bend your knees, keeping your back in its natural arched position, and lift with your legs; leg muscles have more power than the smaller muscles in the back. The object to be lifted should be directly in front of you. Lift it straight up, using a smooth motion. Avoid asymmetric lifting (twisting while lifting).

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Work Station

Evaluate your work station including leg room, reach radius, accessibility of commonly used materials, and height of the work surface. Adequate space should be available to accommodate equipment and allow for full range of motion. ChairPersonnel who sit for long periods of time should adjust chairs so that feet are flat on the floor or on a footrest. Chairs should have some primary features that can be easily adjusted including controls to raise and lower chair, seat pan adjustment, lumbar support, and backrest tilt or angle. Adjust the seat back slightly forward if necessary to avoid leaning forward unsupported or jutting your head forward. Reach radius Regularly used items should be close to the worker to avoid leaning forward and over-extending reach radius. Adjust your work space so that you can reach tools and equipment without unusual bending or twisting.Avoid reaching or bending - arrange the work area properly within the "work zone". Avoid reaching more than 10 - 15 inches in front of the body for frequently used materials or 20 inches for items that are used occasionally.Avoid reaching above shoulder height, below waist level, or behind the body to minimize shoulder strain.Avoid repetitive work that requires full arm extension (i.e., the elbow held straight and the arm extended).The image illustrates a workstation that is used by a technologist who performs microscopic work for the majority of the workday. The workstation is designed to prevent musculoskeletal disorders and fatigue.

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What is the recommended reach radius for items that are used routinely at your work station?View Page

Laws and Rules of the Florida Board of Clinical Laboratory Personnel (retired 9/1/2010)
Description of Specialties (1)

Specialists in microbiology perform testing to diagnose and stop the spread of infectious organisms, including bacteria, viruses, and parasites. Specialists should be able to isolate and identify a wide variety of these organisms. Testing procedures include direction examination and antigen detection methods. Specialists in serology and immunology measure antibodies to infectious organisms. Specialists should be familiar with all serology techniques (except those specific to immunohematology). This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in hematology must be able to identify and evaluate cells in blood and bone marrow and identify disorders of these cell. Specialists should be familiar with routine and special tests to determine the number, morphology, and function of cells in body fluid.

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Description of Specialties (2)

Specialists in immunohematology perform all testing prior to blood transfusions and work to prevent transfusion infections. They also investigate any post-transfusion reactions. This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in clinical chemistry analyze body fluids such as blood, urine, and spinal fluid to determine the chemical makeup, including the amount of carbohydrates, proteins, enzymes, and trace elements. The special covers urine microscopics and chemical evaluation of the liver, kidneys, lungs, heart, and other vital organ systems. This specialty also covers all testing performed in the specialties of radioassay and blood gas analysis. Specialists in blood banking can perform all immunohematology testing as well as testing from the specialties of clinical chemistry, hematology and serology/immunology that relates to donor blood. Clinical laboratory personnel who are licensed in the specialties of immunohematology, clinical chemistry, hematology, and serology / immunology may perform all tests in the blood banking specialty.

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Description of Specialties (3)

Specialists in radioassay use radionuclides to determine the chemical makeup of body fluids such as blood and urine. Specialists in blood gas analysis evaluate lung and breathing function by levels of oxygen, carbon dioxide, pH, and hemoglobin with automated tests. Specialists in histology examine cellular and tissue samples using fixation, dehydration, embedding, microtomy, frozen sectioning, staining, and other similar techniques. Histology specialists licensed as technicians can perform specimen processing, embedding, cutting, staining, and frozen sectioning only under the general supervision of a director, supervisor, or technologist. Specialists in cytology process and interpret samples relating cytopathological disease. Non-gynecological cytology preparations can be screen by a specialist in cytology but final review and interpretation must be done by a physician.

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Medical Error Prevention (retired)
Sentinel Event Categories

Sentinel Events are sentinels--they function as guards or watchkeepers. They indicate serious situations that require immediate attention: Patient deathParalysisComaPermanent loss of functionAny procedure on the wrong patient, the wrong side of the body, or the wrong organ Hemolytic transfusion reaction involving major blood group incompatibility

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Medicare Compliance for Clinical Laboratories
Medical Necessity

The Centers for Medicare and Medicaid Services (CMS), the US agency that administers the Medicare program, defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicare will not pay for any tests that CMS determines as unnecessary for diagnosis or treatment of disease.A laboratory may not submit a claim to Medicare or other government payers for any test it suspects is not medically necessary unless: The patient has signed an Advanced Beneficiary Notice (ABN), or A patient has requested the lab to submit such a claim for a determination by Medicare. Medicare does not pay for screening tests or tests that are ordered in the absence of signs or symptoms. Billing department employees are responsible for following all policies and procedures related to the submission of claims to reduce erroneous billings.

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Metabolic Syndrome
A physician discusses weight with an overweight 60-year-old female at her yearly physical appointment. The female exercises regularly and eats healthy most of the time. The physician suggests she decrease carbohydrate intake and decrease portion size at meals.Review patient vital signs and laboratory assay results to decide if a diagnosis of metabolic syndrome is appropriate using the NCEP:ATP lll Diagnostic Criteria shown on the right.Height: 5' 7'Weight: 192 lbsBMI: 30.1Waist Circumference: 37 inchesBlood Pressure: 108/70Fasting Blood Glucose: 92 mg/dLTotal Cholesterol: 172 mg/dLLDL-C: 112 mg/dLHDL-C: 46 mg/dLTriglycerides: 70 mg/dLhs-CRP: <1.0 mg/LWhich of these statements regarding this patient is true?View Page
Adipose Tissue as an Endocrine System

Adipose tissue is no longer considered just a storage area for fat for future energy needs or a provider of body insulation. Recent discovery that adipose tissue secretes a large number of bioactive peptides known as adipokines classifies adipose tissue as an endocrine system. Besides adipocytes (fat cells), adipose tissue also contains connective tissue, nerve tissue, stromovascular cells, and immune cells. Each adipocyte can synthesize and secrete into systemic circulation a large number of adipokines. Additionally, the nonadipocyte fraction of adipose tissue secretes proteins.

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Role of Adipokines

Over twenty adipokines have been identified. Some adipokines are secreted solely by adipocytes; several are secreted by adipocytes and other body cells. Their role is very widespread as they integrate with various body organs and tissues: skeletal muscle, adrenal cortex, brain and sympathetic nervous system. Adipokines function in: Energy balance Immune reactions Insulin sensitivity Angiogenesis Blood pressure maintenance Lipid metabolism Hemostasis

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TNF-alpha

TNF-alpha (TNF-α) produces different effects as it is secreted; many of these effects are immunological and result in increased inflammation. The original name for TNF, tumor necrosis factor, came from its first discovered activity, tumor regression. TNF-α is synthesized and secreted by adipocytes, macrophages, lymphoid cells, endothelial cells and other body cells.Adipocyte-secreted TNF-α stimulates adipocytes to increase their release of NEFAs and decrease adiponectin synthesis. TNF-α also inhibits insulin activity, leading to insulin resistance. Adipocyte TNF-α secretion is increased in obesity causing an increased insulin resistance in obesity.

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Leptin

The role of leptin in obesity and insulin resistance is sometimes confusing. Some authors refer to leptin as a hormone, not an adipokine. Leptin is synthesized and released from adipose cells in response to adipose tissue changes. It reduces intracellular lipid levels in many types of body cells and thus improves insulin sensitivity. It is an appetite suppressant and inhibitor of fatty liver formation.Leptin is referred to as a "starvation signal" and the leptin gene, is sometimes referred to as "the obesity gene". These names refer to leptin's important function as a messenger in energy metabolism. Leptin signals the hypothalamus when there are increases in fat stores. The hypothalamus then restores metabolic balance by decreasing appetite, stimulating physical activity, and burning of excess calories. During fasting, leptin levels decrease rapidly and hypothalamus signaling results in an increase in cortisol and a decrease in thyroid, sex, and growth hormones. These actions work together to restore energy balance. Leptin is usually increased in obesity, however, similar to increased insulin in obesity, leptin resistance develops. In obesity, appetite suppression does not take place and metabolic rates are lowered. Secreted leptin is not able to stimulate energy balance and healthy caloric intake.

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Which adipokine is synthesized and released by adipocytes and many other body cell types, is an inflammatory cytokine that stimulates the liver to produce C-reactive protein (CRP), and is increased in obesity and insulin resistance?View Page
Insulin Resistance

Insulin is a pancreatic hormone that plays a vital role in carbohydrate and lipid metabolism. Insulin regulates glucose concentrations by: Promoting glycolysis - the uptake of glucose by cells for energy Stimulating glycogenesis - the conversion of excess blood glucose to glycogen storage in the liver Inhibiting glycogenolysis - the conversion of glycogen back to glucose Inhibiting gluconeogenesis - the formation of glucose from noncarbohydrates Insulin increases lipid synthesis in the liver and fat cells and inhibits lipolysis, the release of non-esterified fatty acids (NEFAs) from triglycerides in fat and muscle cells. Insulin also promotes protein synthesis.If insulin resistance occurs, carbohydrate and lipid metabolism are impaired. Insulin resistance ordinarily results in increased insulin levels as the body senses a need for more insulin action. The impaired insulin action results in elevated plasma glucose levels. The increase in lipolysis increases blood concentrations of NEFAs and causes abnormal blood lipid levels.

