Identification Information and Courses from MediaLab, Inc.

1. Based on these reactions, which antibody or antibodies could be present?2. Based on these reactions, which antibodies can be ruled out?3. What further testing, if any, should be done to assist in the antibody identification?

Based on these reactions, which antibody or antibodies could be present? Is there any significance to the varying reaction strengths? Which antibodies can be ruled out based on these reactions? What further testing, if any, should be done to help in the antibody identification?

Monospecific anti-human globulin (IgG) enables sensitized red cells to cross-link so that agglutination is visible.Enhancement media are sometimes used to further promote agglutination and reduce incubation time. Low ionic strength saline (LISS) is the most common enhancement media. LISS reduces the ionic strength in the testing sample and causes reduction of the zeta potential. It increases antibody uptake and decreases incubation time. Polyethylene Glycol (PEG): brings red blood cells (RBCs) closer together and concentrates antibodies by removing water molecules from the testing sample. It is the most sensitive of the enhancement media; strengthening almost all clinically significant antibodies. However, it will also enhance some clinically insignificant antibodies as well. Centrifugation should be avoided when PEG is used. PEG can cause aggregates to form if the sample (red cell - serum mixture) with PEG added is centrifuged. Reaction readings should only be done at the AHG phase. 22% Albumin: reduces zeta potential, bringing the RBCs closer together and enhancing agglutination. Albumin does not contribute much to antibody uptake. Longer incubation time is needed with this media than with the previously discussed media. Detection of some IgG antibodies can be enhanced with enzyme test methods. Proteolytic enzymes (papain and ficin) denature some RBC antigens and remove negative charges from the RBC membranes. This reduces the zeta potential, bringing the cells closer together. Enzyme techniques are particularly useful in the identification of Rh antibodies and antibodies in the Kidd, Lewis, P and I systems. However, enzymes destroy some antigens including Fya, Fyb, M, and N. The effect of proteolytic enzymes on the S and s antigens are variable.

Antibody screening and antibody identification are critical components in blood bank testing. Clinically significant antibodies must be identified so that appropriate blood products are selected for transfusion and the risk of adverse reaction is minimized. Clinically significant antibodies are capable of causing transfusion reactions, hemolytic disease of the newborn and in severe cases, death.This course will discuss the techniques that are used by blood bank technologists to detect and identify various types of antibodies.

Superoxol is an additional spot test that may be helpful in the presumptive identification of N. gonorrhoeae.Superoxol is 30% hydrogen peroxide, in contrast to the 3% solution that is used in the catalase test.Other Neisseria species and Moraxella catarrhalis are either negative for this test or give a weak, delayed reaction.

Smith KR, Fisher HC III, Hook, EW III: Prevalence of fluorescent monoclonal antibody-nonreactive Neisseria gonorrhoeae in five North American sexually transmitted disease clinics.J Clin Microbiol 34:1551-1552, 1996We compared a direct fluorescent monoclonal antibody (DFA) test with alternative enzymatic and fermention tests for identifying presumptive gonococcal isolates in a systematic sample from patients attending five sexually transmitted disease clinics in five cities.Fourteen (2.5%) of 556 isolates from three clinics were nonreactive with the DFA confirmatory reagent and reactive by both the Quad-Ferm and Rapid NH tests. The prevalence of DFA-nonreactive Neisseria gonorrhoeae isolates varies geographically and is independent of local methods for the identification of possible gonococci.On the basis of our findings, we recommend that for use in medicolegal and other instances in which a diagnosis of gonorrhea has the potential to have far-reaching effects, it is appropriate to test DFA reagent-nonreactive, oxidase-positive, gram-negative diplococci by alternative methods of gonococcal confirmation.Although the prevalence of such isolates could change, the fluorescent monoclonal antibody confirmation reagents remain useful for many clinical situations. Their ease of use and ready applicability for screening large numbers of isolates make them useful for many laboratories.

The definitive identification of C. septicum can be made using a profile of biochemical reactions, as is contained in the RapID ANA strip (see photograph). The upper set of tubules are reactions before addition of reagents; the bottom set of reactions after reagents are added.The upper set of letter codes is used to read the reactions before addition of reagents; the lower set of labels indicate the tests to read following addition of reagents.Of all the reactions included, only ONPG and NAG in the upper set are positive.The biotype number derived from this profile of reactions, 014000 codes for Clostridium septicum, thus confirming the identification.

