Drug Information and Courses from MediaLab, Inc.

The antinuclear antibody test (ANA) is a test used to screen for the presence of autoantibodies that are directed toward components in the nucleus of the cell. Clinicians use the ANA test to assess the likelihood that a given patient has a SARD. The results of the ANA test alone are not diagnostic for the SARD. The patient must also have clinical evidence of the disease as well. Because the early clinical presentation for many of the SARDs are nonspecific, the results of the ANA test and subsequent follow-up testing are key pieces to making the correct diagnosis.Rheumatoid arthritis (RA) is the most prevalent disease in this group; however, the ANA assay is not the primary laboratory test for RA. Instead, the test for RA looks for the presence of rheumatoid factor (RF) or more recently, cyclic citrullinated peptide antibodies (anti-CCP).For the other diseases in the SARD group, especially SLE and SSc, the results of the ANA test can be useful in determining a correct diagnosis. The utility of the ANA test is to detect the antibodies early in the disease process.The ANA results in conjunction with clinical presentation give the clinician solid evidence to intervene with an appropriate treatment. Studies have shown that once treatment is started, the formation of new antibodies slows or even halts.(Ref3)Currently there are no cures for the SARDs. Treatments primarily focus on keeping the patient comfortable and the immune response in check. Treatments can vary from non-steroidal anti-inflammatory drugs, to immuno-suppressive drugs, to stem cell transplants. Individual treatment is often dependent on the severity of the disease and the response to the selected drug regimen.

Treatment guidelines recommend that patients receive treatment if they have any of the following: Significant bleeding risk <20 x 109/L platelets and moderate bleeding <10 x 10 9/L platelets with no bleeding symptomsCorticosteroids are effective treatments for 50 - 80% of individuals with either acute or chronic ITP. Even with a reduction or discontinuation of corticosteroid treatment, remission can be maintained.Anti-D immunoglobulin, administered intravenously, may be an effective treatment for Rh-positive children or adults diagnosed with acute or chronic ITP. Anti-D immunoglobulin forms red blood cell complexes that block the destruction of platelets. This treatment cannot be used for patients who are Rh-negative or who have undergone a splenectomy. When a patient is refractory to the above treatments, other treatment possibilities include thrombopoietic drugs to stimulate the megakaryoblast or Rituximab, a treatment that targets CD 20-positive B-cells.Splenectomy may be a last resort treatment for chronic ITP sufferers if their platelet counts are below 30 x 109/ L or if symptoms warrant it. In ITP, antibodies develop that coat the platelets. The spleen produces macrophages whose Fc receptors recognize and destroy these antibody-coated platelets. Removing the spleen would decrease platelet destruction, but it is a last resort since the immunologic function of the spleen would also be lost.

Risk stratification in cardiac disease is the use of biomarker assays and other diagnostic testing of an individual with disease to predict risk of future disease and cardiac events. The results are also utilized in treatment and drug intervention plans. Studies conducted recently use multiple markers for risk stratification for patients with CHF, ACS, and previous AMIs. Multiple markers (BNP, NT-ProBNP, cardiac troponins, and hs-CRP) may be used in near future to predict short-term and long-term risks of cardiac disease and death. Serial troponin levels are currently measured in those with ischemia to determine the risk of AMI. Troponin levels are used to plan medical and surgical treatments.

Clinical and Laboratory Standards Institute (CLSI). Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically; Approved Standard-Eighth Edition. CLSI document M07-A8. Wayne, PA: 2009. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; Twenty-First Informational Supplement. CLSI document M100-S21. Wayne, PA: 2011. It is important to detect ESBL-producing stains of Klebsiella pneumoniae, K. oxytoca, Escherichia. coli, and Proteus mirabilis as treatment failure may occur if the wrong cephalosporin is selected. These enzymes have the ability to hydrolyze third-generation cephalosporins and aztreonam, but are inhibited by clavulanic acid. ESBL-producing organisms can also exhibit co-resistance to many other classes of antibiotics. In January 2010, the Clinical and Laboratory Standards Institute (CLSI) published revised cephalosporin (cefazolin, cefotaxime, ceftazidime, ceftizoxime, and ceftriaxone) and aztreonam interpretive criteria for Enterobacteriaceae. The criteria for cefepime and cefuroxime (parenteral) did not change. Laboratories using these new criteria detailed in the M100-S21 document, table 2A, published in January 2011, no longer need to routinely test for extended-spectrum beta-lactamases (ESBLs) prior to reporting results. IF using the new criteria, there is no longer a need to change the interpretive criteria for cephalosporin's, aztreonam or penicillin's from susceptible to resistant before reporting. IF reporting moxalactam, cefonicid, cefamandole, or cefoperazone for E. coli, Klebsiella, or Proteus species, ESBL testing should still be performed as outlined in CLSI document M100-S21, supplemental table 2A-S1. If these isolates test ESBL positive, they should be reported as resistant. These drugs have limited availability in many countries, so the interpretive criteria were not evaluated by CLSI. CLSI notes that ESBL testing could still be useful for epidemiology and infection control purposes. ESBL testing should also continue to be performed until the new CLSI interpretive criteria is implemented.

A urine specimen that has remained at room temperature for an extended period of time may produce a false-positive protein result on a reagent strip. A false positive may also occur in the presence of bacterial contamination, alkaline medication, or quaternary ammonium compounds such as disinfectants or drugs, and with skin cleansers containing chlorhexidine.

No blood is found in the urine of healthy individuals although samples from menstruating females, frequently, but not always, test positive for blood. Hematuria is associated with renal or genital urinary disorders in which the bleeding is the result of irritation to the involved organs or trauma. Examples include renal calculi, pyelonephritis, glomerulonephritis, tumors, trauma or exposure to toxic chemicals or drugs and/or strenuous exercise. Hemoglobinuria may be due to the lysis of red cells within the urinary tract. If it is caused by intravascular hemolysis, the hemoglobin is then filtered through the glomeruli. In the normal individual, the hemoglobin molecule attaches to haptoglobin and in this way bypasses the kidney filtration system. When the hemoglobin/haptoglobin system is overwhelmed, as in cases of hemolytic anemia, severe burns, transfusion reaction, infection or strenuous exercise, hemoglobin passes into the urine.