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Obesity

Obesity is another major risk factor for the metabolic syndrome. Obesity and insulin resistance are interrelated and the effects of obesity are the cause of some of the ensuing resistance to insulin.Those at risk for metabolic syndrome generally have an abnormal fat distribution. The excess adipose tissue is located in the upper body, resulting in an increased waist circumference. The greater the upper body fat, the greater the insulin resistance.

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Risk Factors

According to the American Heart Association, the risk factors for metabolic syndrome include:Abdominal obesity (excessive fat tissue in and around the abdomen) Atherogenic dyslipidemia (blood fat disorders – high triglycerides, low HDL cholesterol and high LDL cholesterol – that foster plaque buildups in artery walls) Elevated blood pressure Insulin resistance or glucose intolerance (the body can't properly use insulin or blood sugar) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) Proinflammatory state (e.g., elevated high sensitivity C-reactive protein in the blood) Reference: Metabolic syndrome.The American Heart Association website. Available at:http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/Metabolic-Syndrome_UCM_002080_SubHomePage.jsp#. Accessed December 5, 2011.

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Microbiology / Serology Question Bank - Review Mode (no CE)
Match the type of hepatitis with its route of transmissionView Page

Multi-drug Resistant Organisms: MRSA, VRE, and Clostridium difficile
Selection of Drugs for Testing

The panel of drugs selected for testing must take into consideration a number of factors: The laboratory performing the testing The number of drugs that can practically be tested Infection control requirements Drugs that are available in formularies Susceptibility patterns exhibited locally Consideration of the body site of the infection and whether the drug is an appropriate therapy

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Mycology: Hyaline and Dematiaceous Fungi
Several saprophytic, hyaline molds have microscopic characteristics that mimic the mold forms of the dimorphic fungi (Histoplasma capsulatum, Blastomyces dermatitidis, etc.). Each of the following can be used to differentiate the saprophytic from the dimorphic fungi except:View Page

Normal Peripheral Blood Cells
Erythrocytes or Red Blood Cells (RBC's)

The first group is composed of erythrocytes or red blood cells (RBC's). The main function of the erythrocytes is the transport of oxygen from the lungs to the body tissues. All of the cells in this Wright's stained peripheral blood smear are red blood cells. The image to the right shows the normal morphology of red blood cells.

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During phagocytosis the neutrophilic granules release digestive enzymes into the vacuole to kill or destroy the phagocytized particle.View Page
More on Phagocytosis in Neutrophils

Neutrophils have a relatively short life span. They are produced in the bone marrow, and when they reach the band or segmented stages are released into the peripheral blood. They remain there for approximately ten hours before randomly entering body tissues.Neutrophils in the blood stream can be divided into circulating granulocyte pool (CGP) and marginating granulocytic pool (MGP). The white blood cell count reflects the cells in the circulating pool. The cells in the marginating pool move quickly into the circulating pool when needed.During an infection the neutrophil concentration of the peripheral blood can increase almost immediately due to the shift of these cells from the marginating pool and release from the bone marrow storage pool, if needed. Neutrophils then migrate to areas of tissue damage or infection. Neutrophils do not reenter the blood stream from the tissues, thus end their life in the tissues either as a result of phagocytosis or senescence.

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Mast Cells

Mast cells are similar in appearance to basophils and are a separate cell line of life-long residents in connective tissue throughout the body. They have some functions similar to those of basophils.

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Where is the main site of action for monocytes?View Page
Monocytic Function

Monocytes are phagocytes which remove injured and dead cells, cell fragments, microorganisms and insoluble particles from the blood and body tissues. Monocytes also secrete substances that affect the function of other cells, especially lymphocytes. They are produced in the bone marrow, and when mature are released into the peripheral blood. Although they do serve a phagocytic role in the blood, their main site of action is the body tissues. The half-life for monocytes in the peripheral blood is approximately 8 hours. Monocytes migrate into the tissues, often to sites of inflammation, where they serve their primary purpose. Here they transform into fixed or free macrophages, and continue their function as avid phagocytes. When activated, macrophages may enlarge and have enhanced metabolism.Monocytes provide defense against mycobacteria, fungi, bacteria, protozoa and viruses. They respond to chemotactic factors, phagocytize and kill the microorganisms.

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Erythrocyte Function and Kinetics

Erythrocytes are produced in the bone marrow and released into the peripheral blood where they may remain for approximately 120 days before senescence. Their main function is the transport of the respiratory gases (oxygen and carbon dioxide) between the lungs and body tissues.Each erythrocyte can be thought of as an "envelope" containing hemoglobin. Each hemoglobin molecule contains iron which has a high affinity for oxygen. As a result, when an erythrocyte passes through one of the capillaries of the lungs, it picks up oxygen. The oxygen is transported through the blood to the tissues where it is released. Carbon dioxide from the tissues then diffuses into the RBC where it undergoes chemical changes. About 70% of the altered carbon dioxide diffuses into the plasma, 25% binds to the hemoglobin molecule, and 5% goes into simple solution within the red cell. In each of these three ways carbon dioxide is transported from the body tissues back to the lungs, where it is released.

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Glossary of Terms A through M.

Antibody - A modified type of serum globulin synthesized by lymphoid tissue in response to antigenic stimulus. By virtue of specific combining sites each antibody reacts with only one antigen. Anucleate - Having no nucleus. Azurophilic granules - The well-defined large reddish granules (lysosomes) which may be present in large lymphocytes. They are called "azurophilic granules" because they stain blue with the azure stains which were originally used. Basophilic granules - Specific granules present in the cytoplasm of basophils. These granules are large and stain purple-black due to their strong affinity for basic stain. B-cell - Bone marrow derived lymphocytes which produce humoral antibodies. Biconcave - Having two concave surfaces. Cellular Immunity - The capacity of a small proportion of lymphoid population to exhibit response to a specific antigen. Chromomere - The centrally located granular portion of the platelet. Clone - A population of cells descended from a single cell. Delayed Hypersensitivity - (part of cellular immunity) that develops slowly over a period of 24-72 hours after an antigenic stimulus. It consists of an accumulation of cells around small vessels and/or nerves. Example: Tuberculin skin test reaction. Digestive Enzyme - A substance that catalyzes or accelerates the process of digestion. Eosinophilic Granules - Specific granules present in the cytoplasm of eosinophils. These granules are large, refractile spheres which stain reddish-orange due to their strong affinity for acid stain. Erythrocyte (red blood cell, RBC) - One of the elements found in peripheral blood. Normally the mature form is a non-nucleated, circular, biconcave disk adapted to transport respiratory gases. Fixed Macrophage - A phagocyte that is non-motile. Free Macrophage - An ameboid phagocyte present at the site of inflammation. Graft Rejection - A transplanted tissue that is rejected by the body's antibodies. Graft vs. Host Reaction - A complication that occurs when an implanted piece of tissue, which contains antibodies, rejects the host's tissue. Granulocyte - A leukocyte which contains granules in its cytoplasm, i.e., neutrophilic, eosinophilic, or basophilic granules. Half-life - is the length of time it takes for half of the cells circulating at a given time to leave the blood for the tissues. Hemocyte - Any blood cell or formed element of the blood. Hemostasis - A mechanism of the vascular system to arrest an escape of blood. It involves an interaction between blood vessels, platelets, and coagulation. Heparin - A mucopolysaccharide acid which, when present in sufficient amounts, functions as an anticoagulant by inhibiting thrombin. Histamine - A powerful dilator of capillaries and a stimulator of gastric secretions. Humoral Immunity - Acquired immunity produced after response to an antigenic stimulus in which B cells produce circulating antibodies. Hyalomere - the clear, blue non-granular zone surrounding the chromomere of a platelet. Immune Response - The interaction of a cell and an antigen that results in a proliferation of the cell and a capacity to produce antibodies. Isotonic Fluid - A fluid whose elements have an equal osmotic pressure. Leukocyte (white blood cell, WBC) - One of the formed elements of the blood; involved primarily with the body's defense. Lysosome - A microscopic body within cell cytoplasm; contains various enzymes, mainly hydrolytic, which are released upon injury to the cell. Megakaryocyte - A giant cell of the bone marrow from which platelets are derived. Mononuclear - A cell having a single nucleus.

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Glossary of Terms N through Z.