Citron DM. Appelbaum PC.: How far should a clinical laboratory go in identifying anaerobic isolates, and who should pay? Clinical Infectious Diseases. 16 Suppl 4:S435-8, 1993Identification of anaerobic bacteria in specimens from sites of infection due to mixed organisms can be time-consuming and expensive. Laboratories should limit anaerobic workups by testing only those specimens that have been properly collected and transported to the laboratory.Use of selective and differential media for initial processing can provide rapid and relevant information to the clinician. Anaerobes isolated from normally sterile sites and sites of serious infection should always be completely identified. Group-or genus-level identifications may suffice in other instances.The Bacteroides fragilis group of organisms should always be identified because of their virulence and resistance to many antimicrobial agents.Some of the other organisms that warrant identification include Clostridium septicum (associated with gastrointestinal malignancy); Clostridium ramosum, Clostridium innocuum, and Clostridium clostridioforme (which are resistant to antibiotics); Clostridium perfringens (a cause of myonecrosis and gas gangrene,potentially serious infection); anaerobic cocci (which may be resistant to metronidazole and clindamycin); and fusobacteria (which may be virulent and resistant to clindamycin and penicillin).

Enhanced growth under CO2 incubation is an additional clue to the identification of S. milleri.Note in the photograph the increased growth of the colonies grown on the plate incubated under CO2, compared to those incubated in ambient air (O2).

Listeria monocytogenes is optimally motile at 25C; and is non-motile at 35-37C.Motility may be directly assessed by observing bacterial cells with a tumbling motion in a direct mount preparation.In soft motility agar, the identification can be made by observing for a thin, umbrella-like lateral extension of growth from the stab line (see photograph).

Regardless whether you are collecting a Federally Regulated or a Non-Federally Regulated urine drug screen, there are five areas which demand specific prerequisites or conditions prior to performing a proper collection. These are: Requirements for the collection site. Supplies needed to conduct a collection. Criteria that must be met by collectors. Complete and accurate documentation. Proper identification of the donor.We will explore each of these in more detail over the next several pages.

One of the most important aspects of a urine drug screen collection is the correct identification of the donor. It is the responsibility of the donor to provide the collector appropriate identification upon arrival at the collection site.Acceptable forms of identification include: A photo identification such as a driver's license, an employee badge, or any other picture ID issued by either a federal, state, or local government agency. Identification made by an employer or a representative of the employer. In this latter case, the employer or employer representative can describe the donor to the suitability of the collector via a phone call.

Unacceptable forms of identification include: Identification by a co-worker. Identification by another employee also working in a safety sensitive position. Use of a single non-photo identification card such as a social security card, credit card, membership card, pay voucher, or voter registration card. Faxed or photocopies of identification documents.

After a positive identification has been made, invite the donor into the area where the collection will be conducted. Be pleasant, but professional. Introduce yourself and generally explain the collection procedure. Be prepared to accommodate donors who do not speak English. Never argue with the donor or be judgmental. Always remember that you are a professional. Conduct yourself in that manner. Ask the donor to remove any unnecessary out clothing such as a coat, jacket, hat, etc., and to leave any briefcase, purse, or other personal belongings with the outer clothing. The donor may retain his or her wallet. If the donor asks for a receipt for any belongings left with the collector, the collector must provide one. Direct the donor to empty his or her pockets and display the items to ensure that no items are present that could be used to adulterate or dilute the specimen or be used as a substitute. If nothing is there, the donor may return the items to his or her pockets.

In addition to the specimen sample, support medium and buffer for electrophoresis, a power supply, positive and negative electrodes, chamber, and identification or detection method are needed.The power supply is a source of constant voltage or current that provides energy to the electrodes. This drives the movement of the ions in the medium and results in the movement and separation of the molecules or solutes in the specimen. Control of current or voltage comes with the power source in order to make adjustments.The chamber is divided into two sections or has two reservoirs for the buffer and one electrode is placed in each. The support medium is laid over the chamber in such a way that it connects the two reservoirs. A lid or cover is placed over the chamber during electrophoresis.