False negative results may occur in the presence of significant levels of protein or glucose and in urines with high specific gravity which may crenate the white blood cells causing them to be come unable to release esterases. Some drugs such as Cephalexin (Kelfex®), Cephalothin Keflin®) or high concentrations of oxalic acid may also cause decreased test results. Tetracycline may cause decreased activity, and high levels of the drug may cause a false negative reaction. Large amounts of ascorbate may cause false negative results.

The reagent strip test for bilirubin may not be sensitive enough to detect small amounts of bilirubin in urine, which may be present in the earliest phases of liver disease or viral hepatitis. The Ictotest® reagent tablet is more sensitive and is recommended when bilirubin in the urine is particularly of interest. False-positive results can occur in screening procedures for bilirubin due to color interference from large amounts of blood in the urine, very concentrated urine, or drugs that discolor the urine, such as phenazopyridine (Pyridium). Because of this, it is important to verify positive or questionable bilirubin results with a confirmatory method, such as the diazo tablet test, available commercially as the Ictotest®. Ictotest® will detect as little as 0.05-0.10 mg bilirubin/dL urine, making it the procedure of choice for confirming bilirubin in urine specimens.

The federal drug testing custody and control form (CCF) must be used to document every urine collection required by the Department of Transportation drug testing program. At the present time, these include the: Federal Motor Carrier Safety Administration (FMCSA) Federal Aviation Administration (FAA) Research and Special Programs Administration (Pipeline) (RSPA) Federal Transit Administration (FTA) Federal Railroad Administration (FRA) United States Coast Guard (USCG)

It should also be understood that a Federally Regulated CCF need not be used in every situation involving a company regulated by the Department of Transportation. For example, if an interstate truck driver slips and falls while standing on the loading dock of a trucking terminal, and the trucking company for which the driver works requires a post-accident drug screen, a Non-Federally Regulated CCF would be appropriate for this collection. The driver was not involved in a safety sensitive assignment. On the other hand, if the driver had an accident while driving, then a Federally Regulated CCF must be used since the driver was in a safety sensitive position when the accident occurred.

This program is intended to provide guidance and training to those individuals who will be conducting both Department of Transportation (DOT) and Department of Health and Human Resources (HHS) regulated urine specimen collections. While this program is more than just an overview, obvious restraints prohibit an in-depth discussion of every procedure or problem that might be encountered. This program only serves as a training program. It does not represent final authority. Every effort has been taken to keep this course up-to-date with current regulations. However, if anything in this program conflicts with the Urine Specimen Collection Guidelines, U.S. Dept. of Transportation, Office of Drug and Alcohol Policy and Compliance (Aug. 31, 2009), that reference prevails and must be followed.Training to qualify as a drug screen collector must include the flawless completion of five mock collections. These mock collections must include the following scenarios and must be performed in the presence of a qualified collector: Two uneventful collections. One collection in which the quantity of specimen is not sufficient. One collection in which the temperature of the specimen is out of range. One collection in which the donor refuses to sign either the donor certification on the Medical Review Officer's (pink) copy of the CCF or refuses to initial the security strips.

All collection sites must meet the following security requirements: Must be able to prevent unauthorized access to the site during collection. Ensure that the donor does not have access to items that could be used to adulterate or dilute the specimen (e.g. soap, water, cleaning agents, etc.) Secure faucets, toilet tank tops, and other appropriate areas with tamper-evident tape if necessary. Ensure that the donor is at all times under the supervision of the collector or other collection site personnel. Provide for the secure handling and storage of specimens. (Specimens should be stored at 4-6° C. The refrigerator used should not be readily accessible to the general public and should be used only for the storage of urine drug screens and other clinical specimens. The refrigerator should be marked with a biohazard sign. No food or drink should ever be placed in the refrigerator.)

Refusal to Complete Donor Certification on Pink Copy of CCF or Initial Security Strips.If the donor refuses to complete the donor certification on the pink copy of the CCF, or refuses to initial the security strips after they have been affixed to the specimen vials, this is not considered a refusal to test. Do not debate with the donor. It is the responsibility of the collector to note the fact in the "Remarks" section of the CCF. Failure to do so may result in a Fatal Flaw. The MRO may not release the results of the drug screen unless the collector has noted in the "Remarks" section why the donor certification was not completed.Refusal to Provide ID or Social Security NumberIf the donor refuses to provide the collector with an ID or Social Security Number, this is not considered a refusal to test. The collector must make a notation of the fact in the "Remarks" section of the CCF. Failure to do so may result in a Fatal Flaw. After making the notation, the collector continues with the collection.

Scenario 1:A donor was asked to wash her hands prior to picking out the drug screen collection kit. The collector noticed that the donor was washing only one hand.Collector's response:The collector tells the donor that not washing both hands is an indication of possible interference with the testing process and that it could be interpreted as a refusal to test. If the donor still refuses to wash both hands, the collector must stop the collection process, note the refusal on the CCF and notify the DER.Scenario 2:The donor was asked to remove his hat before going into the restroom. As he reluctantly did so, it was noticed that he was trying to conceal a container that was hidden inside the hat.Collector's response:The collector first explains the circumstances to a supervisor. If the supervisor concurs that an observed collection should be done, the collector then tells the donor that a directly observed collection will be conducted because his conduct indicated a possible attempt to adulterate, substitute, or dilute the specimen. The collector marks on the CCF that the collection was observed and notes under Remarks why it was observed.

Recent research has indicated that an appropriate dilution of sucrose solution when administered to an infant may serve as a pain relief measure. In some institutions, the nursing staff may require that an infant receive several drops of sucrose immediately prior to the puncture of a heel. This may release endorphins to relieve pain and reduce crying by the infant. Excessive crying may adversely affect some test results such as white blood cell count and capillary blood gases.If it is the policy of your institution to administer a sucrose solution, coordinate the timing of the dermal puncture with the administration of the sucrose solution by the clinical staff. Outpatients would also require the intervention of a nursing staff member to provide the sucrose solution. Phlebotomists are not licensed to administer medications or drugs. Therefore, it is typically NOT the responsibility or duty of the phlebotomist to administer sucrose solution. There may be contraindications for sucrose administration with some infants. Therefore, the clinical person in charge of the patient's care must determine if it is safe to administer the solution. As with all procedures, follow the policies and guidelines of your facility.