N:C Ratio - Nuclear: cytoplasmic Ratio - The ratio of nuclear volume to cytoplasmic volume within any one cell.Neoplasm - Any new and abnormal growth, such as a tumor.Neutrophilic Granules - Specific granules present in the cytoplasm of neutrophils. These granules resemble pencil stippling and stain a lilac color due to their affinity for both basic and acid dyes.Phagocyte - Any cell that ingests microorganisms or other cells and foreign particles.Phagocytosis - The ingestion and destruction of microorganisms or other foreign particles.Plasma - The fluid portion of blood in which the various blood cells are suspended.PF3 (platelet Factor 3) - A lipoprotein component of the platelet membrane; functions as a surface catalyst during blood coagulation.Pseudopod - A temporary protrusion of the cytoplasm of a cell.Refractile - Capable of refracting or changing the direction of light.Senescence - The process or condition of growing old.Serotonin - A constituent of blood platelets and other cells and organs; induces constriction of the blood vessels.Specific Granules - Granules found in cells of the more mature stages of the granulocytic series. They have distinct staining reactions which differ with each type of granulocyte.T-cell - Thymus derived lymphocyte which mediates cellular immunity.Thrombocyte (Platelet) - A circular or oval disk found in the blood; concerned with hemostasis.Thymus - A ductless gland-like body situated in the anterior mediastinal cavity; reaches its maximum development during the early years of childhood.Vacuole - Any small space or cavity formed in the cytotoplasm of a cell.

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Normal Peripheral Blood Cells (retired 6/20/2012)
Where is the main site of action for monocytes?View Page
What is the Function of Lymphocytes?

Lymphocytes are primarily involved in the body's immune response mechanism. This involves complex phenomena which end in the development of humoral and cellular immunity.

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Monocytes

Monocytes are phagocytes which remove injured and dead cells, cell fragments, microorganisms and insoluble particles from the blood and body tissues.Monocytes also secrete substances that affect the function of other cells, especially lymphocytes.They are produced in the bone marrow, and when mature are released into the peripheral blood. Although they do serve a phagocytic role in the blood, their main site of action is the body tissues.The half-life for monocytes in the peripheral blood is approximately 8 hours. Monocytes migrate into the tissues, often to sites of inflammation, where they serve their primary purpose.Here they transform into fixed or free macrophages, and continue their function as avid phagocytes.When activated, macrophages may enlarge and have enhanced metabolism.

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Function and Kinetics

Erythrocytes are produced in the bone marrow and released into the peripheral blood where they may remain for approximately 120 days before senescence.Their main function is the transport of the respiratory gases (oxygen and carbon dioxide) between the lungs and body tissues.Each erythrocyte can be thought of as an "envelope" containing hemoglobin.Each hemoglobin molecule contains iron which has a high affinity for oxygen.As a result, when an erythrocyte passes through one of the capillaries of the lungs, it picks up oxygen.The oxygen is transported through the blood to the tissues where it is released.Carbon dioxide from the tissues then diffuses into the RBC where it undergoes chemical changes.About 70% of the altered carbon dioxide diffuses into the plasma, 25% binds to the hemoglobin molecule, and 5% goes into simple solution within the red cell.In each of these three ways carbon dioxide is transported from the body tissues back to the lungs, where it is released.

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Erythrocytes or Red Blood Cells (RBC's)

The first group is composed of erythrocytes or red blood cells (RBC's). The main function of the erythrocytes is the transport of oxygen from the lungs to the body tissues. Most of the cells in this Wright's stained peripheral blood smear are red cells. On is shown at the arrowhead.

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Leukocytes or White Blood Cells (WBC's)

The second group of cells are the leukocytes or white blood cells (WBC's). The leukocytes can be divided into two groups: mononuclear and granulocytic cells. Leukocytes are involved in various ways with the body's defense mechanisms. The cell shown in the upper image is a mononuclear cell, in this case a monocyte. The cell shown in the lower image is a granulocyte, in this case a neutrophil. These cells will be presented in much more detail later.

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Glossary of Terms A through M.

Antibody - A modified type of serum globulin synthesized by lymphoid tissue in response to antigenic stimulus. By virtue of specific combining sites each antibody reacts with only one antigen. Anucleate - Having no nucleus. Azurophilic granules - The well-defined large reddish granules (lysosomes) which may be present in large lymphocytes. They are called "azurophilic granules" because they stain blue with the azure stains which were originally used. Basophilic granules - Specific granules present in the cytoplasm of basophils. These granules are large and stain purple-black due to their strong affinity for basic stain. B-cell - Bone marrow derived lymphocytes which produce humoral antibodies. Biconcave - Having two concave surfaces. Cellular Immunity - The capacity of a small proportion of lymphoid population to exhibit response to a specific antigen. Chromomere - The centrally located granular portion of the platelet. Clone - A population of cells descended from a single cell. Delayed Hypersensitivity - (part of cellular immunity) that develops slowly over a period of 24-72 hours after an antigenic stimulus. It consists of an accumulation of cells around small vessels and/or nerves. Example: Tuberculin skin test reaction. Digestive Enzyme - A substance that catalyzes or accelerates the process of digestion. Eosinophilic Granules - Specific granules present in the cytoplasm of eosinophils. These granules are large, refractile spheres which stain reddish-orange due to their strong affinity for acid stain. Erythrocyte (red blood cell, RBC) - One of the elements found in peripheral blood. Normally the mature form is a non-nucleated, circular, biconcave disk adapted to transport respiratory gases. Fixed Macrophage - A phagocyte that is non-motile. Free Macrophage - An ameboid phagocyte present at the site of inflammation. Graft Rejection - A transplanted tissue that is rejected by the body's antibodies. Graft vs. Host Reaction - A complication that occurs when an implanted piece of tissue, which contains antibodies, rejects the host's tissue. Granulocyte - A leukocyte which contains granules in its cytoplasm, i.e., neutrophilic, eosinophilic, or basophilic granules. Half-life - is the length of time it takes for half of the cells circulating at a given time to leave the blood for the tissues. Hemocyte - Any blood cell or formed element of the blood. Hemostasis - A mechanism of the vascular system to arrest an escape of blood. It involves an interaction between blood vessels, platelets, and coagulation. Heparin - A mucopolysaccharide acid which, when present in sufficient amounts, functions as an anticoagulant by inhibiting thrombin. Histamine - A powerful dilator of capillaries and a stimulator of gastric secretions. Humoral Immunity - Acquired immunity produced after response to an antigenic stimulus in which B cells produce circulating antibodies. Hyalomere - the clear, blue non-granular zone surrounding the chromomere of a platelet. Immune Response - The interaction of a cell and an antigen that results in a proliferation of the cell and a capacity to produce antibodies. Isotonic Fluid - A fluid whose elements have an equal osmotic pressure. Leukocyte (white blood cell, WBC) - One of the formed elements of the blood; involved primarily with the body's defense. Lysosome - A microscopic body within cell cytoplasm; contains various enzymes, mainly hydrolytic, which are released upon injury to the cell. Megakaryocyte - A giant cell of the bone marrow from which platelets are derived. Mononuclear - A cell having a single nucleus.

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Glossary of Terms N through Z.

N:C Ratio - Nuclear: cytoplasmic Ratio - The ratio of nuclear volume to cytoplasmic volume within any one cell.Neoplasm - Any new and abnormal growth, such as a tumor.Neutrophilic Granules - Specific granules present in the cytoplasm of neutrophils. These granules resemble pencil stippling and stain a lilac color due to their affinity for both basic and acid dyes.Phagocyte - Any cell that ingests microorganisms or other cells and foreign particles.Phagocytosis - The ingestion and destruction of microorganisms or other foreign particles.Plasma - The fluid portion of blood in which the various blood cells are suspended.PF3 (platelet Factor 3) - A lipoprotein component of the platelet membrane; functions as a surface catalyst during blood coagulation.Pseudopod - A temporary protrusion of the cytoplasm of a cell.Refractile - Capable of refracting or changing the direction of light.Senescence - The process or condition of growing old.Serotonin - A constituent of blood platelets and other cells and organs; induces constriction of the blood vessels.Specific Granules - Granules found in cells of the more mature stages of the granulocytic series. They have distinct staining reactions which differ with each type of granulocyte.T-cell - Thymus derived lymphocyte which mediates cellular immunity.Thrombocyte (Platelet) - A circular or oval disk found in the blood; concerned with hemostasis.Thymus - A ductless gland-like body situated in the anterior mediastinal cavity; reaches its maximum development during the early years of childhood.Vacuole - Any small space or cavity formed in the cytotoplasm of a cell.

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The Process of Phagocytosis

?Neutrophils have a relatively short life span.They are produced in the bone marrow, and when they reach the band or segmented stages are released into the peripheral blood.They remain there for approximately ten hours before randomly entering body tissues.Neutrophils in the blood stream can be divided into circulating granulocyte pool(CGP) and marginating granulocytic pool (MGP).The white blood cell count reflects the cells in the circulating pool.The cells in the marginating pool move quickly into the circulating pool when needed.During an infection the neutrophil concentration of the peripheral blood can increase almost immediately due to the shift of these cells from the marginating pool and release from the bone marrow storage pool, if needed.Neutrophils then migrate to areas of tissue damage or infection.Neutrophils do not reenter the blood stream from the tissues, thus end their life in the tissues either as a result of phagocytosis or senescence.

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Mast Cells

Mast cells are similar in appearance to basophils, are a separate cell line and are life-long residents of connective tissue throughout the body. They have some functions similar to those of basophils.

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Where do neutrophils serve their primary function?View Page

OSHA Bloodborne Pathogens
You Are At Risk!

