Guidelines Information and Courses from MediaLab, Inc.

Slide-based ANA testing using a cell substrate started in the 1950s and continues to be the gold standard method. In the early days of ANA testing, rodent tissue (stomach, liver and/or kidney) was commonly used as the substrate. Rodent tissue however had several drawbacks such as small cell size, a lack of dividing cells (mitotics) and poor antigen expression that made interpretation of ANA patterns difficult. In the 1980s, cultured cell lines were examined for utility as an ANA substrate and the human epithelial- like cell line HEp-2 gained popularity. HEp-2's advantages over rodent tissue are: A large nucleus Better antigen expression Abundant mitotic cells that assist in interpretation of the ANA pattern (if grown properly).More recently a cell line called HEp-2000® has become popular for ANA detection. HEp-2000® is a HEp-2 cell line that has been transfected with the cDNA for overexpression of the SSA/Ro antigen. This results in a substrate with all of the original advantages of HEp-2 plus an added advantage of increased sensitivity for detection of antibodies directed to the SSA/Ro antigen and the ability to identify these clinically significant antibodies during the screening process.(Ref4)It has also been demonstrated that antibodies to SSA/Ro develop early in the disease process.(Ref5) Perhaps most importantly, if a woman has anti-SSA/Ro antibodies and becomes pregnant there is a risk of the antibodies crossing the placenta, resulting in the fetus developing neonatal lupus and congenital heart block in utero.The advantage of using these transfected cells is documented in the current Clinical and Laboratory Standards Institute (CLSI) guidelines for ANA testing. Here they note the "dramatically increased" sensitivity of transfected cells for the detection of SS-A/Ro and the unaltered effect of transfection on other ANA patterns.(Ref6)

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.

The focus of this course will be on the technical process of producing human tissue blocks embedded in paraffin wax. Other embedding techniques using various media such as gelatin, ester wax, polyethylene glycol, and epoxy resin are also used in some histological techniques. However, in this course we will be discussing the method of embedding human tissue samples in molten, or melted, paraffin wax. This is the most commonly utilized method for routine tissue embedding and is the method most utilized in nearly all hospital histopathology laboratories for processing human tissue samples for diagnostic interpretation.In the order of events (chronology) of the total histology process, paraffin embedding takes place following tissue processing and prior to and in preparation for microtomy. For proficiency in paraffin embedding, the histologist needs:An understanding of basic anatomy for use in tissue type orientationKnowledge of basic tissue sampling methods used in gross dissectionTo develop manual dexterity and spatial reasoning in order to correctly orient the specimen in the tissue block for microtomyThis course will introduce and review some of the essential background information needed for correct embedding technique. Also discussed in this course will be guidelines for orientation of common histology specimens. Mastery of this information facilitates practice and application of these concepts during execution, to increase the histologist's technical proficiency at paraffin embedding in the histology laboratory.

Specimens with a longer side versus width, such as core biopsies, are ideally arranged in parallel rows perpendicular to what will be the long axis of the slide.Larger specimens should be embedded face up or face down, making sure they lie flat and are in one plane.Multiple fragments of any specimen should be embedded within the same level and in a manner to show the most surface area.Lumen openings must be embedded in cross-section.Stratified layers should be embedded on edge to show all layers.Place at an angle any dense, rigid, or brittle specimens to aid microtomy.Leave a large perimeter of paraffin, especially around fatty specimens.Special orientation instructions are best given in relationship to the block face.If there are questions or concerns about orientation, it is always best to hold the specimen and ask for assistance from the grossing pathologists' assistant (PA) or pathologist to avoid losing important diagnostic information due to incorrect orientation.