CE is very rapid, efficient, easily automated, computerized, and requires only a microvolume of sample. Again a cooling system is included in instrumentation to prevent problems associated with the heat generated as discussed previously. The resolving power of CE is another important advantage.Proteins can be separated with CE along with inorganic ions, amino acids, drugs, vitamins, carbohydrates, oligonucleotides, and DNA fragments.

Lipoprotein (a) is a modified version of LDL containing a unique protein, apolipoprotein (a). It was discovered in 1963 and is well-associated with vascular disease. Do not confuse apolipoprotein (a) with apolipoprotein A that is found on high density lipoprotein particles. Lipoprotein (a) is abbreviated as Lp(a). Lp(a) is an LDL particle whose ApoB molecule has formed a disulfide bond with another protein called Apo(a), see figure. Apo(a) is a protein very similar in structure to plasminogen. Numerous retrospective case control studies and prospective studies have shown Lp(a) to be an independent risk factor for vascular disease. This means that Lp(a) levels alone (not in conjunction with LDL, or patient risk factors) can predict cardiovascular risk. Lp(a) has been called the most atherogenic lipoprotein. Serum concentrations of Lp(a) are related to genetic factors; drugs and diet changes do not typically lower Lp(a) as they do LDL.

PT is a screening test that helps to assess the functionality of both the extrinsic and common pathways. The effectiveness and presence of factors I, II, V, VII, and X are assayed in this diagnostic test, as they are all found in the aforementioned pathways. The results of the PT test are used in conjunction with other diagnostic tests, as well as the clinical picture of the patient, to determine any hemostatic abnormalities that may be present.In addition to being an integral part of the coagulation disorder assessment process, the PT is also used to determine therapeutic effectiveness of the oral anticoagulant, warfarin. PT test results are reported as the number of seconds needed for a clot to form in the patient specimen using the laboratory's instrument/reagent system, and as the International Normalized Ratio (INR).

A platelet function assay (PFA) is a screening test for the evaluation of platelets/primary hemostasis. Common clinical applications include the following:Preoperative evaluation of platelet functionDetermining the presence of drug-induced platelet dysfunctionDetermining platelet functionality in high-risk pregnancyEvaluation of patients with suspected inherited or acquired platelet disorders such as von Willebrand diseaseEvaluation of a bleeding patientA PFA instrument is able to differentiate between drug-induced platelet defects and other platelet defects. PFA tests are superior to the bleeding time test. The bleeding time is often not reproducible and, in spite of attempts at standardization, remains prone to variations in test results between persons performing the test. It is also relatively insensitive to platelet function. The bleeding time cannot be used to identify patients who may have recently ingested aspirin or non-steroidal anti-inflammatory drugs or patients who may have a platelet defect attributable to these drugs. The bleeding time is used to assess platelet function, but may be affected by platelet quantity. NOTE: Aspirin, and some other drugs, may falsely prolong bleeding times. Patients must be asked about aspirin use, and be aspirin free for 7-10 days prior to testing, for valid results.

Molecular methods have been expanding into the arena of pharmacogenetics (pharmacogenomics). Pharmacogenetics is the study of human genetic variations and their corresponding affects on the pharmacology of a drug.

Molecular methodologies offer numerous advantages to the clinical laboratory. These include:Sensitivity: Amplification methodologies are particularly useful in increasing the sensitivity of a methodology and useful in the identification of target molecules of interest that are only present in low concentrations. Specificity: Molecular methods minimize false positive test results by targeting the specific molecule of interest.Turn around time: In comparison with standard traditional culture methods, molecular methodologies usually offer better turn around times from receipt to result reporting.Application: Broader application can be found with molecular methodologies such as infectious diseases, genetic testing, forensics, drug resistance, and tumor marker detection and monitoring.

Most sickle cell patients who have increased levels of HbF experience milder forms of the disease than do patients with normal or low levels of HbF. Therefore, the focus of molecular treatments for sickle cell is to increase the level of fetal hemoglobin (HbF). The only drug currently approved by the FDA, which is used to induce increased production of HbF, is hydroxyurea. Hydroxyurea is a myelosuppresent and a ribonucleotide reductase inhibitor. However, the mechanism of hydroxyurea's influence in HbF production is not well understood. Hydroxyurea may also contribute to reduction of vaso-occlusion.

Phlebotomy is considered the treatment of choice for patients with iron overload due to hereditary hemochromatosis (HH). Each unit of blood contains approximately 200 to 250 mg of iron. As erythrocytes are removed by phlebotomy, iron stores are mobilized and utilized in the production of new, circulating erythrocytes. Through periodic phlebotomies, stored iron is removed until iron-deficient erythropoiesis is induced. The initial, or iron reduction, phase of treatment typically consists of removing one unit (450 mL) of whole blood once or twice weekly. Prior to beginning phlebotomy, the patient's hemoglobin and hematocrit must be checked to ensure that the patient is not anemic. A sample for serum ferritin is also collected at this time.Initial treatment goals include inducing iron deficient hematopoiesis without the development of debilitating symptoms of anemia. A hemoglobin concentration of 10.0 to 12.0 g/dL is often used as a target range. The initial treatment phase continues until excess stored iron is removed and ferritin levels decrease to approximately 50 ng/mL. (13) Ferritin and hemoglobin levels are periodically monitored during this phase. The number of phlebotomies needed to reduce iron levels and induce anemia is related to the degree of initial iron overload. Patients may be referred to a hematologist or gastroenterologist during the initial treatment phase. Many patients receive therapeutic phlebotomy services in a hospital or doctor's office, but patients may also undergo phlebotomy at a blood center. Blood collected from persons with HH may be used for transfusion or as blood products if it has been collected from a facility with an approved variance from the US Food and Drug Administration. Not all blood centers have applied for or been granted this variance.(14)The initial treatment phase continues until excess stored iron is removed and ferritin levels decrease to approximately 50 ng/mL. Removal of excess stored iron may take from one month to three years.

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.

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.