The appearance, composition and associated physiology is specific for each type of inclusion. Identification and quantification of these inclusions is important because their presence may indicate an abnormality in the red cell system. Each of the inclusions listed above can be seen in more than one condition. There are erythrocyte inclusions specific to disorders which cannot be seen with either Wright-Giemsa stain or Perls' Prussian blue iron stain.

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

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

Hereditary hemochromatosis (HH) is frequently discovered only during management of associated illness or routine health evaluations. It has been estimated that only a small percentage of all affected persons are actually diagnosed. Individuals with HH may be symptomatic for several years prior to diagnosis and may have consulted multiple health care providers.Under-diagnosis of HH is thought to occur due to:• Lack of specificity of early signs and symptoms• Asymptomatic status of some patients until damage to organs and tissues has occurred• Confusion with liver disease due to other causes• Insufficient awareness and knowledge of HHEarly identification of persons with HH is essential to prevent serious and irreversible complications associated with severe iron overload. A classic triad of skin hyperpigmentation (bronzing), type 2 diabetes, and hepatic cirrhosis has long been recognized as evidence of advanced iron overload. However, persons with HH may present with a much wider variety of signs and symptoms, particularly if they are seen before significant iron accumulation has occurred. Age of presentation and disease severity are highly variable. A diagnosis of HH is based on laboratory evidence of iron overload, genetic mutations associated with HH, and presence of clinical signs and symptoms consistent with HH.(10)

 While at work, there are a few simple precautions you can take to help keep your lab as safe as possible: Keep security entrances locked. Don’t let others borrow your keys or access card. Don’t let someone enter the work area without proper identification. If you see someone in your area that is unknown to you, check their identification to make sure that they have permission to be in the area. Report any suspicious personnel or activities. Account for all supplies and specimens entering or leaving your facility. Report gaps in security measures such as broken windows, security lighting out.

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.

When viewing a confusing cell, it is helpful to focus through several planes, taking special note of overall chromatin structure, appearance or presence of any filaments, and general cytoplasmic characteristics.For example, here we see a neutrophilic cell that is folded, making exact identification difficult.However, due to the thickness of the nucleus and the absence of a filament, we would classify it as a band.

Name of the chemical, indicated by words or symbols. Information about the company that made or imported the chemical: Company name Address Emergency phone number Physical hazards that are associated with the chemical: Reactivity Flammability

Further information: Manufacturer product number An emergency phone number CAS identification number The DOT shipping name and hazard class The chemical family name and synonyms The chemical's formula and molecular weight

A category B infectious substance is not in a form generally capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals when exposure to it occurs. The proper shipping name and Identification number is:Biological substance, Category B, UN 3373

Packages that contain category A substances must exhibit these labels.Proper shipping name and UN number(Category A label) or Hazard class 6 infectious substance label that includes this statement:In case of damage or leakage, immediately notify public health authority. In the US, notify the CDC 1-800-232-0124 UN package certification markOrientation arrows (if greater than 50 mL)Contact information (Shipper or Consignee Identification)The contact person (usually the shipper), referred to as the "responsible person" by IATA, must be someone who can be reached 24 hours a day, seven days a week (24/7) and can answer questions about the content of the package. The 24/7 number must reach that person directly and not a pager or answering machine/service. If the contact person that you are listing is the person receiving the specimen, be certain that the person is aware you are listing him/her as the contact person and has consented to it.

When the results on Mr. John Ready were called to the nurse, she was very surprised that the result of his CBC was normal. The nurse explained to the lab tech that Mr. John Ready had a known diagnosis of lower GI bleeding. His hemoglobin had been very low for the past 24 hours because of the internal bleeding, and she thought it was very surprising that his hemoglobin had normalized so quickly without having received a blood transfusion. Mr. Ready’s doctor decided the patient should be redrawn to ensure a correct result. The nurse further questioned if the phlebotomist could possibly have drawn the wrong patient because earlier that day Mr. Ready had been moved to room 831, and room 825 was presently occupied by a patient named Walter Redding. If Julie had checked the patient’s armband, she would have realized that the patient in 825 was the wrong patient.Relevant topics:Importance of patient ID, Patient identification continued, Specimen labeling, Specimen labeling Continued, Blood bank specimens

Proper labeling generally includes:Patient’s first and last nameHospital identification numberDate & timePhlebotomist initialsYour institution may provide bar coded computer generated labels that contain this information.