Many organizations and agencies provide service in healthcare issues relating to cardiac and vascular disease. They provide guidelines, recommendations, and updates on research. Organizations and agencies whose guidelines and recommendations are referenced in this unit are: American Association of Clinical Chemistry (AACC) American College of Cardiology (ACC) American Heart Association (AHA) Centers for Disease Control and Prevention (CDC) European Society of Cardiology (ESC) International Federation for Clinical Chemistry (IFCC) World Health Organization (WHO)

Cardiac troponins are the preferred marker. CK-MB (specified as mass measurement) is an acceptable alternative when cardiac troponins are not available. The 2007 ESC/ACC/AHA guidelines recommend use of cardiac markers to detect myocardial necrosis in the following manner: Elevations of cTnI or cTnT over decision limit on one occasion in the first 24 hours after chest pain. Elevations of CK-MB (specified as mass measurement) over decision limit on two successive samples or one sample that is two times the upper limit of normal during the first hours following chest pain. The CK-MB levels should exhibit a rising or falling pattern to be diagnostic. If the CK-MB levels do not fall, it is likely not an AMI.Healthcare facilities and cardiology staff develop their own criteria for AMI diagnosis and treatment based on these guidelines. Many facilities assay both cardiac troponin and CK-MB biomarkers and may request serial troponin levels to find two elevations similar to guidelines for CK-MB.

Important safety precautions must be observed when handling cerebrospinal fluid. The following guidelines apply:Semi-automatic micropipettes and disposable plastic chambers are the safest option for CSF testing. Many laboratories still use the hemacytometer with disposable pipets.If disposable materials are not used, soak contaminated reusable pipets, hemacytometer and coverslip in 70% alcohol or Wexide.All disposable items should be placed in a biohazard container for appropriate disposal.Wash hands thoroughly when the examination is completed.Spinal fluids which are to be discarded must be placed in biohazard containers for appropriate disposal.Careful attention to specimen processing and handling will help ensure that accurate results are obtained.

In order to ensure proper stability of the specimen and accurate test results, there are guidelines in place to aid in the appropriate urine processing and transportation. These guidelines include: Ensuring that all urine collection and/or transport containers should be clean and free of debris or interfering substances.Ensuring that the collection and/or transport container has a secure lid and is leak resistant. Leak-resistant containers reduce specimen loss and healthcare worker exposure to the specimen while also protecting the specimen from contaminants.Utilizing urine containers that are made of break-resistant plastic instead of glass.Utilizing urine containers that do not leach interfering substances into the specimen.Utilizing collection containers and/or transport tubes which will not leak within the pneumatic tube system (if one is used within the laboratory facility). A leak-proof device in this situation is paramount.Proper labeling and correct identification should be applied to the collection container or tubes. This includes noting the time the specimen was collected. Remember that urinalysis specimens must be analyzed within 2 hours of collection.Ensuring that there is sufficient volume to fill the tubes and/or perform the test.

Fortunately, the great majority of collections are uneventful, but from time to time problems or the unexpected occur. This section will discuss a few examples of special situations that may take place during a collection and what the response of the collector should be. Obviously, not every special situation can be envisioned or discussed. It is strongly recommended that the collector be very familiar with the Department of Transportation publication: Urine Specimen Collection Guidelines dated October 1, 2010.

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.

Deciding how many classes to use for grouping the data is a compromise between the extremes of too much detail (each observation in its own category) and not enough detail (only one category). Most frequency tables are constructed according to the following guidelines: For most data, 6 to 15 classes are enough Class intervals (lengths) should be equal. Intervals such as 0.1, 0.2, 0.5, 1, 2, 5, 10, 20, 50, etc are desirable. The starting point for each class should be divisible by the interval, For example, in the class 15 - 20, the starting point, 15, is divisible by the interval, 5. Each observation must fit into only one class. When a large number of points falls around a certain value, make this value the approximate center of the frequency distribution.For the data in our example, the minimum is 65 and the maximum is 114, a range of about 50. We can therefore choose intervals of size 5, and have ten of them. Our classes are 65 - 70, 70 - 75, etc.