Many public health and governmental agencies promote awareness and prevention as well as monitor HPV transmission and infections. Additional governmental agencies regulate clinical testing for HPV as well as prevention methods such as vaccines. Clinical organizations recommend testing protocols for the detection of carcinomas that can result from HPV infections. Agencies and organizations referred to in this course are: Centers for Disease Control and Prevention (CDC) Federal Food and Drug Administration (FDA) National Cancer Institute (NCI) American Society for Colposcopy and Cervical Pathology (ASCCP)

This slide shows a marrow aspiration smear with numerous ring sideroblasts. Normal red cell precursors have only one or at most two granules of iron in their cytoplasm. These abnormal red cell precursors have numerous iron containing granules in their cytoplasm indicating abnormal iron incorporation. This iron is actually incorporated into mitochondria. Ring sideroblasts can be seen in idiopathic sideroblastic anemia, and in sideroblastic anemia induced by drugs, lead poisoning, and alcohol abuse.

ABO antibodies are not usually produced by an infant until 3 to 6 months of age. Antibodies found in the sera of newborns are almost always IgG, passively acquired from the mother. Thus, serum testing of newborns is not performed. Anti-A and anti-B titers are highest at ages 5-10 years and then they gradually decrease. Thus, in elderly patients, ABO antibodies may be difficult to detect. In patients with hypogammaglobulinemia, some leukemias, lymphomas or patients who are taking immunosuppressive drugs, the expected antibodies may be weak or even absent, reflecting the low levels of gamma globulin in the patient's serum. As previously mentioned, these and other ABO typing discrepancies must be resolved before true ABO type can be determined.

Specialists in cytogenetics detect chromosome abnormalities and genetic disorders. Cytogenetics counseling may only be performed by an individual licenses in the cytogenetics specialty at the director level. Specialists in molecular genetics analyze DNA and RNA to find disease-related genotypes, mutations, and phenotypes in order to detect or predict disease and identify carriers. Specialists in histocompatibility test to determine tissue compatibility, prevent infections, and investigate and post-transplant problems. Techniques include blood typing, HLA typing, HLA antibody screening, disease markers, flow cytometry, crossmatching, HLA antibody identification, lymphocyte immunophenotyping, immunosuppressive drug assays, allogenic, isogeneic and autologous bone marrow processing and storage, mixed lymphocyte culture, stem cell culture, cell mediated assays, and assays for the presence of cytokines. Specialists in andrology and embryology examine gametes and embryos, including production, morphology, number, and motility, to address issues of fertility and infertility.

Offering or taking a bribe, kickback, bonus, commission, or inducement is against the rules of the Board and against the law. Many companies give away small promotional items, such as pens or note pads, to promote their products. This is legal, but be cautious about accepting more valuable items. This could be seen as a bribe. All of the following are serious violations of Board, state, and federal rules:Participating in any commissions, bonuses, kickbacks, inducements, or split-fee arrangements from physicians, health care providers, suppliers, hospitals, nursing homes, other clinical laboratories, pharmacies, and other facilities.Exploiting or influencing a patient for financial gain, including promoting, selling, or withholding services, drugs, or referrals.

Presence of three or more of these componentsComponentCriteriaAbdominal obesity: Increased waist circumferenceMen: > 40 inchesWomen: > 35 inchesElevated triglycerides> 150 mg/dL ordrug treatment for elevated triglyceridesReduced HDL-Cholesterol (HDL-C)Men: < 40 mg/dLWomen: < 50 mg/dLElevated blood pressure> 130/85 mm Hg or drug treatment for elevated blood pressureElevated fasting glucose> 100 mg/dL ordrug treatment for elevated glucose

The primary goal in treatment of those with metabolic syndrome is reduction of risk factors for atherosclerotic disease. If the person does not already have type 2 diabetes, prevention of diabetes is another critical goal in management and treatment. Lifestyle changes and medications are utilized to meet these goals.Lifestyle changes that reduce obesity are critical: increase physical activity, reduce the fat in the diet, and decrease calorie intake. Exercise provides benefits beyond just burning calories. Exercise stimulates anabolic metabolism, raises basal metabolism rate, decreases stress, and increases hormonal sensitivity. Cessation of smoking is also important.Often drug therapy is needed to address the patient's hyperlipidemia, hypertension, and/or hyperglycemia. Low-dose aspirin and other antiplatelet agents may be used to prevent thrombosis.

In 1988, Gen-Probe marketed the PACE® System, using non-amplified probes for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae. This product was later followed by the PACE® 2 product line.Amplified assays for both Chlamydia and Neisseria followed in subsequent years, offered by several manufacturers. Automation of at least some parts of the process made it more feasible for clinical laboratories to incorporate molecular methods into their test menus.Roche developed a polymerase chain reaction (PCR) methodology focusing on specific nucleic acid sequences for both organisms. The Roche COBAS® AMPLICOR assay, on a semi-automated platform, obtained Food and Drug Administration (FDA) clearance in 1999. The Abbott LCx® semi-automated platform, based on ligase chain reaction, was also introduced around the same time. Shortly thereafter, Gen-Probe offered their APTIMA Combo 2® Assay, an amplification assay that utilized target capture. Later on, the TIGRIS® automated system by PROCLEIX® was added to provide automated specimen processing, enhancing the efficiency of the product line. Becton Dickenson then entered the arena, with the ProbeTec™, another semi-automated system based on strand displacement amplification.Digene also marketed its hybrid capture assay for Chlamydia and Neisseria. Unlike the other commercial assays, this method did not amplify the target DNA sequence, but instead employed a chemiluminescent methodology to amplify the signal of RNA:DNA hybrids.

MRSA presents both clinical and infection control challenges. Because of the increasing incidence of MRSA strains, empiric treatment for serious staph infections is usually vancomycin in the hospital setting. Although PNA-FISH can identify Staphyloccocus aureus more rapidly, it cannot yet differentiate MRSA from methicillin-susceptible S. aureus (MSSA) strains. Early differentiation of MRSA from non-MRSA strains could allow for adjustment from broad spectrum antimicrobial therapy, and reduced risk of development of resistance. Hospital acquired infections have garnered increasing attention from many quarters; MRSA is one of several drug resistant organisms that are of concern. Many institutions have implemented active surveillance culture (ASC) protocols to identify carriers of MRSA, both upon admission, and throughout the hospital stay. Identified carriers are placed under precaution protocols, to minimize risk of transmission to other patients during the hospital stay. MRSA status is also an important consideration for those patients who are being discharged to another facility (long term care or rehabilitation centers). Identifying carriers sooner rather than later can reduce the risk of transmission by earlier implementation of precaution protocols and reduce delays in discharge (and length of hospital stay) in situations where carrier status is needed prior to discharge. PCR methodologies offer the prospect of providing screening results 24 to 40 hours sooner than culture methodologies, depending on the culture medium employed.