As a health care worker, you come into contact with materials that may contain bloodborne pathogens. These are infectious organisms, usually viruses, that live in human blood and body fluids.The bloodborne pathogens that are of greatest concern to health care workers are:Hepatitis B virus (HBV) Human immunodeficiency virus (HIV) Hepatitis C virus (HCV)

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About This Course

This course will provide you with basic information about bloodborne pathogens, the regulations that govern safe work practices when handling blood and other potentially infectious body fluids, and necessary precautions that must be taken to minimize your risk of exposure to these infections.

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Exposure Categories

There are three exposure categories :Category I are those employees who, on a day-to-day basis, will come in contact with blood or body fluids as part of their normal job. This includes medical laboratory professionals, pathologists and operating room nurses.Category II are those employees who may come in contact with blood or body fluid during the course of their normal job. This includes housekeepers, transporters, and some technicians such as EKG techs.Category III are those persons who would not normally ever come in contact with blood or body fluids and generally includes secretaries, administrators, and gardeners.Persons may move from one category to another during the course of a workday.

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Standard Precautions

Standard precautions mean that all blood and body fluids should be handled as if they are infectious and capable of transmitting disease. Standard precautions apply to: BloodBody fluidsSecretions (except sweat)ExcretionsNon-intact skinMucous membranes

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How Can HBV Be Prevented?

You can avoid exposure to HBV by taking the appropriate precautions, such as: Receiving the immunization against Hepatitis B Following standard precautions Maintaining proper work practices Using proper techniques when handling materials, which may be contaminated with blood or other potentially infected materials

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Occupational Exposure to HBV

In the health care setting, the virus is spread most often through contact with infected blood and other potentially infectious materials (OPIM), including body fluids, infectious wastes, and cultures. Body fluids most likely to transmit HBV are: Blood Semen Vaginal Secretions Pleural Fluid Peritoneal Fluid Pericardial Fluid Cerebrospinal Fluid Synovial Fluid Amniotic Fluid Saliva contaminated with blood during dental procedures Any fluid visibly contaminated with blood Sweat is not considered infectious, unless it is contaminated with blood.Contact with HBV may occur when infected blood or OPIM is introduced: Through an opening or sore in the skin Via a puncture with a contaminated sharp such as a needle Through direct contact with mucous membranes that line the insides of the mouth, nose, and eyes

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Who is infected?

Patients infected with HBV or other bloodborne organisms can appear healthy, so you can't tell whose blood is infectious.So treat all:bloodbody fluidssecretions (except sweat)excretionsnon-intact skinmucous membranes as if they were infectious.

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Body Fluids Most Likely To Transmit HBV

Body fluids most likely to transmit HBV are: Blood Semen Vaginal Secretions Pleural Fluid Peritoneal Fluid Pericardial Fluid Cerebrospinal Fluid Synovial Fluid Amniotic Fluid Blood contaminated saliva in dental procedures Any fluid visibly contaminated with blood Sweat uncontaminated by blood is not considered infectious.

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Spread of HBV In The Community

HBV is spread in society most often:Through shared needles used to inject drugsThrough sexual contactFrom mother to child before or during birth

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What Causes HIV Infection?

HIV infection is caused by the human immunodeficiency virus. The infection occurs when HIV enters a person's bloodstream, where it attacks and kills the helper T-cells. Helper T-cells are part of a group of white blood cells known as lymphocytes that are essential for fighting off infections.As the numbers of these cells decreases, so does the body's ability to fight infection.

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Occupational exposure to bloodborne pathogens can be prevented by which of the following means?View Page
Which of the following bloodborne pathogens poses the greatest risk of infection to health care workers?View Page
Contaminated Wastes

It is important to always dispose of contaminated wastes properly.Examples of contaminated wastes: Microbiology waste and pathology waste All body fluids, such as pleural fluid Contaminated sharps and blood specimens

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Gloves

Disposable gloves must be worn whenever there is a risk of contact with blood or other body fluids. Hypoallergenic gloves must be used if you, or the patient you are caring for, has a latex allergy. Keep hand jewelry to a minimum to protect the integrity of the gloves.Replace gloves: Between patient contacts If they are damaged or contaminated Before leaving the work area Cleanse hands after removing gloves. Disposable gloves cannot be washed.Utility gloves or heavy-duty rubber gloves are useful when cleaning up spills or when there is a risk of damage from equipment handling.Utility gloves may be decontaminated and reused if their integrity has not been compromised. They should be inspected regularly, and must be replaced if damaged.

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Gloves Must be Worn...

when there is a reasonable chance of exposure to blood, other infectious body fluids, mucous membranes, or nonintact skin. during vascular access procedures, including phlebotomy. when handling contaminated items or when touching contaminated surfaces.

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Exposure Incident

Even after taking all the proper precautions there is still a small chance of an exposure incident. An Exposure incident occurs when: Blood or another potentially infectious body fluid comes into direct contact with mucous membranes or non-intact skin. Parenteral exposure means: Exposure occurring as a result of piercing the skin barrier through needlesticks, cuts, or abrasions.

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OSHA Bloodborne Pathogens (retired)
You Are At Risk!

As a healthcare worker, you come into contact with bloodborne pathogens. These are infectious organisms, usually viruses, which live in human blood and other potentially infectious body fluids.The most important ones are... Hepatitis B Virus (HBV) Human Immunodeficiency Virus (HIV)

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How is HBV Spread?

Hepatitis B most often spreads when certain body fluids from an infected individual come in direct contact with another person.Contact may occur through: a break or sore in the skin a contaminated sharp contact with mucous membranes that line the insides of the mouth, nose, eyes, and the genital organs. HBV is not spread through casual contact, such as handshake, or through sweat.

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Who is infected?

Patients with Hepatitis B and other bloodborne infections can appear healthy, so you can't tell whose blood is infectious.So treat all:blood, body fluids, secretions (except sweat), excretions, non-intact skin, and mucous membranes as if they were infectious.That's what the term Standard Precautions means.

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Spread of HBV in the community(2)

Body fluids most likely to transmit HBV are: Blood Semen Vaginal Secretions Pleural Fluid Peritoneal Fluid Pericardial Fluid Cerebrospinal Fluid Synovial Fluid Amniotic Fluid Saliva in dental procedures Any fluid visibly contaminated with blood

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Spread of HBV in the community(1)

HBV is spread in the community through: Sexual contact Drug abusers sharing contaminated needles An infant's exposure to its mother's body fluids

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What causes HIV?

HIV is caused by the Human Immunodeficiency virus.When HIV enters a person's bloodstream, it attacks and kills the T-helper cells. These cells are part of a group of white blood cells known as lymphocytes, which are essential to the body in fighting off infections.As these cells are lost, so is the body's ability to fight infection.

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How is HIV spread?

HIV is spread in the community and healthcare workers just like HBV.Sexual contactDrug users sharing infected needlesAn infant's exposure to its mother's body fluids

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Contaminated Wastes(1)

It is important to always dispose of contaminated wastes properly!Examples of contaminated wastes: Microbiology waste and pathology wasteAll body fluids, such as pleural fluids Contaminated sharps and blood specimens

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Biohazard Labeled Bags

Put contaminated wastes which do not have the potential to puncture in a red or orange leakproof biohazard labeled bag.If the external surface of this bag is contaminated, place it within a secondary leakproof bag.Always hold full waste bags away from your body to prevent an injury by a protruding sharp.

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Gloves Must be Worn

Gloves must be worn: when there is a reasonable chance of exposure to blood, other infectious body fluids, mucous membranes, or nonintact skin, during vascular access procedures, including phlebotomy, or when handling contaminated items or surfaces.

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Exposure Incident

Even after taking all the proper precautions there is still a small chance of an exposure incident.Exposure incident: Blood or another potentially infectious body fluid coming into direct contact with mucous membranes or nonintact skin.Parenteral exposure: Needle stick or being cut by a contaminated sharp.

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OSHA Electrical Safety (retired 11/19/2012)
Which of the following can lower the amount of current needed to cause electricity-induced injury?View Page
If a person comes in direct contact with an electrical source and sustains an electrical shock, which of the following actions should be taken once the current has been shut off and/or the person has been freed from contact with the current?View Page
Factors that Determine the Degree of Electricity-induced Injury

The degree of electricity-induced injury is dependent on:The amount of electrical energy that is delivered The resistance that is encountered The type of current The current pathway The duration of contact

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Unplugging an Electrical Cord

Electrical cords should be unplugged by holding the cap and NOT by pulling on the cord. This is because the electrical insulation is more subject to failure.Hands should not be wet when plugging or unplugging electrical cords. Moisture will reduce the contact resistance of the body. Unplug all equipment during servicing.

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Ground

A ground is a conducting connection between an electrical circuit or equipment and the earth, or between an electrical circuit and some conducting body that serves in place of the earth.The purpose of a ground is to prevent the buildup of voltages that may result in a hazardous situation for the connected equipment and/or for the person operating the equipment.All electrical equipment in the laboratory that is not clearly marked as "double-insulated" must be grounded by using a three-pronged power cord.