These are the ranges that are recommended by the 2010 ADA Clinical Practice Guidelines for determining increased risk for diabetes: Glucose test Range indicating increased risk for diabetes Fasting plasma glucose 100 - 125 mg/dL 2-hour plasma glucose following 75g glucose load 140 - 199 mg/dL HbA1C 5.7 - 6.5%

How do physicians interpret risk marker results? Assuming the laboratory offers, and physicians order, cardiovascular risk marker tests, how are these results used? The National Cholesterol Education Program periodically assembles scientists and physicians to create lipid treatment guidelines for patients. These panels are referred to as the Adult Treatment Panel (ATP). The third assembly of the ATP did not give specific guidelines regarding risk marker use in patients but they did acknowledge their potential utility. The general consensus is that novel cardiovascular risk markers should be used in selected patients, such as those who already have significant risk factors (hypertension, smoking, obesity, etc.) or in patients who have family histories of cardiovascular disease. The value in using risk markers is that they will not only uncover cardiovascular risk but they can also be used to motivate patients to alter lifestyle and diet. It is expected that as these emerging cardiovascular risk markers continue to be validated in clinical studies, they will become very useful and perhaps even be part of a new standard of care for patients.If risk marker levels can be correlated to treatment strategies, physicians will find them especially useful in tracking patient success.

It is imperative to follow the individual package insert procedures when collecting and handling specimens. Reference laboratories provide specimen requirements as well as collection, handling, and transport guidelines.The Clinical and Laboratory Standards Institute (CLSI) has published procedures for collection, including those specific to molecular diagnostics.

Protocols for testing newborns vary internationally and within countries. The table below summarizes some of the more common protocols. Scenario Typical Newborn Testing Protocol Comments Mother is D-negative with no unexpected antibodies Newborn is tested at delivery for: ABO and Rh Test for weak D (mandatory) if initial Rh typing appears to be D-negative Direct antiglobulin test (DAT)* A positive DAT does not always mean that the newborn has clinically significant hemolysis. A positive DAT commonly occurs due to ABO incompatibility, yet infants seldom require treatment. Infants born to mothers who received antenatal RhIg sometimes have a positive DAT that does not cause clinically relevant hemolysis. Mother is Rh positive and a blood group other than group O Routine testing not performed Cord blood retained for a specified period of time (e.g., seven days) in the event that the mother has an unexpected antibody at delivery or the newborn develops signs of red cell hemolysis. Routine testing would result in many positive DATs due to ABO incompatibility- not clinically significant. Mother is group O Rh positive Newborn is tested- especially important if women and their infants are discharged within 24 hours since hyperbilirubinemia due to ABO HDFN may develop later. Optional only if there is appropriate surveillance and risk assessment before discharge and provided there is follow-up (American Academy of Pediatrics). *Policies for DAT testing of newborns whose mothers have received antenatal RhIg vary internationally. For example, the British Committee for Standards in Haematology guidelines state that a DAT should not be performed on cord blood routinely since in some cases it may be positive due to antenatal RhIg prophylaxis. A DAT is recommended only if HDFN is suspected because of a low cord blood hemoglobin or the presence of unexpected maternal antibodies. However in North America, DATs are always performed on infants born to Rh negative mothers who are RhIg candidates.

Transferrin saturation (TS) is usually reported along with the serum iron (SI) and total iron binding capacity (TIBC). TS indicates the percent of iron binding sites on transferrin that are carrying iron. TS is derived from a calculation using the formula:TS =(SI/TIBC) x 100TS results are reported as percentages. Typical reference intervals for TS are 20% to 55% for males and 15% to 50% for females. TS is currently considered to be a good test for screening persons for hereditary hemochromatosis (HH) due to its sensitivity and specificity for iron overload. It may be elevated prior to significant deposition of tissue iron. TS levels increase as additional iron is accumulated.A drawback to using the TS is that it is dependent on performing both the SI and TIBC. The unsaturated iron-binding capacity UIBC may be a lower cost alternative.The optimal TS criterion for detecting HH is controversial. Using a TS of >60% for males and >50% for females has been found highly accurate in detecting abnormal iron metabolism in persons with HH. Others studies suggest using lower TS levels, e.g. 45%, as a criterion indicating further testing is warranted. Current guidelines from the American College of Physicians include a TS cutoff level of >55% for identifying iron overload. (11)Patients with initially increased TS should be followed by performing a second TS from a fasting morning specimen. The patient should also be advised not to take vitamins supplemented with iron or oral contraceptives for several days prior to the repeated test. TS levels may be affected by diurnal variation, dietary factors, and co-existing disease states such as inflammation and hepatitis. Patients with HH may have falsely normal TS if chronic blood loss or inflammatory disease is present.