The 2009 H1N1 influenza virus was first detected in the United States on April 15, 2009.The virus was a unique combination of influenza virus genes never previously identified in either animals or people; they were most closely related to swine-lineage H1N1 viruses (hence the designation of "swine influenza"). However, epidemiological investigations of initial human cases did not identify exposures to pigs and it became apparent that this new virus was circulating among humans and not among U.S. pig herds.By April 21, 2009, the Centers for Disease Control and Prevention (CDC) began working on development of a new vaccine effective against this new strain. On April 24, 2009, the CDC uploaded complete gene sequences of the 2009 H1N1 virus to a publicly accessible international influenza database. At the same time vaccine development was occurring, work was also being done at CDC to help laboratories more quickly identify the 2009 H1N1 virus in patient samples. A real time PCR assay developed by the CDC was cleared for use by the Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA) on April 28, 2009.The development of an effective, rapidly performed molecular assay was critical, because a CDC evaluation of non-molecular rapid influenza assays indicated that while these tests were capable of detecting the novel H1N1 strain when present in high concentrations, the overall sensitivity was low. Positive results with these assays were useful, but negative results did not rule out infection with influenza.

Antibiotics inhibit bacterial growth by interfering with one or more cellular processes. Beta lactams are a large group of cell wall active antibiotics used to treat a wide variety of infections. S. aureus cell wall synthesis is dependent on the proper functioning of a number of enzymes. The beta-lactam antibiotics exert their effect by binding with one specific type of enzyme, transpeptidase, thus interfering with its ability to catalyze the final stage of peptidoglycan synthesis, resulting in defective cell wall formation. The beta-lactams comprise four main groups of antibiotics; all have the beta-lactam ring as their basic chemical structure: Penicillins (penicillin, oxacillin/methicillin, ampicillin and piperacillin) Cephalosporins Carbapenems Monobactams The spectrum of antimicrobial activity is dependent upon the particular structural modification of the beta-lactam ring. The transpeptidases are commonly referred to as penicillin-binding proteins (PBPs). Different bacterial species have distinct PBPs, resulting in very specific drug interactions.

The first step in treating patients with CDAD is to discontinue the causative agent wherever possible. The choice for initial antibiotic therapy depends on the severity of disease. Oral vancomycin or metronidazole remain the mainstays of therapy for C. difficile infection, with vancomycin reserved for patients with more severe disease and/or those who have not responded to metronidazole. Metronidazole is currently favored in guidelines from the CDC on the basis of cost and concern that oral vancomycin promotes colonization with vancomycin-resistant Enterococcus. Oral fluids (water and electrolytes) may be necessary to counteract fluid loss as a result of excessive diarrhea, which can quickly lead to dehydration. Patients with fulminant disease and toxic megacolon may require colectomy. Recurrence of C. difficile infection (CDI) is becoming an increasing problem. Most recurrences happen 7 - 14 days after completion of therapy, suggesting relapse rather than re-infection. If a patient develops a second episode of CDI following initial successful treatment, it is recommended that if possible, the same drug be used to treat the second episode. Contributing factors to recurrent CDI include: Continuing exposure to organisms either through re-infection (via contaminated environment or poor hand hygiene) or an endogenous source, such as C. difficile spores in GI tract. An inability to mount an adequate anti-Toxin A IgM and/or IgG antibody response (i.e., poor host immune response); a likely reason why CDI affects an increasingly elderly population. Unfortunately a vicious cycle can arise whereby the initial treatment prescribed, vancomycin or metronidazole, significally disrupts normal colonic flora reducing colonization resistance and leaving the patient vulnerable to the next recurrent episode.Other treatments including the use of probiotics or anion-exchange resins to absorb toxins, may work in some cases but none work in every case.The goal of all treatment is to reestablish normal colonic flora so as to control C. difficile (over)growth.

Clostridium difficile-associated diarrhea (CDAD) is a unique hospital infection that occurs almost entirely in patients who have received previous antimicrobial treatment. Anaerobic gut flora are crucial to colonization resistance, so any disruption of the normal colonic flora (through illness, therapeutic procedures or, most commonly, antibiotic use) is essential to the pathogenesis of C. difficile infection. The association of CDAD with antibiotic use is significant. Early attention (1970s) focused on clindamycin but later on (1980s,1990s & continuing today) the cephalosporins, especially third generation, and broad spectrum penicillins (e.g., amoxycillin/ampicillin) were also implicated. The risk of CDAD is increased if C. difficile is resistant to the particular antimicrobial. In the case of clindamycin, C. difficile resistance is variable. Risk of infection due to a clindamycin-resistant strain increases with use of the drug. For the third generation cephalosporins, C. difficile is universally resistant; thus, any toxigenic strain is capable of causing CDAD during cephalosporin use. Other less commonly implicated antibiotics are the macrolides, e.g., erythromycin, azithromycin, clarithromycin. However, prolonged courses of any antibiotics will increase the risk of disease. Even those antibiotics used to treat colitis (metronidazole, for example) have sometimes been reported to cause CDAD.The fluoroquinolones have been in use since the 1980s. Ciprofloxacin was approved in 1987, but it is only in recent years with the emergence of the epidemic strain 027/NAP1/BI, which is resistant to the fluoroquinolones, that this class of drugs has been implicated in Clostridium difficile disease. The fluoroquinolones were initially considered to be low risk but their use has been increasing, both with hospital inpatients and in the community, and fluoroquinolones are now implicated as a risk factor for C. difficile infection. The newer fluoroquinolones, e.g., gatifloxacin, moxifloxacin, have better activity against anaerobes, but poor in vitro activity against C. difficile, thus increasing the likelihood of CDAD. The CDC now recommends that all fluoroquinolones, as a class, be used sparingly as each poses an increased risk for CDAD.