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Electrical Shock

Direct contact with electrical current can cause sustained muscular contraction that may prevent the victim from releasing the electrical source. Shut off the electrical current if it can be done safely by unplugging the cord or turning off the main power switch. Merely turning off an instrument or appliance will not always stop the flow of electricity.If the current cannot be turned off, a non-conductive material such as a wood or plastic broom or chair, a rug, or a rubber mat can be used to push the victim away from the source of the current. Do NOT use a wet or metal object, and do NOT touch the victim with your bare hands. Verify that the object that is used does not have a metal core. As an extra precaution, stand on something dry and non-conducting such as a mat or stack of paper while attempting to free the victim from the electrical current. Call a physician immediately. Lower the victim's head to slightly lower than the trunk of the body, and elevate the legs. Cover the victim with a blanket or coat. Begin CPR if the victim's breathing and/or pulse has stopped or seems dangerously slow or shallow.

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OSHA Hazard Communication and Chemical Hygiene Updated to the Globally Harmonized System
Sections Twelve Through Sixteen

Sections twelve through fifteen contain ecological information, disposal considerations, transport information, and regulatory information. Section sixteen contains any other information that was not already covered.

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Packaging and Shipping Infectious Materials
IATA and US Postal Service Exempt Specimens

Laboratory specimens that are unlikely to cause disease and do not meet the criteria for category A or B substances are not subject to Division 6.2 regulations. Specimens for which the hazardous materials regulation (HMR) does not apply include human or animal samples (including, but not limited to, secreta, excreta, blood and its components, tissue and tissue fluids, and body parts) being transported for routine testing not related to the diagnosis of an infectious disease. This includes specimens that are being sent for:drug or alcohol testing cholesterol testing blood glucose level testing prostate specific antibody (PSA) testing testing to monitor kidney or liver function pregnancy testing tests for diagnosis of non-infectious diseases such as cancer biopsies The US Department of Transportation (DOT) has no "Exempt Specimen" classification and there are no DOT guidelines for packaging non-regulated specimens.* According to the DOT, in the U.S., if a package is marked as "Exempt Human/Animal Specimen" the understanding is that it contains no infectious substance. However, both IATA and the US Postal Service (USPS) have these requirements for packaging exempt specimens: Packaging IssueIATAUSPSType of packaging requiredTriple packagingTriple packagingOuter containerOne dimension must be a minimum of 100 mm X 100 mm (approximately 4 x 4 inches) Must be able to survive a drop test of 4 feet One dimension must be a minimum of 100 mm X 100 mm (approximately 4 x 4 inches) Must be able to survive a drop test of 4 feet Quantity limits: outer containerNone NoneQuantity limits: Primary receptacleNone500 mLQuantity limits: secondary packagingNone500 mL* Non-regulated specimens may become regulated because of preservatives, such as 10% formaldehyde (class 9) or 25% formaldehyde (class 8); or 25% ethanol (class 3).

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Definitions

Before further discussion of Category A and Category B, it is important to define two additional terms that are used in the classification process. CultureAn infectious substance containing a pathogen that is intentionally propagated, for example a bacterium grown on bacteriological medium as seen in the image below. Culture does not include a human or animal patient specimen.Patient specimenHuman or animal materials collected directly from humans or animals and transported for research, diagnosis, investigational acitivities, or disease treatment or prevention. Patient specimen includes excreta, secreta, blood and its components, tissue and tissue swabs, body parts, and specimens in transport media (e.g., transwabs, culture media, and blood culture bottles).* *It is important to note that this means specimens that have been collected into these transport media, but have not yet been incubated and are not actively growing in the media.

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Parasitology Question Bank - Review Mode (no CE)
Match each parasite listed here with its corresponding infective stage:View Page
Arrange the following parasites in order according to life cycles from simple to most complex:View Page
Arrange the following phases of the hookworm life cycle in order beginning with human contact:View Page
Which of the parasites listed here is/are transmitted via ingestion of contaminated pork?View Page
Which of the following parasites may be contracted by swimming in contaminated water?View Page
Arrange the following life cycle phases of Diphyllobothrium latum in order beginning with human transmission:View Page
Arrange the following phases of the Wuchereria bancrofti life cycle in order beginning with human transmission:View Page
The adult worms of which of the following parasites reside in human intestine?View Page
Which of the following parasites have/has a life cycle that resembles that of the Plasmodium species?View Page
Arrange the general schistosome life cycle phases in order beginning with that found in the human:View Page
This suspicious form was recovered in muscle tissue.View Page
Which parasite listed here is capable of crossing the placenta and causing serious harm to fetus?View Page
A 32 year old male was seen in the emergency room with gastrointestinal discomfort. Upon questioning the patient it was learned that he first began feeling ill after spending a day at the park where he swam and played volleyball barefooted. He first noticed a lesion on his foot. Later, he developed vague respiratory symptoms. Now his largest complaint is severe abdominal pain along with occasional vomiting. This patient is most likely suffering from:View Page
This stool parasite measures 55 µm by 50 µm and is the causative agent of:View Page
Perianal itching is the major symptom of infection with both forms of the organism pictured here. This parasite is the causative agent of:View Page
Arrange the following hookworm symptoms in order of their occurance based on the parasite's migration through the body beginning with human transmission:View Page
Match each parasite name listed below with its corresponding picture:View Page
Match each parasite listed here with its respective common name:View Page
The body of a cestode is known as its:View Page
Adult cestodes utilize this body part to attach to the human intestine:View Page
The body of an adult cestode consists of segments called:View Page
Match each pair of parasites listed here with the key morphologic characteristics that help to distinguish between them:View Page
Match each parasite listed here with the key characteristic that aids in its identification:View Page
Arrange the parasites listed here in increasing order (starting with none) based on the length of their undulating membranes:View Page
Arrange the following morphologic forms based on complexity beginning with the simplest form:View Page
Label the morphologic structures on this parasite form:View Page
A 58 year old male, who recently returned from an extensive overseas business trip to Africa, presented to the local clinic complaining of nausea, vomiting, and an achy feeling all over his body. At first he thought it was just the flu, but it persisted. The doctor ordered a battery of tests including blood smears for parasitic study. This suspicious form was recovered. The patient is most likely suffering from:View Page
A 16 year old male champion athlete went to his doctor complaining of a persistent cough, fever, bloody diarrhea and overall weakness. Upon questioning the patient, it was learned that he had recently competed in a freshwater swimming competition in the Caribbean. Examination revealed a dermatitis on the patient's right calf. A battery of tests were ordered including a CBC, chemistry profile, and a stool for culture and parasitic examination. The CBC revealed the presence of eosinophilia. The other hematology and chemistry tests were unremarkable. The culture was negative. This suspicious form was seen on all parasite preparations made from the stool sample submitted. This form measures 165 µm by 68 µm. This patient is most likely suffering from an infection with:View Page
I am a mouth scavenger and measure about 10 µm.View Page
I have been known to reside in a number of human tissue sites including the liver and lung.View Page
I may be found in blood or in lymph nodes.View Page
A parasite that takes up residence inside the human body host is called a/an:View Page
Match the arthropod common name with its corresponding scientific name:View Page

Pharmacology in the Clinical Lab: Therapeutic Drug Monitoring and Pharmacogenomics (retired 10/15/2012)
Basic Pharmacokinetics

In order to discuss TDM and PGx we need to also introduce the concept of pharmacokinetics. Pharmacokinetics is the study of drug disposition in the body: how and when drugs enter the circulation, how long they remain in the blood, and how they are eliminated. TDM is the clinical assessment of a drug's pharmacokinetic properties. Physicians and pharmacists need to establish that a drug is present at an effective concentration but not at a toxic concentration. The next few pages will describe some of the factors that determine a drug's disposition in the body. These factors ultimately decide the need for therapeutic drug monitoring.

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Protein Binding

Most drugs are bound to proteins when they circulate in the body. Albumin is a major drug-binding protein in serum. Albumin is an alkaline protein, so acidic and neutral drugs primarily bind to it. If albumin binding sites become saturated, acidic and neutral drugs can bind to lipoproteins. Alkaline drugs tend to bind to globulins, particularly to the globulin, alpha-1 acid glycoprotein. Only free, unbound drugs are able to bind drug receptors and have therapeutic effects. An equilibrium exists in the systemic circulation between a free and protein-bound drug and between a free and receptor-bound drug. This is illustrated in the image to the right.

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Other Factors Affecting Drug Absorption and Distribution

In addition to protein availability, other factors may affect drug absorption and distribution in the body as a whole or at specific sites within the body. The following table highlights some of these other factors. Factor Discussion Regional blood flow Reduced area blood flow can be seen in diabetics and enhanced blood flow can be seen in tumors. Lipid solubility of the drug The more lipophilic a drug is, the more likely it will enter the central nervous system. The integrity of the GI tract In a diseased gut, an orally-administered drug may not be absorbed as expected. Age Drug kinetics and dispositions change throughout life. In general, metabolism of drugs is reduced in the elderly. Genetics Mutations or deletions in drug metabolizing enzymes can greatly affect a drug's disposition.