Microwave ovens and guidelines for their usage vary among laboratories. However, the following tips are useful for all technicians using the microwave for special staining procedures: Microwave ovens heat solutions unevenly from the inside out. If possible, stirrers should be used while heating solutions. If stirrers are not available, the solution should be pipetted to mix the solution and even out the distribution of heat. The temperature at which solutions and tissue are placed in the microwave affects the length of heating time. More time is needed to reach a specific temperature for refrigerated materials than for room temperature materials. Never use metal containers because they reflect the microwaves and shield the solutions from heating. Containers used in a microwave oven should be open, vented, or loosely covered to prevent pressurization.

Microwave ovens and guidelines for their usage vary among laboratories. However, the following tips are useful for all technicians using the microwave for special staining procedures:Microwave ovens heat solutions unevenly from the inside out. If possible, stirrers should be used while heating solutions. If stirrers are not available, the solution should be pipetted to mix the solution and even out the distribution of heat.The temperature of solutions and tissue that are placed in the microwave affects the length of heating time. More time is needed to reach a specific temperature for refrigerated materials than for room temperature materials.Never use metal containers because they reflect the microwaves and shield the solutions from heating.Containers used in a microwave oven should be open, vented, or loosely covered to prevent pressurization.

Behrens C, Kindrick A, Harrington R. Antiretroviral Resistance Testing in the Management of HIV-Infected Patients [PowerPoint]. Northwest AIDS Education and Training Center; July 2006. Available at http://aidsetc.org/aidsetc?page=etres-display&resource=etres-9. Accessed December 15, 2008. Coffey S. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents: Initiation of Therapy [PowerPoint]. AIDS Education and Training Centers, National Resource Center; November 2008. Available at http://aidsetc.org/aidsetc?page=etres-display&resource=etres-6. Accessed December 15, 2008. MediaLab Course "HIV: Structure and Replication," Garland Pendergraph. MediaLab Course "OSHA Blodborne Pathogens," Terry Jo Gile MT(ASCP),Ma Ed.MMWR Recomm Rep 2005 Sep 30; 54:RR-9. The 2005 Florida Statutes, Chapters 381, 384,456. Available at www.leg.state.fl.us. Accessed December 1, 2011.Panlilo AL, Cardo DM, Grohskopf LA, Heneine W, Ross, CS. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis, 2005. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm. Accessed December 1, 2011.

The Pap smear remains the primary screening test for cervical cancer. If regular Pap smears are performed, most cervical cancers can be detected and treated. In fact, cervical cancer is one of the most successfully treated cancers. Despite the benefits of Pap tests, many American women do not take advantage of this important form of cervical cancer screening. Slightly more than 80% of American women have Pap smear screening performed every three years. The majority of those diagnosed with invasive cervical cancer had not had a Pap smear performed in the past five years. Routine Pap smears are less utilized or available in other nations. Worldwide, cervical cancer mortality rates are higher than the rates in the United States. In many developing countries, cervical cancer has become the major cause of female cancer deaths. Pap Smear RecommendationsCurrent guidelines recommend a Pap test for women at least every three years. The first Pap test should be about three years after beginning sexual intercourse but no later than age 21.

Recent events, including the terrorist attacks on September 11, 2001 and the subsequent bioterrorist releases of anthrax, have been a harsh awakening that the nation’s workplaces could be terrorist targets.Traditionally laboratory safety guidelines have emphasized use of optimal work practices, appropriate containment equipment, well-designed facilities, and administrative controls to minimize risks of unintentional infection or injury for laboratory workers. Today, in addition to the above, laboratories must make a risk and threat assessment, secure data and electronic technology systems, plus develop policies regarding specimen accountability, facility security, and emergency response.The next few pages will cover a number of things that you can do to assist in making your laboratory more risk free to a terrorist attack and some things you can do in case that security is breached. You too have a role in the security of your workplace!

The minimum frequency for QC testing is the frequency defined by the manufacturer or the frequency defined by the regulatory agency that inspects your laboratory, whichever is more stringent. Other factors may cause the laboratory to decide to test controls more frequently. These factors include:The stability of the analyte and the method systemThe number of patient tests that are routinely performedChange of instrument operators at change of work shiftReagent changeRecalibrationRemember that if a problem is discovered, the samples in previous runs of the instrument may also have been affected. Once the problem(s) are corrected, it may be necessary to go back and re-run previous samples working in reverse order, until the retested results match the original results.

