Clinical laboratory Information and Courses from MediaLab, Inc.

The following table lists the various cell types and macroscopic descriptions of CSF, and the patient conditions that could cause those properties to be present in the patient's CSF: Predominant Cell Appearance Conditions lymphs variable; clear - turbid viral meningitis tubercular meningitis multiple sclerosis drug abuse lymphoma leukemia Guillain-Barré syndrome chronic alcoholism neutrophils variable; clear - turbid bacterial meningitis mycotic meningitis early tuberculosis hemorrhage cerebral abscess tumors monocytes variable chronic bacterial meningitis partial treatment of meningitis tumors macrophages clear - turbid or clear - xanthochromic bloody tuberculosis fungal meningitis following hemorrhage blood contamination eosinophils variable parasitic meningitis fungal meningitis allergic reaction medications shunts dyes tumor cells variable metastatic carcinoma blast cells variable leukemia lymphoma normal to increased lymphs clear - xanthochromic benign tumor spinal cord brain ependymal or orchoid cells (often clumped) variable; may be xanthochromic bloody trauma spinal tap Adapted from Saunders Manual of Clinical Laboratory Science. Craig A. Lehrmann, Ed. WB Saunders, 1998.

Many people involved in the clinical laboratory sciences need to be familiar with basic statistics for a variety of reasons.  These reasons include: performing quality control, and interpreting of results of instrument testing determining suitability of different methods or instruments for the same task understanding how acceptable laboratory procedures and methods are established determining ranges for clinical tests of normal, healthy individuals understanding clinical trials and new methods presented in journals and articles performing those trials and research projects yourself

Here are the criteria for the preparation of tables, as specified by the Journal of Clinical Laboratory Science: Write table titles at the top of the table. Number tables sequentially with Roman numerals. Include the following information in a title, whenever possible: who, what, where, why and when. Put the independent variable in the left column, and the dependent variable in the right, if you are listing data with independent and dependent variables. Label each column with the appropriate units. Adequately space tables that appear on the same page. Example:Table I Patient specimens analyzed for blood urea nitrogen on the Dimension RxL and the Vitros 250 at City Hospital Sample # RxL (mg/dL urea) Vitros 250 (mg/dl) urea 1 8.8 8.8 2 11.2 10.0 3 12.4 13.6 4 16.2 13.2 5 20.0 21.2 6 25.0 20.0 7 28.8 26.2 In this case, the Dimension RxL is the "reference method" and is considered the independent variable, while the Vitros 250 is the "test method" and is considered the dependent variable.

Coefficient of variation is commonly used as a means of measuring the variability of an instrument. The data are gathered by recording the values for the normal and abnormal controls for each test run. At the end of the month, the standard deviation, mean, and coefficient of variation are calculated. The testing data for a particular instrument might look like this: January February March Normal Control s CV 100.9 2.43 2.41 103.1 2.99 2.90 102.0 2.21 2.17 Abnormal Control s CV 209.5 4.41 2.11 211.6 4.00 1.89 206.8 3.95 1.91 The coefficient of variation stays fairly constant from month to month. If there is a sudden increase, there might be a problem with the method or the equipment.In the clinical laboratory, the use of CV as a measure of relative variability should not be confused with the use of the standard deviation as a measure of absolute variability. For example, support physicians agreed that for accurate patient treatment, the inherent variability in a glucose method should be less than 5 mg/dL. In this case, neither the hexokinase nor the orthotoluidine method is acceptable. It does not matter which is more precise if neither is precise enough to result in adequate patient care.

Routine electrophoresis is a generic term for the traditional clinical laboratory electrophoresis performed on a rectangle-shaped slab gel. Routine electrophoresis is mostly used for separation of proteins and has some use in separating nucleic acids. Generally several patient specimens and control(s) can be placed on one gel and solutes separated in one run. This type of electrophoresis is sometimes called zone electrophoresis.A serum sample with normal plasma proteins yields five zones or bands of separated proteins: albumin, alpha-1-globulins, alpha-2-globulins, beta-globulins, and gamma-globulins. Proteins in CSF and urine proteins are also separated with routine electrophoresis. Using whole blood treated with a reagent to lyse red blood cells, variant and glycosylated hemoglobins can be detected. With different visualization methods, isoenzymes and lipoproteins in a serum sample can be identified.A manual agarose gel electrophoresis of eight serum samples is pictured below. After electrophoresis, the gel was stained with Ponceau S.