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Given what you have learned thus far, which of the following statements below do you think is true?View Page
Unexpected Concentrations

TDM provides a quantitative measure of the circulating concentration of a drug. The physician determines if the dosage of the drug needs to be adjusted based on this information.If a drug concentration is determined to be outside the therapeutic range, it may be for one of the reasons listed in the table below. Reason Discussion Noncompliance Patients may (intentionally or unintentionally) not take the drug. TDM can thus help monitor compliance. Dosing errors The dose may have been erroneous or inappropriate given the patient's condition. Malabsorption The TDM result will reveal if the drug cannot be absorbed well through the gut and an alternative route of administration will be needed. Drug interactions Many drugs interfere with the absorption or metabolism of other drugs. These interactions will be revealed by TDM. Kidney or liver disease Any pathology that affects elimination will cause an elevation in a drug level that will be unmasked by TDM. Altered protein binding Changes in serum proteins can lead to big changes in the amount of free drug in serum. Variations in the genetics of drug-metabolizing enzymes can also affect drug concentrations in the body. This is the field of pharmacogenomics that will be discussed later in the course.

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Drug Concentration Over Time

When a drug enters the body, it reaches a peak concentration that starts to fall as the drug is eliminated. The figure on the right shows a typical kinetic with a drug given intravenously (IV).

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Half-life

The amount of time it takes for a drug's concentration in the body to decrease by 50% is called the drug's half-life (t1/2).The longer a drug's half-life, the slower it is removed from the body. Most drugs are eliminated from the body in 1 to 3 days, but some drugs with longer half-lives can still be detected in the body weeks after the initial dose. The figure below illustrates a typical kinetic pattern for an oral drug.

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Drug Elimination

Most water-soluble drugs are eliminated from the body through hepatic metabolism. renal filtration, or a combination of the two.An alteration in renal function will have a major effect on the clearance of the drug or its active metabolite(s). Decreased renal function results in elevated serum drug concentrations.

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Phlebotomy
Venipuncture Standard precautions

Treat all blood & body fluids as if they were infectious.Always wear gloves during vascular access procedures.

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Hematosis

A hematoma is a blood clot which forms within the body. It is caused by leakage of blood into the tissues from an injured vein . It will resolve spontaneously.Hematomas are caused by excessive needle trauma to a vein, for example, by a needle which passed entirely through a vein and came out the other side.Apply compression to help stabilize a hematoma.

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What are bloodborne pathogens?

Bloodborne pathogens are infectious micro-organisms which live in the bloodstream.You can be exposed to bloodborne pathogens if you are injured with a contaminated needle.You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids.

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Standard precautions

Standard Precautions means treating all body fluids and substances as if they were infectious. Since you can't tell which specimen may carry a bloodborne pathogen, use appropriate infection control measures during all patient contacts & when handling all specimens.

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Standard precautions continued

Potentially infectious body fluids include: Blood, Semen, Vaginal Secretion, Peritoneal, pericardial and pleural fluids, and Saliva Sweat and tears are not generally considered infectious. It is important to remember that bloodborne pathogens are not transmitted by casual contact, like a handshake.

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Personal protective equipment

An impermeable lab coat should be worn to protect clothing from blood & other body fluids. Gloves must be worn while drawing blood and during all other patient contact. Appropriate face masks must be worn during contact with patients in certain types of isolation. A sign posted on the patients door will indicate special protective equipment that may be required prior to entering a patient room.

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Integumentary system : function

The function of the integumentary system is to: Protect the underlying tissues from the external environment. Help regulate body temperature. Conserve moisture.

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White blood cells

Leukocytes, or white blood cells, help the body fight infections. Leukocytes are shown in the photomicrograph of the stained blood smear to the right.

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Red blood cells

Red blood cells contain hemoglobin, which carries oxygen from the lungs to the tissues of the body. Hemoglobin gives blood its red color. Red blood cells are shown in the photomicrograph of a stained blood smear to the right.

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Anatomy & physiology: definitions

Anatomy is the branch of science concerned with the study of the structure of the body. Physiology is the branch of science concerned with the study of the function of the body.

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Preliminary Identification of the Primary Select Agents of Bioterrorism
Viruses

VirusMost Likely Means of Dissemination Primary Route of EntryGeneral Signs and SymptomsLaboratory TestingSmallpox: Image courtesy of CDCAs an aerosol Inhalation High fever with extreme lethargySevere headache, backache, and abdominal painRash that starts as red bumps but quickly develops into small, itchy blisters Consult local APHL prior to sample collectionShell vial and DFA Monoclonal IFAMolecular tests Viral Hemorrhagic Fevers (Ebola, Marburg, Lassa, and Argentine): SolidLiquidAerosol AbsorptionInhalationIngestion Vary by type of viral hemorrhagic fever (VHF), but initial signs and symptoms often include: Marked feverFatigueDizzinessMuscle aches, loss of strength, and exhaustionSevere cases of VHF often show signs of bleeding under the skin, within internal organs, or from body orifices like the mouth, eyes, or ears Enzyme-linked immunosorbent assay (ELISA)Polymerase chain reaction (PCR)Viral culture

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Category A Agents: Reasons Why They May be Used to Create Public Health Emergencies

Anthrax (B. anthracis): Inhalation of anthrax spores is virtually 100% fatal Spores can remain infectious for decadesBotulism: Most lethal toxic agent known Toxin could be used to contaminate food supplies Can be aerosolized in enclosed areasPneumonic Plague (Y. pestis): Aerosolized in large amounts Short incubation period, usually in less than three days, and invariably fatal without early and effective antimicrobial therapy Untreated, fatality rate exceeds 90% Disease is spread from direct exposure to respiratory droplets of infected humansSmallpox: Highly contagious and deliberate spread by aerosol is extremely infectious Mass panic would be createdTularemia (F. tularensis): Highly contagious and easily spread An aerosol containing as few as 25 organisms can cause infection Easily penetrates the smallest breaks in the skinViral Hemorrhagic Fever: Causes internal and external bleeding and would likely cause great panic and easily spread by direct contact with body fluids or respiratory droplets Outbreak due to bioterrorist attack could lead to mass illness and death

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Reading and Reporting Gram Stained Direct Smears
Significance of Specific Findings

When evaluating Gram stains of clinical samples, keep in mind the source of material from which the smear was made. Bacteria found in cerebrospinal fluid (CSF), blood, tissue and specimens from other sterile sites are always significant. Gram stains of body fluids that are normally sterile must be examined carefully. For every one organism per oil immersion field, there are about 105 organisms per mL present in the sample! Examining stained smears of CSF sediment may assist the clinician in establishing a presumptive diagnosis. The Gram stain result and the results of other special stains could also guide in the selection of culture media. If bacteria are observed in a CSF specimen, it is important to determine and report whether the bacteria are inside or outside of white blood cells (intracellular or extracellular). The quantity of organisms seen and the amount and type of host cells are also important to report. Bacteria observed in specimens from the throat, genital tract and other areas containing normal flora suggest infection only if their composition and type varies significantly from the norm.

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Reading Gram Stained Direct Smears
Significance of Specific Findings:

Epithelial cells in large numbers within sputum smears means that the specimen is predominantly oral saliva, rather than true sputum from the lung. Epithelial cells in urine smears indicate that the sample has been contaminated by organisms found on the vulva or distal urethra. Bacteria found near or on epithelial cells are usually normal contaminating bacterial flora.White blood cells indicate inflammation and possible infection. The direct smear examination should focus within and around these cells.Red blood cells in a direct smear are not usually significant.Yeast may be present as normal flora in upper respiratory tract or genital tract. They may be significant if they predominate, or if budding yeast forms are seen.Hyphae are more likely to indicate the presence of fungal infection, but this determination requires correlation with clinical findings.Bacteria found in spinal fluid, blood, tissue and specimens from other sterile sites are always significant.Body fluids which are normally sterile must be examined carefully. If only one organism per oil immersion field is identified, then there are about 105 organisms per mL present in the sample! Bacteria observed in specimens from the throat, genital tract and other areas containing normal flora suggest infection only if their composition and type varies significantly from the norm.

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Red Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
Conditions suggested by the macrocytes and the neutrophil in the photograph to the right include which of the following?View Page
Normal Red Blood Cell (RBC) Morphology

In order to properly understand and identify the abnormal red blood cell morphologies associated with RBC disorders, the laboratorian must first become competent in normal RBC characteristics.Normally, RBCs will display a defined morphology in the peripheral blood. Mature RBCs, under normal circumstances, are round, biconcave disc-shaped, anuclear cells measuring approximately 7-8 microns in diameter with an internal volume of 80-100 fL. The term used to express RBCs of normal size is normocytic. Mature red blood cells, under normal circumstances, will also have an appropriate hemoglobin content (a normal MCH and MCHC), giving them a red-orange appearance on Wright-stained smears. These cells will display a central pallor (lighter area inside of the cell) no larger than 3 microns in diameter. This normal morphology is indicated by the term normochromic. It is paramount for RBCs to contain an adequate amount of hemoglobin for the purpose of transporting oxygen to the tissues and carbon dioxide back to the lungs. An example of a normocytic, normochromic peripheral blood picture is shown on the right.In addition, the RBC membrane plays a key role in allowing the deformability of the cell to take place in order to travel through smaller vessels. Normally functioning RBCs survive for approximately 120 days in the peripheral blood circulation before being removed by the liver or spleen. Under normal circumstances, the body produces enough RBCs each day to account for the senescent (old) cells that are removed. Certain disease states can alter the normal RBC characteristics described above. This course will illustrate and correlate various RBC morphologic changes with the specific disease states or conditions, which they are associated.