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.

Laboratory discussion meetings help to prevent medical errors. The staff can meet periodically to discuss recent averted adverse events and ones that might have been averted.Discussion should not be about blame. Privacy must be protected, so real names should not be identified. Management can provide guidelines for discussion and analysis.A suggested format for discussion:1. Briefly describe each adverse event.2. Identify its possible causes.3. Discuss relevant guidelines.4. Suggest possible preventive actions.Discussion can include actions that do and do not work to prevent medical errors.

All health care providers, including laboratories, could potentially submit erroneous claims for Medicare reimbursement. These billing errors can trigger an investigation. The creation of a voluntary compliance program, using the guidelines provided by the Office of Inspector General (OIG), can assist health care institutions and laboratories to audit themselves, thereby preventing submission of erroneous claims and a possible fraud and abuse investigation.

All sales offerings and/or written proposals must be in compliance with policies or guidelines or pre-approved by the sales manager or compliance officer.The manner in which a sales or marketing person presents a discount of special price is as important as the amount of the discount.Sales and marketing employees must be very aware of the language used during the sales process to insure the customer understands exactly what is being offered.The offering of an illegal discount is the same as actually giving it.If a client solicits a questionable or illegal discount, it should be reported to the sales manager or compliance officer.

All sales offerings and/or written proposals must be in compliance with policies or guidelines or pre-approved by the sales manager or compliance officer.The manner in which a sales or marketing person presents a discount of special price is as important as the amount of the discount.Sales and marketing employees must be very aware of the language used during the sales process to insure the customer understands exactly what is being offered.The offering of an illegal discount is the same as actually giving it.If a client solicits a questionable or illegal discount, it should be reported to the sales manager or compliance officer.

The National Heart, Lung, and Blood Institute (NHLBI) initiated the National Cholesterol Education Program (NCEP) in 1985. The goal was to reduce the number of Americans with elevated cholesterol and thus reduce illnesses and deaths in the United States due to coronary heart disease. Three adult treatment panels have been published since then with clinical practice guidelines for managing cholesterol levels in adults. The most recent panel, Adult Treatment Panel III (ATP III), was published in 2001 and updated in 2004. The NCEP: ATP III also includes criteria for the diagnosis of metabolic syndrome. This criteria is the most frequently used criteria in the United States.

Armstrong C. Practice guidelines AHA and NHLBI review diagnosis and management of the metabolic syndrome. Am Fam Physician. 2006;74:891-1062.D'Amore PJ. Evolution of c-reactive protein as a cardiac risk factor. Lab Med. 2005;36:234-238.Devaraj, S, Swarbrick MM, Singh U et al. CRP and adiponectin and its oligomers in the metabolic syndrome evaluation of new laboratory-based biomarkers. Am J Clin Pathol. 2008;129:815-822.Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet. 2005;365:1415-1428.Expert Panel in Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (authors). Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA.2001;285:2486-2497.Gade W, Gade J, Collins M et al. Failures of feedback: rush hour along the highway to obesity. Clin Lab Sci. 2010;23:39-50.Gade W, Gade J, Collins M et al. Beyond obesity: the diagnosis and pathophysiology of metabolic syndrome. Clin Lab Sci. 2010;23:51-61.Grundy SM. Does a diagnosis of metabolic syndrome have value in clinical practice? Am J Clin Nutr. 2006;83:1248-1251.Grundy SM, Brewer HB, Cleeman JI, et al. Definition of metabolic syndrome: report of the national heart, lung, and blood institute/american heart association conference on scientific issues related to definition. Circulation. 2004;109:433-438.Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation. 2005;112:2735-2752.Grundy SM. Obesity, metabolic syndrome, and cardiovascular disease. J Clin Endocrinol Metab. 2004;89:2595-2600.Mathew B, Francis L, Kayalar A, et al. Obesity: effects on cardiovascular disease and its diagnosis. J Am Board Fam Med. 2008;21:562-568.Metabolic Syndrome. National Heart Lung and Blood Institute. Diseases and Conditions Index. Available at http://www.nhlbi.nih.gov/health/dci/Diseases/ms/ms_whatis.html. Accessed December 5, 2011.Mittal S. The Metabolic Syndrome in Clinical Practice. London, England. Springer-Verlag Springer Science; 2008.Molinaro RJ. Metabolic syndrome: an update on prevalence, criteria, and laboratory testing. MLO. 2007;39:24-27.Ronti T, Lupattelli G, Mannarino E. The endocrine function of adipose tissue: an update. Clin Endocrinol. 2006;64:355-365.