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

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

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

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).

Therapeutic drug monitoring and pharmacogenomics are both pharmacy-related areas within the clinical laboratory. Although each is considered a sub-discipline within laboratory medicine, the two fields overlap significantly. In this course, we will provide an overview of each of these laboratory sub-disciplines and discuss the utility, rationale, and practice of each one.

The liver plays a major role in converting lipophilic nonpolar molecules (drug molecules) to more polar, water-soluble forms through a series of enzymatic reactions. Drug molecules can be modified by either phase I or phase ll reactions. Phase I reactions alter chemical structure by oxidation, reduction, or hydrolysis. Phase ll reactions conjugate drugs to create products that are water-soluble.

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.

Most drugs are not given as a single dose but are part of a regimen. It is the physician's responsibility to prescribe a drug so that the concentration of that drug reaches a safe and effective level. The dosing-goal for the prescribing clinician, if multiple doses of a drug will be given, is for both the peak and the trough drug levels to be consistently within the therapeutic range. If a drug is given at intervals that are the same as its half-life, it will take about 5 half-lives to reach steady state.

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.

Four major classes of drugs are frequently monitored by TDM: Antibiotics Anticonvulsants Immunosuppressants Cardiac medicationsThere are other drugs that are monitored by TDM that are not included in any of the above classifications, but the majority of TDM testing is performed for drugs that are included in one of these four categories.

Drug-binding proteins in serum can fluctuate in disease states. For example, if albumin levels fall, as can occur in liver failure or nephrotic syndrome, less albumin will be available for drug binding; a subsequent dose may produce a toxic concentration of free drug.The image on the right illustrates the loss of equilibrium between a protein-bound drug and a free drug when drug-binding proteins are diminished.Doses of drugs that are highly protein-bound may need to be adjusted in patients with lower drug-binding protein levels. Examples of some common drugs that are highly protein-bound include thyroxine, warfarin, diazepam, heparin, imipramine and phenytoin.

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).

Bioavailability refers to the amount of drug that actually reaches the circulation. It is calculated by comparing (in the same subjects) the area under the serum concentration - time curve (AUC) of an equivalent dose of the intravenous form and oral form. This is illustrated in the diagram on the right.For IV drugs, the bioavailability is 100%For oral medications, the bioavailability will be less than 100%, due in part to any of these reasons:* Oral drugs take longer to enter the circulation.* Oral drugs have slower absorption and distribution than IV drugs.* The amount of drug that is absorbed can depend on the status of the GI tract (stomach pH, presence of food, integrity/health of the intestines, speed of the GI tract, etc.)For oral drugs to be effective, bioavailability typically should be greater than 70%.Not all of a drug taken orally is able to have a pharmacologic effect; the dose would need to be higher than an IV dose.Since the absorption of an oral drug is slower than an IV drug and the drug takes longer to enter the circulation, clearing the drug will also most likely take a longer time.

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: Oral: One hour after drug is taken (assumes a half-life of > two hours) IV: 15-30 minutes after injection/infusion Intramuscular (IM): 30 minutes - one hour after injection

However, every patient is unique. Changes in the gut (if the drug is taken orally), genetic variations in the liver's metabolizing enzymes, and the status of organs (like the kidneys and liver) all affect how a drug will be handled by an individual. TDM helps to ensure that a dosing regimen is appropriate for a given patient.

TDM is not useful for these drugs or in these specific situations: Intracelluar drugs that need to be converted to active forms (like AZT) Drugs in which the effects last much longer than the serum concentrations of the drugs; examples include antineoplastics (cancer chemotherapies) and warfarin Narcotic pain medications where continued use can lead to tolerance such that the levels needed for pain relief in one person would be toxic to another person

Anticonvulsants typically have narrow therapeutic windows. When levels are too low, the risk for seizure remains present. Drug levels that are too high can depress the central nervous system and may even lead to coma. Examples of anticonvulsants that are monitored by TDM include: Carbamazepine (Tegretol) Valproic acid (Depakene) Phenytoin (Dilantin) Phenobarbital Primidone (Mysoline)

Inotropics (drugs used to increase the pumping ability of the heart) and antiarrhythmics may need TDM. The cardiac glycoside inotropics digoxin and digitoxin have narrow therapeutic windows. Overdose can cause vomiting, diarrhea, confusion, visual disturbances, and cardiac arryhthmias. Examples of cardiac medications that are monitored by TDM include: Digoxin Digitoxin Procainamide N-Acetylprocainamide (NAPA) -the metabolite of procainamide Quinidine

Fluoresence polarization immunoassay (FPIA) is also a homogenous competitive immunoassay. In this system, fluorescein-labeled drug competes with unlabeled drug from the patient's serum sample for binding sites on an antibody reagent. The patient's sample, presumably containing the therapeutic drug that is being monitored, and the fluorescein-labeled drug are added to a chamber containing antibody for that drug. The labeled and unlabeled drug will compete for binding sites on the antibody. The greater the amount of drug in the sample, the fewer the number of binding sites that are available for the labeled analyte, leaving a greater number of small, free fluorescein-labeled molecules in the solution.When the chamber is excited with plane polarized light, fluorescein will absorb the light and emit it at a higher wavelength as fluorescent light. A small, free fluorescein-labeled drug rotates randomly and faster than it would if it were bound to antibody, interrupting the light and leading to less emission of light. The larger antibody-drug-fluorescein complexes rotate slower and emit more light in the measured plane. A lower level of drug in the patient's sample results in greater emission of polarized light because there are more antibody-drug-fluorescein complexes present to produce light in the measured plane. A higher level of drug in the patient's sample results in a lower emission of polarized light. This inverse relationship between the concentration of the drug and the polarization units (signal) is illustrated in the image below.

It has been said that we live in a new era of "individualized medicine." One of the primary drivers for this idea is the emerging field of pharmacogenomics (PGx). PGx is the study of how individual variations in the human genome affect responses to medications. The term "pharmacogenetics" is also used for this discipline (people in the field use both terms); however, the term 'pharmacogenomics' is becoming more popular since we now know the entire human genome. The primary reason that individuals metabolize and respond to drugs differently is the inter-individual differences in receptor proteins and enzymes that metabolize the drugs. Mutations in these receptor proteins and enzymes can give rise to very different responses to drugs. In PGx, these mutations are referred to as variants.