We have listed the 'classic' cardiovascular risk markers as LDL-C, HDL-C and triglycerides. But there are many more cardiovascular risk markers as well as cardiovascular risk factors. A cardiovascular risk factor is a condition (not a laboratory analyte) that is associated with an increased risk of developing cardiovascular disease. Examples include: Age Gender (males are at increased risk) Heredity Hypertension Cigarette Smoking Obesity Diabetes StressThere are also negative risk factors, factors which decrease a person's risk of cardiovascular disease. Examples include: Optimal HDL-C concentration Exercise Estrogen Moderate alcohol intakeThis course will not focus on cardiovascular risk factors. Instead we will focus on newer, emerging cardiovascular risk markers. There are well over twenty well-studied cardiovascular risk markers; in this course we will focus on some of the more established markers and the ones which are becoming more commonly measured in the clinical laboratory. These include apolipoprotein A1/apolipoprotein B100, Lp(a), oxidized LDL, LpPLA2, hsCRP and lipoprotein particle size and concentration.It is important to remember that the association between a cardiovascular risk marker and actually having or developing cardiovascular disease is a statistical one. The fact that a patient has a particular risk marker which is abnormal simply increases the probability of developing cardiovascular disease, it does not mean that he or she is certain to develop cardiovascular disease. Conversely, if an individual does not have a particular cardiovascular risk marker present it does not guarantee protection against cardiovascular disease. We must always remember that some percentage of individuals who have heart attacks or strokes will not have abnormal risk markers present.

C-reactive protein (CRP) is a very sensitive acute phase reactant. Serum CRP levels increase following a variety of pro-inflammatory events such as infection, tissue necrosis, trauma, surgery and even malignancy. CRP levels can increase quickly and dramatically (often 100 fold) during inflammation. CRP can activate compliment, bind Fc receptors and can function as an opsonin, enhancing phagocytosis with certain infections. Measurement of CRP is not new, it has been on clinical laboratory testing menus for decades. However, a newer version of the CRP test is now in use to assess cardiovascular risk.High sensitivity-CRP (hs-CRP) assays have been developed that are more sensitive to the more subtle changes that can occur during chronic vascular inflammation. (Recall that atherosclerosis is an inflammatory process.) By measuring hsCRP we can get a glimpse at vascular function. CRP has been shown to be an independent risk factor for atherosclerotic disease and cardiac death. A 2002 prospective study of more than 27,000 patients showed that the CRP concentration is a stronger predictor of cardiovascular events than the LDL-cholesterol level.

The INR component of the laboratory result is a calculated value that is used by the clinician to monitor anticoagulant therapy and adjust dosage as dictated by clinical status. An INR of 2.0 - 3.0 is often desired as the therapeutic range. The following formula is used by the clinical laboratory to derive an INR value. The INR must be adjusted for every new lot of PT reagent. INR= (PT of patient/PT of geometric mean of the normal population)ISI The International Sensitivity Index, or ISI value, is provided by the reagent manufacturer as the relative sensitivity of the reagent itself. The INR is used to standardize PT results, and in turn, anticoagulant therapy, across laboratory instrumentation, methodologies, and locale. Be sure to frequently check that ISI values match those of the lot currently in use as erroneous results may otherwise occur .

Much research has been conducted to identify the alphabet of the human cellular language otherwise known as the human genome. This identification or roadmap of the human genetic material has opened the door to the mainstreaming of molecular diagnostics within the clinical laboratory setting.While the mapping of the human genome project is complete, many times it is not necessary to be able to identify the entire sequence; rather, we can use the specific portion of the code that is unique to the disease or condition in question. These short portions of the genetic molecular sequence or oligonucleotides, can then be used as probes to seek out and detect or amplify the target sequence.

Molecular methodologies are continuously increasing in application in the clinical laboratory as well as other venues. Many methodologies have been developed and, depending on the target of interest, multiple methodologies may exist to assist in the determination of the same target of interest.

The importance of quality control is recognized by the federal government. Federal regulations, such as the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88), require successful participation in external quality control programs for clinical laboratories, regardless of size. These regulations are aimed at providing all citizens with the highest quality of health care and at the same time controlling costs.

As a clinical laboratory science worker in the state of Florida, you are bound by several sets of laws designed to protect you, your employer, and patients of the facility in which you work. This program summarizes the major pieces of legislation that govern Clinical Laboratory Science in Florida and explain how these laws affect you at your job. These are Chapter 483, Part III Florida Statutes: Clinical Laboratory Personnel, and Rules: Chapter 64B3, Florida Administrative Code. Important: This course is only a brief summary of Florida legislation. While every effort has been taken to include all relevant laws and requirements, we encourage you to review the complete legislation, available at http://www.doh.state.fl.us/mqa/ClinLab/clp_statutes.html.