Blood is normally sterile. Any bacterial growth in the bloodstream is abnormal, and is an important cause of fever.Blood culture means the incubation of blood in appropriate media to allow growth and identification of bacteria or other organisms that may be present in a patient’s bloodstream. Blood cultures are performed on febrile patients to identify and treat bloodborne organisms with the most appropriate antibiotic.

Identification of bacteria in direct smears may be of lifesaving importance. For example, a rapid diagnosis of bacterial meningitis, made after examining a gram stained smear of the patient's cerebrospinal fluid, allows the physician to begin treatment immediately. The appearance of bacteria on gram stained smears is suggestive of a certain species, but identification may not be made on the basis of the stain alone. An exception to this rule is the presence of gram negative intracellular diplococci from a male urogenital specimen, which is presumptive identification of Neisseria gonorrhoeae. In addition, culture results can be correlated with the direct smear report.

It is important to note the Gram stain reaction, shape, and cellular arrangement when examining culture smears. This information may be useful in making a presumptive identification. The following nine screens contain ungraded practice questions covering the material that has been covered so far.

Reticulocytes are red blood cells prematurely released from the bone marrow. On a Wright-Giemsa stained blood smear, they appear as polychromatic macrocytes. Their presence in the peripheral blood may suggest hemolysis or bleeding. Their presence is expressed as a percentage of the red cell count: newly born= 3-7%; up to one week of age=1-3%; >one week =0.3-1.8%. Automated or manual methods may be used to enumerate reticulocytes. In clinical context, retics must be separated from debris, precipated stain, Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies.

Red blood cells can vary in size (diameter/volume) from smaller than normal, microcytes, to larger than normal, macrocytes. When red cells of normal size, microcytes and macrocytes are present in the same field, the term anisocytosis is used.Since the purpose of this unit is to acquaint you with the appearance (identification) of abnormal red cell morphology, percentages of abnormalities present will not be considered. It is important to be aware that rating red cell morphology for the purpose of reporting it is a skill which must be learned before you are able to complete this aspect of a differential count.

Examples of stomatocytes can be seen in the center of this slide and to the left of the center. Conditions in which a significant number of in vivo stomatocytes can be seen include hereditary stomatocytosis, neoplastic disorders, liver disease and Rh null disease. The largest numbers of in vivo stomatocytes are seen in hereditary stomatocytosis and their identification is necessary to make the diagnosis.

In order to prevent errors that affect specimen quality, the phlebotomist must pay close attention to detail during the entire venipuncture process. All steps of the phlebotomy procedure must be included for every venipuncture. This will help to maintain specimen integrity during the collection, transport, and handling of blood specimensProperly identify the patient every timeThe phlebotomist is responsible for correctly identifying the patient using two unique patient identifiers that include the patient's complete first and last name, medical record or hospital number, and/or date of birth. The patient location or room number, bed tag and chart are not reliable forms of identification and should not be used for patient identification. Every patient must verbalize his/her name to the phlebotomist, if able to do so. It is unacceptable for the phlebotomist to ask the patient to confirm his/her name that was verbalized by the phlebotomist. For example, the phlebotomist should say, "Would you please tell me (or spell) your name and birthdate. " The phlebotomist should NOT say, "Are you Sally Brown, and is your birthdate June 1, 1925?" If this is a hospital inpatient, check the information on the patient's wristband and confirm that the name and hospital number or medical record number matches the patient information on the test order. Never rely on identification attached to a bed, chart or door. NEVER draw a patient whose identity is not established or is in conflict. If there is a discrepancy, the phlebotomist must STOP and seek assistance to have the discrepancy resolved before proceeding with the venipuncture. If this is an outpatient that does not have a wristband, ask the patient (or guardian/caregiver) to state the patient's date of birth. A picture ID, such as a driver's license, can also be used for positive patient identification.

The p value is a statistical tool that increases the confidence that an antibody has been identified with a scientifically acceptable level of uncertainty (0.05). As applied to antibody identification, it is computed using Fisher's exact test. Tidbit: This is the same Fisher who helped developed the Fisher-Race theory of Rh inheritance.The p value is calculated using the number of cells that are positive and negative with the patient's plasma. Calculating p values is beyond the scope of this case study but basic understanding of p values at the conceptual level is covered.