Many CYP450 enzymes have been characterized, and the substrates (drugs) that each can recognize have been worked out to a large extent. These subfamilies of CYP450 enzymes have all been associated with polymorphisms that can affect drug disposition: CYP1A2, CYP2C9, CYP2C19 and CYP2D6.

When discussing PGx, we classify a person according to his/her phenotype (metabolic capacity for a given enzyme).A poor metabolizer (PM) is a person who lacks the functional enzyme and therefore exhibits decreased metabolism of drugs. This person would require lower doses of a drug that is metabolized by that enzyme. A PM who receives a standard dose is more likely to experience unwanted side effects or toxicity. A PM can also experience diminished effects with drugs that need to be metabolized to active compounds by the enzyme in question.An ultrarapid metabolizer (UM) will require a higher dose than usual since he/she will eliminate the drug more quickly. A UM may be resistant to standard treatments, and it may take some time to adjust the dosage before therapy is achieved.An intermediate metabolizer (IM) has one wild-type (normal) copy of the gene and one absent or dysfunctional copy. The IM group is very heterogeneous.A person with normal enzyme activity is referred to as an extensive metabolizer (EM). This person should respond to standard dosages of a drug. Most people are EM's. This is the population in which most dosing regimens have been worked out in clinical trials.

Genotyping can give us a definitive profile of a given CYP450 enzyme's mutations. But since there are dozens of mutations usually associated with each enzyme, a complete characterization of a CYP450 is not always realistic. Without complete sequencing of the entire allele, it may not be possible to entirely rule out a mutation in a patient who shows none of the more common polymorphisms. If we consider the number of possible mutations and the possible presence of inducing/inhibiting substances, phenotyping for drug metabolism may sound more reasonable than genotyping.

By knowing a patient's disposition to specific drugs, the physician should be able to start the patient on an appropriate regimen rather than perfecting treatment based on trial and error. Drugs whose metabolism may prove to be problematic can be avoided, and second-line therapies that are metabolized by different, unaffected enzymes can be chosen. Clinical chemists, pharmacologists, and physicians need to translate knowledge of CYP450 polymorphisms into clinically-validated treatment algorithms. Dosing recommendations for PM, EM, IM and UM patients are beginning to appear in the literature for various classes of drugs, and the FDA is encouraging the incorporation of pharmacogenomic testing in the development process for new drugs.

The genes involved in warfarin metabolism are CYP2C9 and vitamin K epoxide reductase complex subunit 1 (VKOR). Warfarin owes its anticoagulant action to its inhibition of VKOR. This enzyme recycles vitamin K, a critical element for the clotting factors II, VII, IX, and X, as well as for proteins C, S, and Z. There are six CYP2C9 alleles that are known to cause prolonged metabolism of warfarin: CYP2C9 *2, *3, *4, *5, *6, and *11. (Polymorphisms in CYP450 genes are denoted with asterisks.)One-third of the patients that receive warfarin metabolize it differently than expected and experience a higher risk of bleeding.Genetic testing for the two most common polymorphisms (CYP2C9*2 and *3) as well as for VKOR may be able to reduce the variability associated with warfarin dosing response. Labs performing PGx testing can provide general warfarin dosing recommendations based on the patient's genotype analysis. The lab report will indicate whether a patient has a normal, mild, moderate, high, or very high sensitivity to warfarin. For example, a patient who has one CYP2C9 normal wild-type allele (CYP2C9 *1), one polymorphism (CYP2C9*3), and also a VKOR polymorphism is predicted to have a moderate sensitivity to warfarin. This patient should have frequent INR monitoring and possible warfarin dose reduction. It is important to recognize that knowing a genotype does not necessarily guarantee accurate dose prediction; other drugs and/or environmental or disease factors can also alter CYP2C9 activity. Therefore, monitoring the INR is still very important.

Phenotyping involves measuring the metabolism of a probe drug. For example, with CYP2D6, dextromethorphan or debrisoquine can be given to a patient to see how well the drug is metabolized. Both these drugs are safe and extensively metabolized by CYP2D6. By measuring the parent drug and the metabolite in urine, the metabolic capacity of a CYP450 enzyme can be estimated. Such testing is complex and tedious, however, and has not become routine in clinical laboratories. Therefore, genotyping is likely to be the main tool that is used for assessing the PGx of a patient.

Drugs and toxins including therapeutic drugs and drugs of abuse may be present in the plasma. Other substances too numerous to mention are also present in plasma.

A trough level is drawn immediately before the next dose of the drug is administered.A peak level is drawn 1 to several hours after the drug is administered (depending on the drug).

Physicians need to know the blood concentration of certain drugs in order to select the best dose for their patients.As a phlebotomist, you might be asked to draw peak (highest), and trough (lowest) levels of various therapeutic drugs.

There are numerous applications for real-time PCR in the laboratory for both diagnostic and research purposes. Diagnostic applicationsReal-time PCR can rapidly detect nucleic acids that are diagnostic of infectious diseases, cancers, and genetic abnormalities. Real-time PCR has allowed for viral quantitation of infectious and newly emerging diseases such as influenza A H1N1 subtype. In malignant diseases, real-time PCR can be performed directly on genomic DNA to detect translocation-specific malignant cells. For RNA samples, real-time PCR has become extremely important for the detection and monitoring of HIV, hepatitis C and CMV. Real-time PCR can also be used for array verification and drug therapy efficacy. Research applicationsIn a research setting, real-time PCR is primarily used to measure gene transcription. The technology is commonly used to determine genetic expression of a particular gene over time in response to different pharmacologic agents or environmental conditions and can also be used to compare gene expression in exposed and unexposed individuals. The use of real-time PCR in this manner can help researchers find and detect diagnostic or prognostic indicators to increase the understanding of disease pathogenesis.