The Board of Clinical Laboratory Personnel oversees clinical laboratory affairs in the state of Florida. The Board's seven members are appointed by the Governor of Florida to serve four-year terms. Five of the seven members are licensed clinical laboratory practitioners and the remaining two, referred to as "consumer members," have never been licensed as clinical laboratory personnel and have no connection to the laboratory profession. The Board has the authority to: Establish rules for clinical laboratory science Set the necessary qualifications for clinical laboratory science personnel, including higher education, training programs, and examinations administered by the Board Oversee clinical laboratory training program and continuing education providers Issue licenses to clinical laboratory personnel Collect fees for licensing, license renewals, and delinquent licenses Enforce penalties, including license suspension and fines up to $10,000, for violations of Board rules governing ethics in clinical laboratory science

To practice as a clinical laboratory scientist in the state of Florida, you must have an appropriate Florida license. Without a license, you cannot conduct clinical laboratory examinations or report test results. You do not need a Florida license to work in: Laboratories run by the federal government. Labs that perform only waived testing. Labs run exclusively for research and teaching purposes that do not report patient results.These laboratories may have other licensing and training requirements.

Licenses must be renewed every two years. To have your license renewed, you must show documentation that you have met competency and continuing education requirements and paid the renewal fee, which varies by license type: Director: $150Supervisor: $143Technologist: $121Technician: $82 Part of renewing your license is demonstrating your competency. This is done by completing Board-approved continuing education programs (such as this one). Depending on your license type, you'll have at least 24 hours of continuing education for each renewal period (two years). You'll find more information about this in the next section.

Committing any violation listed on the prior pages carries severe penalties. An individual's clinical laboratory license can be put on probation or permanently revoked, and fines can range from $300 to $10,000 per offence. A license can also be put on probation, meaning the individual may continue to practice but under limited circumstances. In addition, some violations listed in the previous pages carry criminal charges. These include: Felonies (3rd degree)Practicing as clinical laboratory personnel without an active license Using a suspended or revoked license to practiceAttempting to obtain a license by misrepresentationMisdemeanors (1st degree)Concealing information relating to violations on the preceding pagesLying to the BoardMisrepresenting one's self as a licensed clinical laboratory practitioner

Licensed as a technologist or meets the requirements to be licensed Completes a Board-approved two-hour course related to the prevention of medical errors that includes root-cause analysis, error reduction and prevention, and patient safety. Meets one of the following: Doctoral degree in chemical science, biological science, or clinical laboratory science + one year of laboratory experience in the category in which licensure is sought, and 25 hours of Board-approved continuing education in supervision and administration Doctoral degree in chemical science, biological science, or clinical laboratory science + one year of laboratory experience in the category in which licensure is sought, and DLM(ASCP) or CLSup(NCA) for all categories or ASCP specialty certification for the category in which licensure is sought Master's degree in chemical science, biological science, clinical laboratory science, or medical technology + three years of laboratory experience including one year experience in the category in which licensure is sought and either 25 hours of Board-approved continuing education in supervision and administration; or DLM(ASCP) or CLSup(NCA) for all categories or ASCP specialty certification for the category in which licensure is sought Bachelor's degree with 24 semester hours of academic science including 8 semester hours of biological sciences and 8 semester hours of chemical sciences + five years of lab experience, of which two must have been as a technologist and at least 1 year experience in the category in which licensure is sought, and either 25 hours of Board-approved continuing education in supervision and administration or DLM(ASCP) or CLSup(NCA) for all categories or ASCP specialty certification for the category in which licensure is sought.

When you apply for a license at any level, you must indicate one or more specialties. Each specialty has slightly different requirements, including which exams you can use to qualify for licensure. You can later add more specialties to your license by taking the appropriate exam. The following is a partial list of specialties available to clinical laboratory personnel: MicrobiologySerology / ImmunologyChemistry HematologyImmunohematologyRadioassay HistocompatibilityBlood BankingBlood Gas AnalysisCytologyCytogenetics HistologyMolecular PathologyAndrologyEmbryology

If a license is not renewed or placed on inactive status before the expiration date, it is considered delinquent. The license holder can remedy this by paying the delinquency fee and fulfilling continuing education requirements within two years. If this is not done, the license will be cancelled, and the former license holder will have to reapply for a license to work in a clinical laboratory in the future.