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.

International Air Transport Association. Guidance document: Dangerous Goods Regulations (DGR). 52nd ed. 2011.National Laboratory Training Network. Packaging and shipping Division 6.2 materials. Georgia Public Health Laboratory; 2011. Sentinel laboratory guidelines for suspected agents of bioterrorism: Clinical laboratory bioterrorism readiness plan. Available at: http://stanfordhospital.org/PDF/bioterrorism/labGuidelinesSuspectedAgentsBT.pdf. Accessed January 31, 2011.US Department of Transportation Pipeline and Hazardous Materials Safety Administration. Transporting Infectious Substances Safely. Available at http://www.phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Files/Transporting_Infectious_Substances_brochure.pdf.

The American Society for Microbiology (ASM) has developed standardized guidelines in coordination with the Centers for Disease Control (CDC) and the Association of Public Health Laboratories (APHL). These protocols should be integrated into the standard operating procedures of any sentinel laboratory. The purpose is to provide the algorithms used to rule out suspected critical agents of bioterrorism and to refer the specimens to public health laboratories for confirmation. The protocols are available to sentinel laboratories at: http://www.asm.org/index.php/policy/sentinel-level-clinical-microbiology-laboratory-guidelines.html

Cell TypeRBC Morphology Reporting Per High Power Field (400x)FewModerateManyAcanthocytes (spur cells)Up to 1% of the fieldor1-2 cells per field1-2.5% of the fieldor3-5 cells per field> 2.5% of the fieldor> 5 cells per fieldFragmented red cells (schistocytes, helmet cells, keratocytes/horn cells)Polychromatophilic cellsSickle cells (drepanocytes)SpherocytesTeardrop cells (dacrocytes).FewModerateManyEchinocytes (burr cells) 5-25% of the fieldor10-50 cells per field25 - 50% of the fieldor51-100 cells per field> 50% of the fieldor> 100 cells per fieldHypochromic cells Macrocytes Microcytes Ovalocytes (elliptocytes) Stomatocytes Target cells (codocytes)....Double Cell PopulationReport if presentRBC AgglutinationRouleaux

Tests on Newborn ( mandatory if mother is Rh negative) ABO and Rh*; Mandatory: Test for weak D if initial Rh typing appears to be D-negative; DAT**. * ABO typing of the infant does not require a reverse serum group with A1 and B cells since the newborn is not expected to have ant-A or anti-B (unless of maternal origin).* If cord blood is used for ABO and Rh(D) typing, the red cells should be well washed to remove possible Wharton's jelly.** A positive DAT does not indicate that the newborn has clinically significant hemolysis. For example, a positive DAT commonly occurs due to ABO incompatibility, yet infants seldom require treatment. Also, infants born to mothers who received antenatal RhIg sometimes have a positive DAT that does not cause clinically relevant hemolysis.Also note that policies for DAT testing of newborns whose mothers have received antenatal RhIg vary internationally. For example, the British Committee for Standards in Haematology guidelines state that a DAT should not be performed on cord blood routinely since in some cases it may be positive due to antenatal RhIg prophylaxis. A DAT is recommended only if HDFN is suspected because of a low cord blood hemoglobin or the presence of unexpected maternal antibodies.However in North America, DATs are always performed on infants born to Rh negative mothers who are RhIg candidates.