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A ten-year-old boy came to a physician's attention because of recent jaundice and icteric sclerae after taking the medication Primaquine before a trip to Africa. The immediate laboratory work revealed: Hct 24%(normal 36%-47%), MCV 79.5 fl (normal 78-95fl),RDW 13%(normal 11.5-15.0%). His blood smear findings are reflected in the images to the right. The upper image is a Wright-Giemsa stained smear while the lower is a supravital-stained smear. Which condition should be considered for this patient when analyzing his symptoms, history, and laboratory results?View Page

Red Cell Morphology
Sickle Cells (Drepanocytes)

Sickle cells, also referred to as drepanocytes, are formed as a result of the presence of hemoglobin S in the red cell. As the red cell ages, it becomes rigid as it passes through the low oxygen tension atmosphere of the small capillaries in the body. In the absence of oxygen, hemoglobin S polymerizes into rods, causing the sickle cell shape. The shape of sickle cells can vary from cigar-shaped, as shown in the upper image, to the more severe sickled-form, shown in the bottom image.

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Notes about Poikolocytosis

Some forms of poikilocytosis represent in vitro artifact rather than being the result of abnormal physiology within the body. Inconsistent terminology also hampers communication about red cell morphology, in that various terms are used to describe the same type of change. Uniform terminology based on Greek roots has been applied in an attempt to provide standardization, although it has not been widely accepted.

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Routine Venipuncture
Explore the Possibilities!

The antecubital area of the arm is usually the first choice for routine venipuncture. This area contains the three vessels primarily used by the phlebotomist to obtain venous blood specimens: the median cubital, the cephalic and the basilic veins.Although the veins located in the antecubital area should be considered first for vein selection, there are alternate sites available for venipuncture. These include the top of the hand, the side of the wrist, and the forearm. These sites should only be considered after determining that the veins of the antecubital area cannot be accessed or cannot be used. Vein Location Reason for Choice Placement Direction Median Cubital Mid antecubital fossa Vertical to diagonal Musculature assists in stabilizing vein; very often largest; ease of access Cephalic Thumb side of antecubital fossa Vertical Ease of access; few nerves and tendons in area Basilic Body side of antecubital fossa Vertical to diagonal More difficult to access; proximity of artery, nerves and tendons. Use this vein only as the final alternative.

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Tourniquets, Alcohol, and Gauze

A tourniquet is used by the phlebotomist to assess and determine the location of a suitable vein for venipuncture. Single-use, latex-free tourniquets are preferred but reusable tourniquets are acceptable. However, if the reusable tourniquet becomes contaminated with blood or body fluid, it must be discarded immediately to avoid the spread of harmful contaminants to other patients. Follow the guidelines established by your facility for cleaning reusable tourniquets.Proper application of a tourniquet will partially impede venous blood flow back toward the heart and cause the blood to temporarily pool in the vein so the vein is more prominent and the blood is more easily obtained. The tourniquet is applied three to four inches above the needle insertion point and should remain in place no longer than one minute to prevent hemoconcentration. If the tourniquet is used during preliminary vein selection, it is best to release the tourniquet after assessing the vein and while you are assembling your supplies. Reapply the tourniquet just before starting the venipuncture; it should then be released soon after the needle has been inserted into the vein and the blood flows into the first tube. If collecting multiple tubes, the tourniquet may remain in place until blood enters the last tube.

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Semen Analysis
Collection (continued)

Other aspects of specimen collection that must be considered are the temperature of the specimen and the time needed to transport it to the laboratory.Ideally, the specimen should be collected in a room at the testing site.If onsite collection is not possible:The specimen should be kept between 20 -37°C (room temperature to body temperature) from the time of collection until it arrives at the laboratory. This can be facilitated by holding the container close to the body, for example by carrying it in an inside pocket.Semen should arrive at the laboratory as soon as possible after collection, preferably within one hour.The man should record the time of semen production.The report should note that the sample was collected at a location outside the laboratory.

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Which of the following statements are TRUE for semen specimen collection and transport?View Page

Special Topics in Phlebotomy
Therapeutic Drug Monitoring

Therapeutic drug monitoring helps to ensure that a dosing regimen is appropriate for a given patient. The blood plasma concentration of the drug is measured to determine the correct dose that will achieve a therapeutic level of the drug without overdosing into a toxic range. When a drug enters the body, it reaches a peak concentration that starts to fall as the drug is eliminated.The amount of time it takes for a drug's concentration in the body to decrease by 50% is called the drug's half-life. The longer a drug's half-life, the slower it is removed from the body. Most drugs are eliminated from the body in one to three days, but some drugs with longer half-lives can still be detected in the body weeks after the initial dose.The figure on the right illustrates a typical concentration pattern for a drug that is given orally (ingested).

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Peaks and Troughs

As the prescribed drug is used or metabolized by the body, the drug level decreases. The lowest level of the drug in the patient's body is called the trough level. The peak for a drug is when the level of the drug in the patient's body is the highest.To assess drug concentrations during the trough phase, blood should be drawn immediately before the next dose.To assess peak levels, the time for drawing depends on the route of administration:Intravenous (IV): 15 - 30 minutes after injection/infusionIntramuscular (IM): 30 minutes - one hour after injectionOral: One hour after drug is taken (assumes a half-life of > two hours)

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Hints For Successful Pediatric Venipuncture

While pediatric phlebotomy can be challenging, these guidelines can contribute to success.Communication: Always be honest with the child. Never lie to a child and say that it won't hurt. If asked by the child if it will hurt, you could explain that it may feel like an insect bite or it may sting, but if he/she holds really still, it will be over very soon.Correct hold of child: Ask the parent or guardian to assist. If you have determined that the child's parent is willing and able to assist throughout the procedure, have the child sit on the parent's lap . The parent can gently "hug" the child in a way to limit the child's movement and stabilize the arm that will be used for venipuncture. Alternately, the child can lie on a bed or exam table. If the parent does not choose to help, ask for assistance from a coworker. Correct hold of the child's arm: A health care professional familiar with the procedure should assist by holding the arm that will be used for the blood collection. The holder should face the child and gently position the child's arm so that the arm is straight and palm facing up. Next, the holder should place one hand underneath the child's elbow grasping lightly yet firmly to stabilize the elbow. With the other hand, the holder should hold the child's hand firmly. This hold will help prevent movement of the arm, even if the child is moving his/her body. This hold also allows the phlebotomist easy access to the venipuncture site during the procedure. Distractions: At times, the phlebotomist may employ a technique to distract the child during the procedure. For example, to help the child keep still, tell the child that the only thing he/she can move is his/her eyelashes. This places the child's focus on moving only their eyelashes and before you know it, the procedure is done!

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The Influenza A Virus: 2009 H1N1 Subtype
Signs and Symptoms of the H1N1 Virus

Symptoms of the Influenza A 2009 H1N1 virus are similar to what is currently recognized as typical flu-related symptoms. The most common symptoms for the H1N1 virus include: fever (greater than 100.0° F or 37.8 ° C) sore throat fatigue cough runny / stuffy nose chills diarrhea nausea / vomiting headaches body aches (muscle & joint pain) More severe symptoms may be present.

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Which of the following is NOT a typical symptom associated with the 2009 H1N1 virus?View Page

The Urine Microscopic: Microscopic Analysis of Urine Sediment
Sperm Under Phase Contrast

Under phase contrast, the oval body of the sperm appears bright whereas the tail is dark.

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Sperm

Sperm may be present in urine sediment. Sperm have a characteristic oval body with a long thin tail and are 50 microns in length.

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Match the following:View Page

Theoretical and Practical Aspects of Routine H&E Staining
Clinical Significance and Correlation of Histology

Histology involves studying the structure of body tissues. Because structure is closely related to function, different tissue types are distinguishable from one another by examination of their individual components. Knowledge of the normal histology of the multitude of tissue types within the body is necessary for the recognition and understanding of disease.The tissue on which a diagnosis is made can be taken from a patient in the operating room, a doctor's office, or from an autopsy. Autopsy is an important part of pathology which seeks to establish the cause of sudden or unexpected death, to examine disease progression, and to assist police during the investigation of criminal cases. However, most anatomic pathologists deal with tissue from living patients and a large part of this is the detection and diagnosis of cancer. A tissue diagnosis is essential before a clinician can start treatment involving major surgery, radiation, or drugs.

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Healthy Versus Diseased Tissue with H&E Stain

Histology involves looking at the structure of body tissues. Because structure is closely related to function, different tissue types are distinguishable from one another by examination of their component parts. Knowledge of the normal histology of all of the multitude of tissue types within the body is necessary for the recognition and understanding of disease.The following pages show microscopic photos of some select human tissue stained with the hematoxylin and eosin (H & E) stain.