All licensed clinical laboratory personnel must earn at least 24 hours of continuing education credits every two years. These continuing education hours must be completed by time your license. Continuing education requirements include:At least one hour for each specialty for which you are licensedA two-hour course on medical errorsA one-hour course on laws and rules of the Florida Board (this course)A one-hour course in administration and supervision (directors and supervisors only)If you have just received your license, you do not need to complete this continuing education requirement during the first two-year period of your license, except for courses that may be required by your specialty.

A clinical laboratory director is responsible for the overall operation and administration of the clinical laboratory. The director can delegate responsibilities to licensed supervisors, but is ultimately responsible for the following: Ensuring the employment of personnel who have the necessary education and experience and who are competent to perform the procedures and tasks that are assigned to them. Overseeing performance and reporting of accurate test results Verifying the laboratory's compliance with federal and state laws, rules, and regulations Delegating certain administrative duties to supervisors Being available for on-site, telephone, or e-mail consultation Ensuring that test methods and procedures, quality control, and verification methods provide reliable and accurate results Ensuring compliance with quality control and quality assurance programs Ensuring enrollment and active participation of the laboratory in a proficiency testing program, monitoring proficiency testing results, and implementing corrective action when necessary Assessing laboratory staffing needs and advising management when insufficient clinical laboratory personnel are employed Selecting which tests the laboratory offers and which employees may perform them Establishing and maintaining a patient identification system for the laboratory Establishing and maintaining accurate billing practices

Clinical laboratory personnel must be licensed and competent to perform their duties. This means holding the appropriate type of license for the task being performed (director, supervisor, technologist, or technician) and being certified in the appropriate specialty for any testing being performed. For example, an individual licensed as a technician in hematology may not perform the duties of a technologist in hematology, nor may that individual perform testing in the microbiology specialty. Showing a lack of competence to perform even licensed duties is a violation of Board rules. Consistent errors can tarnish a laboratory's reputation, and even a single error can harm patient care. Licensed personnel must be certain that they can perform their duties accurately and competently. All of the following are violations of Board rules:Performing clinical duties for which one does not hold a license.Performing services one knows one is not competent to perform.Showing lack of competence or making consistent errors in testing or reporting.Having a license revoked or suspended in another state.

The accuracy and safety of patient testing depends on the capability and honesty of clinical laboratory personnel. If an individual's ability to perform testing is influenced by illness, injury, drug use (legal and illegal), or alcohol use, he or she may no longer practice. The Board can order a doctor's exam to determine if illness, injury, drugs, or alcohol is a factor. The individual can get his / her license back after recovery and proving that the condition is no longer a problem. If an individual commits a crime in any state relating to matters of honesty (such as filing false reports or advertising false services), that individual's Florida license may be suspended. Other licensed personnel who know that an individual is practicing despite being under the influence of drugs or alcohol, is physically or mentally incapable, has been convicted of a lab-related crime, or is not competent to perform his / her duties are required to report the individual to the Board. The following are violations of Board rules:Continuing to practice after becoming unable to safely perform testing because of illness or use of alcohol or drugs, or another mental or physical condition. Continuing to practice after being judged mentally or physically incapable.Being convicted of any crime relating to activities of clinical laboratory science or involving dishonesty or lack of morals. Failing to report to the Board that one has been convicted of a crime (as listed above), been judged mentally or physically incapable, or had a licensed revoked in another state. Knowingly allow an unqualified person to perform clinical laboratory duties.

Clinical laboratory personnel are extremely important in patient care. Physicians and patients must trust that all reports and test results provided by clinical laboratory personnel were obtained by competent, licensed individuals who are free from bias. The Board of Clinical Laboratory Science has strict rules regarding clinical laboratory personnel. A violation of these rules can result in fines, suspension, or even criminal and civil legal penalties. Please pay carefully attention to the next several pages, which cover these violations.

Daily Documentation and evaluation of quality control is vital to diligently monitor sources of error. One of the most commonly used methods for documentation is the Levey-Jennings control chart (often referred to as the L-J chart). In 1931, Dr. Walter Shewhart, a scientist at the Bell Telephone Laboratories, proposed applying statistical based control charts to interpret industrial manufacturing processes. In 1950, S. Levey and E.R. Jennings suggested the use of Dr. Shewhart’s control chart in the clinical laboratory.

On April 24, 2003, the Clinical Laboratory Improvement Amendments (CLIA) Final Rules went into effect.As of that date, each laboratory that introduces a nonwaived, unmodified, FDA-cleared or approved test system must do the following before reporting patient test results: Demonstrate that it can obtain performance specifications comparable to those established by the manufacturer for the following performance characteristics: Accuracy. Precision. Reportable range of test results for the test system. Verify that the manufacturer's reference intervals (normal values) are appropriate for the laboratory's patient population.