In 1988, Congress passed The Clinical Laboratory Improvement Amendments in order to establish quality standards for all laboratory testing to ensure accuracy, reliability and timeliness of laboratory results regardless of where the patient's specimen was tested. The CLIA regulations are based on the complexity of the test method. The more complicated the method, the more stringent the requirements. Three categories of tests have been established: waived, moderate (which includes the sub-category of provider-performed microscopy), and high complexity. CLIA stipulates the quality standards for proficiency testing, patient management, quality control, personnel qualifications, and quality assurance for those laboratories performing moderate and/or high complexity testing. Those laboratories performing only waived testing must enroll in CLIA and are required to follow the manufacturer's instructions for those testing methods performed. The Centers for Medicare and Medicaid Services is charged with laboratory registration, fee collection, surveys, surveyor guidelines and training, enforcement, approval of proficiency testing providers as well as accrediting organizations and exempt states. The Centers for Disease Control and Prevention is responsible for CLIA studies, convening the CLIA Committee, and providing scientific and technical support and consultation to the Centers for Medicare and Medicaid Services. It is the responsibility of the Food and Drug Administration to categorize new test methodologies.

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.

Safety precautions should be observed when handling seminal fluid. The following guidelines should be followed:If non-disposable items are used, soak contaminated items(e.g., hemocytometers and coverslips) in 70% alcohol or other appropriate decontaminate.All disposable items should be placed in a biohazard bag.Non-latex or powder-free latex disposable gloves must be worn and hands thoroughly washed when the examination is completed.Seminal fluids that are to be discarded should be placed in biohazard bags.

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!

According to the CDC guidelines, patients with clinical illness consistent with uncomplicated influenza who reside in an area where influenza viruses are circulating may not require diagnostic influenza testing for clinical management. Most mild cases of H1N1 infection are self-limiting and do not require confirmation. However, if a patient is hospitalized due to the severity of the symptoms, or if the diagnosis of the patient will provide needed information to the physician to direct clinical care, infection control decisions, or management of close contacts, diagnostic influenza testing should be done. In any case, if a decision to use antiviral treatment is made, the treatment should commence as soon as possible, without waiting for the results of confirmatory diagnostic tests.

•Public health guidelines recommend that manipulation of samples for influenza testing be done inside a safety cabinet.If an employee has close contact with a patient with known or probable Influenza A 2009 H1N1 illness, an N95 respirator, as shown in the image below, should be worn, according to CDC guidelines. Note that if an N95 respirator is used, it must first be fit tested to ensure a complete seal around the mouth and nose.Laboratorians should always observe basic infection control procedures including equipment/counter top decontamination and Standard Precautions that include the use of engineering controls such as safety cabinets; personal protective equipment (PPE), such as gloves, fluid-resistant outer clothing, and respiratory protection; and work practice controls, such as frequent hand washing.

If the hematoxylin is used beyond its' expiration date or has been improperly stored (excessive heating or freezing) it will show signs of deteriortion in the form of black precipitate scattered throughout the section. Proper storage and attention to expiration dates will prevent this problem. Manufacturer's of H&E provide guidelines for storage requirements and shelf-life.

The Centers for Disease Control and Prevention (CDC) issued Guidelines for Prevention of Tuberculosis in Healthcare Settings in 2005.These guidelines have broader applications than the Guidelines for Prevention of Tuberculosis in Healthcare Facilities issued by CDC in 1994.

Biosafety. The Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/biosafety/publications/bmbl5/BMBL.pdf. Accessed November 1, 2012.Clinical and Laboratory Standards Institute (CLSI). Protection of Laboratory Workers From Occupationally Acquired Infections; Approved Guideline. 3rd ed. CLSI document M29-A3. CLSI. Wayne, PA: 2005.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.Tuberculosis (TB). The Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/tb/pubs/slidesets/InfectionGuidelines/program.htm. Accessed November 1, 2012. Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuburculosis infection-- United States, 2010. CDC website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5905a1.htm?s_cid=rr5905a1_e. Accessed November 1, 2012.

Automated cell counters will flag abnormal findings. The following guidelines represent typical review criteria, although specific requirements vary between laboratories. Follow the criteria established by your laboratory's procedure:Total white blood cell count <3.0 X 109/L or >12.0 X 109/LNeutrophils >80% Lymphocytes >45% or <10% Monocytes >15% Eosinophils >10% Basophils >5%A morphology review may also be indicated if the platelet count is <100 X 109/L or >650 X 109/L.