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Transfusion Reactions
Categories of Transfusion Reactions

Adverse complications of transfusions can be classified into several categories: Immune-mediated transfusion reactions are those that trigger a response from the patient's immune system. Many transfusion reactions are mediated by the recipient's immune system. These reactions occur as a result of antigen-antibody interactions. Antibodies involved include those with specificity towards antigens on red cells, white cells, or platelets. In general, the immune responses occur in three stages: the immune system detects foreign material (antigen) the immune system processes the antigen the immune system mounts a response to remove the antigen from the body Non-immune mediated hemolytic transfusion reactions are caused by the physical or chemical destruction of transfused RBCs, bacterial contamination, circulatory overload, or citrate toxicity. Acute reactions are those that occur during or within 24 hours after the transfusion. There is usually a rapid onset of symptoms and these reactions may be fatal. Delayed reactions occur weeks or months after the transfusion of blood or blood components.

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Definition/Manifestations/Prevalence

Allergic reactions are grouped into three categories depending on severity: mild or uncomplicated moderate or anaphylactoid life-threatening or anaphylactic reactionsMild allergic reactions occur in about 1-3% of patients receiving blood products containing plasma. Symptoms are usually mild and include urticaria, erythema (skin redness), and itching. Hives can appear any where on the body and may vary in size. Symptoms usually occur within minutes after the start of the transfusion. They can often last for hours or even days. Mild allergic reactions result from a patient's hypersensitivity to soluble allergens in the plasma of the donor unit. The blood recipient forms antibodies to these allergens that are bound to IgE on mast cells and causes the release of histamines. Allergen substances may be drugs or food consumed by the blood donor. Anaphylactoid and anaphylactic reactions have similar presentations. These reactions are rare but life-threatening. Anaphylactoid and anaphylactic reactions are severe systemic reactions with symptoms such as hypotension, dyspnea, nausea, vomiting, urticaria, and diarrhea. The most life-threatening symptoms include lower airway obstruction, laryngeal edema, cardiac arrhythmia, cardiac arrest, shock, and loss of consciousness. None of these reactions present with fever.

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Physical and Chemical Mechanisms of Hemolysis

Patients can experience a transfusion reaction caused by a range of physical or chemical factors. These factors can either affect the blood component or result from a transfusion event. These reactions include physical red cell damage, depletion or dilution of coagulation factors and platelets, hypothermia, citrate toxicity, hypokalemia or hyperkalemia, and air embolism. Membrane damage and lysis can occur to red blood cells (RBCs) because of hypotonic or hypertonic solutions, heat damage from blood warmers, and mechanical damage caused by blood pumps. Platelets and coagulation factors may become depleted or diluted from a massive transfusion. Hypothermia, a core body temperature of less than 35oC, can occur from transfusions of large volumes of cold products. Hyperkalemia is caused by the intracellular loss of potassium from the red cells during storage. Hypokalemia may result from transfusion of potassium depleted cells such as washed RBCs. Signs and symptoms of physically or chemically induced reactions are non-specific. Some of the more common signs include: Chills Numbness Nausea Vomiting Cardiac arrhythmias Altered respirations Additional laboratory tests to investigate a reaction are electrolytes, blood pH, glucose, urinalysis, complete blood count (CBC), prothrombin time (PT) and activated partial thromboplastin time (aPTT). Treatment involves correcting the underlying cause of the symptoms. For example, a patient with hypothermia may be given a heat blanket. Attention to proper transfusion practices will help prevent these types of reactions.

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Tuberculosis Awareness for Health Care Workers
Tuberculosis Infection

TB infection is usually followed by an immune response and latency after exposure. In about 5-10% of cases, the latent period progresses to an active infection.Infection occurs when a susceptible person inhales droplet nuclei containing Mycobacterium tuberculosis and the organism reaches the alveoli of the lungs. The minimal infectious inoculum may be as low as one viable organism.About 2-12 weeks after infection, the immune system limits multiplication of additional bacteria and the immunological test becomes positive.Latent tuberculosis infection (LTBI) is the stage when the viable organism remains in the body; the individual has no symptoms and is noninfectious.Most persons infected with M. tuberculosis do not experience clinical illness and are noninfectious. About 5-10% of persons who are infected and are not treated will develop active TB during their lifetime. The risk for progression is highest during the first several years after infection.Most often, M. tuberculosis infects the lungs. However, it can infect almost any organ in the body, including bones and joints. Tuberculosis meningitis is a TB infection that occurs outside the lungs with devastating consequences, most often in young children and patients with AIDS.

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High-Risk Progression Groups

The following persons are at high risk for progression from LTBI to TB disease: Persons infected with HIVPersons infected with Mycobacterium tuberculosiswithin the past two yearsPersons with untreated or inadequately treated TB diseaseInfants and children <4 years of agePersons with chronic medical conditions or immunocompromising conditions

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Variations in White Cell Morphology -- Granulocytes
Variations in Morphology

Many variations in morphology may be seen when examining Wright stained peripheral blood smears. One method of classifying these variations in white cell morphology is based on the way the body responds to a stimulus, deficiency, or the presence of an inherited defect. This classification falls into three groups:Pathological: Cells may show abnormalities in appearance and/or function. The body is responding abnormally to a stimulus or inherited defect, resulting in physiological impairment in the patient. Nonpathological: Cells may show variation in morphology but their function is normal. Their presence does not cause physiological impairment. Reactive: Cells show variation in morphology but are functioning normally in response to a specific stimulus, such as a virus or bacteria. There is a disease process in progress to which the cells are responding. Although the morphology has varied from normal and their presence is significant, the body is responding normally to a stimulus.

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Match the following:View Page
Conditions Associated with Hypersegmented Neutrophils

There are a number of conditions in which hypersegmented neutrophils may be seen, such as megaloblastic anemias (including folic acid deficiency and pernicious anemia). Individuals who are receiving chemotherapy or have long-term chronic infections may also have hypersegmented neutrophils.The cells seen in these conditions would be classified as pathological since the body is responding abnormally as a result of either a deficiency of a component needed for DNA production or because of the toxic effect that chemotherapy drugs have on DNA.

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May-Hegglin Anomaly

This blood smear was taken from a patient with the May-Hegglin anomaly. A May-Hegglin Dohle body is indicated by the arrow near the edge of the cytoplasm at the top of the neutrophil. In addition, notice the giant platelet that is indicated by the red arrow, another characteristic of May-Hegglin anomaly.

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Classification

Vacuoles, toxic granulation and degranulation are classified as reactive since the body is responding normally in an effort to rid itself of infection caused by bacteria. Morphological changes related to aging are also classified as reactive.

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Which of the following inclusions has a similar appearance on a Wright's stained smear to a Döhle body?View Page
May-Hegglin Like Inclusion

Another example of a May-Hegglin-type body. This smear was from a case of pseudo May-Hegglin caused by drugs. Bizarre appearing platelets can also be seen in cases of pseudo May-Hegglin.

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Albinism and Chediak-Higashi Anomaly

Albinism, one of the striking physical characteristics of Chediak-Higashi anomaly, is also thought to be related to the general dysfunction of cells. Albinism has been specifically related to the aggregation of melanosomes, the pigment producing cells in the body.

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Döhle Bodies, continued

Döhle bodies are seen in a number of conditions, including:infections burns measles leukemia chemotherapyDöhle bodies are only present when the body is responding to unusually severe stress or stimulus. This severe stress may cause the cytoplasm of some cells to mature improperly. Their presence does not aid in the diagnosis of the disorders in which they are found, but they are frequently seen along with toxic granulation and/or vacuoles in cases of infection or burns.

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Alder Anomaly (Alder-Reilly Anomaly )

Alder anomaly is a rare autosomal recessive disorder in which the basic defect involves protein-carbohydrate complexes called mucopolysaccharides. The accumulation of partially degraded (broken down) protein-carbohydrate complexes within the lysosomes account for the larger than normal purple-staining inclusions seen in all types of mature white blood cells, and sometimes in earlier cells. The granules may occur in clusters, rather than diffusely, throughout the cytoplasm as in toxic granulation. These inclusions may be seen in the bone marrow more frequently than in peripheral blood. The physical characteristics associated with this disorder include gargoylism and dwarfism. The function of the cells involved is not affected. This morpholical change would be classified as pathological since the body is responding abnormally even though the function is not affected.

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White Cell and Platelet Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
The cell containing the inclusions indicated by the arrows are often associated with which of the following conditions?View Page
May-Hegglin Anomaly

May-Hegglin anomaly is an inherited dominant condition in which large (2 - 5 um) basophilic inclusions, resembling Döhle bodies, are present in granulocytes, including neutrophils, eosinophils, basophils, and monocytes. The inclusions are caused by accumulation of free ribosomes. A May-Hegglin body is indicated by the black arrow in the image on the right. Note that this inclusion is well-defined and there is no evidence of toxic granulation in the cytoplasm. When Döhle-like bodies are identified, May-Hegglin anomaly should be considered in the differential diagnosis, even though this entity is rare. Giant platelets containing few fine granules are also characteristic of May-Hegglin anomaly. The red arrow in the image on the right points to a giant platelet, observed in the same field as a neutrophil containing a May-Hegglin body. Sometimes the platelets have bizarre shapes and variable sizes. Variable degrees of thrombocytopenia complicated by mild bleeding problems and purpura may accompany the aberrant platelets.

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