Several federal agencies share responsibilities for oversight of the healthcare industry in the United States. These agencies include: U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services- Responsible for regulating clinical laboratory testing through the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Food and Drug Administration (FDA)- Responsible for protecting public health through regulation of food, drugs, vaccines, blood and blood products, medical devices, and more. U.S. Department of Labor Occupational Safety and Health Administration (OSHA)- Ensures safe working conditions in healthcare as well as other industries. Some of the federal laws/regulations that affect clinical laboratories in the United States and relate either directly or indirectly to risk management include: Clinical Laboratory Improvement Amendments of 1988 (CLIA) Health Insurance Portability and Accountability Act of 1996 (HIPAA) OSHA standards for hazard communication, chemical hygiene, and bloodborne pathogens Safe Medical Devices Act of 1990 (SMDA) The Patient Safety and Quality Improvement Act of 2005

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).

The laboratory plays an important role in monitoring the level of therapeutic drugs. Communication with clinical personnel is critical. Blood specimens are collected at specific time intervals to determine the trough level and peak levels of the drug. The pharmacist uses these trough and peak values to adjust the dose of the drugs appropriately.It is the responsibility of the phlebotomist to obtain the specimen at the precise time ordered for the specific peak or trough drug level. With some drugs, altering the draw time by even 15 minutes can have an adverse affect on adjusting and administering the next drug dose.Obtain the specimen at the requested time. If the time is missed, ask the clinical staff if the test should still be obtained or if another draw time is desired. If the clinical staff still wants a specimen collected, make a note of the time the drug was administered in relation to when the specimen was collected.Failure to communicate could have an adverse effect on the patient who may be given too little or too much medication based on an erroneous test result.

Let's briefly review using p values in medical research. A simple example would be a randomized clinical trial to assess whether a new drug decreases levels of low-density lipoprotein (LDL) more than an established drug. Data are collected from subjects treated with new Drug A and established Drug B. Let's suppose that the mean LDL of Drug A is lower than that of Drug B. We want to know whether the difference is due to an effect of Drug A or if the difference is due to chance. There is no way we can ever be certain whether the observed difference reflects a true difference (Drug A is more effective in lowering LDL) or is just a coincidence of random sampling. All we can do is calculate probabilities (the p value) based on a null hypothesis. A null hypothesis states that there is no difference between the drugs. The p value is the probability of observing a difference as large or larger than was observed in the study, if the null hypothesis of no difference were true.

The CDC not only monitors the influenza A 2009 H1N1 virus, but also provides guidance to physicians, public health/healthcare employees, and the general public. The CDC also ensures that there are sufficient quantities of medicines and medical supplies in the event of a public health emergency. The branch in charge of stockpiling and dispersing these supplies is called the Strategic National Stockpile or SNS, which is a division of the CDC. During the outbreak of the H1N1 virus, the SNS dispersed antiviral drugs and respiratory protection devices and other personal protective equipment (PPE) across the United States as well as U.S. territories to assist in the response to the Influenza A 2009 H1N1 virus.

Increased numbers of cuboidal cells are found in renal transplant rejection, acute tubular necrosis (diuretic phase), injuries that interrupt blood flow to the kidney, and acute glomerulonephritis accompanied by tubular damage. Ingestion of various drugs and chemicals may cause significant tubular shedding of these epithelial cells. Cuboidal cells are easily seen in urine in cases of salicylate intoxication.

The characteristics of the more common types of abnormal crystals are summarized in the table below. CrystalColorSignificanceLeucineYellowMetabolismTyrosineColorless–yellowLiver disease (rare)CystineColorlessCystine metabolismCholesterolColorlessRenal tubular diseaseBilirubinGold-orangeIncreased bilirubinHigh doses of ampicillin, sulfonamide drugs, or other drugs may also result in urine crystal formation. It is important to check the patient's current medications when unusual crystals are found in the urine specimen.

Transfusion of blood components has the potential for both benefit and risk to the patient. According to the FDA Annual Summary of Fiscal Year 2009, 74 fatalities were reported following blood transfusions; forty-four of those fatalities were transfusion-related. Medical errors that could result in transfusion reactions include: Patient misidentification Sample labeling error Wrong blood type issued Transcription error Technical error Storage error Transfusion policies and procedures must be carefully followed to reduce transfusion reactions and prevent transfusion related death or serious injury.Several causes of transfusion-related deaths are summarized in the table below.Reference: U.S Food and Drug Administration. (2009). Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2009. Retrieved from http://www.fda.gov/downloads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/UCM205620.pdf. Accessed April 26, 2011.

Harmening, DM. Modern Blood Banking and Transfusion Practices. 5th ed.Philadelphia, PA: FA Davis; 2005.Hillyer CD, Silberstein LE, Ness PM, Anderson, KC, Roback, JR. Blood Banking and Transfusion Medicine: Basic Principles and Practice. 2nd ed. Philadelphia, PA: Churchill Livingstone; 2007.Roback JD, Combs MR, Grossman BJ, Hillyer CD ed. AABB Technical Manual. 16th ed. Besthesda, MD: AABB; 2008.Rudman, SV. Textbook of Blood Banking and Transfusion Medicine. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.U.S. Food and Drug Administration. Blood Products Advisory Committee. April 27, 2007. Available at: http://www.fda.gov/ohrms/dockets/AC/07/briefing/2007-4300B2_01.htm. Accessed December 15, 2010.U.S. Food and Drug Administration. Infectious Disease Tests. 2009. Available at: http://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/BloodDonorScreening/InfectiousDisease/default.htm. Accessed December 15, 2010.U.S. Food and Drug Administration. Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2009. Available at: http://www.fda.gov/downloads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/UCM205620.pdf. Accessed December 15, 2010.

In 2005, a report from the Centers for Disease Control and Prevention (CDC) stated that "one of the most critical risks for health care-associated transmission of Mycobacterium tuberculosis in health care settings is from patients with unrecognized TB disease who are not promptly handled with appropriate airborne precautions or who are moved from an AII [airborne infection isolation] room too soon."*These fundamentals of infection control have proven to substantially reduce health care-associated transmission of TB, including multi-drug resistant TB:Use of standardized anti-tuberculosis treatment regimens in the initial phase of therapyRapid drug susceptibility testingDirectly observed therapy in which a health professional watches a patient swallow each dose of medication and records the date that the administration was observedImproved infection control practices *Reference: Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. The CDC website. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf. Accessed November 1, 2012.

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.

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.