When p values are calculated for antibody identifications, we think of the null hypothesis as meaning, "the relative proportions of one variable (panel cell being antigen-positive) are independent of the second variable (patient's plasma reacting with the cell). In other words, the results could be due to another cause (different antibody, combination of antibodies, or spurious reactions), not the antibody that we have identified as being probable.Therefore, a p value of 0.05 can be interpreted as meaning that the same results produced by another antibody or cause would be expected to occur by chance alone only one in 20 times (5% of the time), given the number of cells tested. By scientific tradition, this is an acceptable level of uncertainty.A p value of 0.05 does not mean that we have identified the correct antibody.

Immediate post-transfusion antibody identification results Cell Rh Rhesus Kell Duffy Kidd MNSs P Lewis Lu Results1 Results2 C D E c e Cw K k Kpa Fya Fyb Jka Jkb M N S s P1 Lea Leb Lua Gel IAT Gel IAT 1 rr 0 0 0 + + 0 0 + 0 + 0 + 0 0 + + + +S + 0 0 0 w+ 2 rr 0 0 0 + + 0 0 + 0 0 + + + 0 + + + +S + 0 0 0 0 3 rr 0 0 0 + + 0 0 + 0 + 0 0 + 0 + + 0 + 0 + 0 0 0 4 r"r 0 0 + + + 0 0 + 0 + + 0 + 0 + 0 + + + 0 0 0 0 5 R2R2 0 + + + 0 0 + 0 0 + 0 + + + 0 + 0 + 0

Recognizing and identifying casts is an essential part of the urine microscopic examination. The table below summarizes the different type of casts and their clinical significance. Type Condition Hyaline 0-2/LPF is normal; increase in fever, diuretic therapy, exercise or stress. Glomerulonephritis Pyelonephritis Chronic renal disease White Blood Cell Renal Infection Inflammation of the nephron Red Blood Cell Bleeding in the nephron Glomerulonephritis Strenuous exercise Epithelial Cell Renal tubular damage Coarsely Granular Urinary stasis Gomerular and tubular disease Finely Granular Further degeneration of coarsely granular Amyloid disease Chronic renal disease Fatty Degenerative tubular disease Broad Extreme stasis of urine flow Renal failure

There are a number of crystals which are seen less frequently but are of considerable significance when they appear. Their presence should be verified by further testing and confirmed by a supervisor or pathologist before reporting the results. Polarized light can aid in crystal identification.

Identification of crystals found in the urine sediment requires knowledge of the urinary pH. Large crystals are identifiable under low power. High power magnification is required for smaller crystals. Most crystals can be identified by morphology alone. Urine pH and reagent strip results can provide supporting information. If further examination is necessary birefringence and solubility characteristics should be performed.

Auer rods are red staining, needle-like bodies seen in the cytoplasm of myeloblasts, and/or progranulocytes in leukemia. Auer rods are cytoplasmic inclusions which result from an abnormal fusion of the primary (azurophilic) granules. Single or multiple Auer rods may be seen in the cytoplasm of a cell. If more than one is present, they are frequently close together and may even be overlapping. Their identification is very important because, if found, they can confirm the presence of myeloblasts indicating the presence of a myeloid (non-lymphoblastic) leukemia. They can also be seen in myeloid blast crisis in chronic granulocytic leukemia. Auer rods are never seen in lymphoblasts. This differentiation is important because the treatment of lymphoblastic and myeloblastic leukemia are different. Auer Rods are always classified as pathological.

In most clinical hematology laboratories, an initial blood count is performed by an electronic instrument. Some of these instruments also produce a differential blood count, and a platelet count. Instruments that provide a 3-part differential indicate the percentage of neutrophils, lymphocytes, and a mixed field group that includes monocytes, eosinophils, basophils, immature and atypical cells. Thus, the atypical cells shown in the photograph would be counted as mixed cells and a smear review would be needed to make an identification. Instruments providing a 5-part differential count include monocytes and eosinophils. In cases where the mixed cell count is high, or there are other indications that atypical cells may be present, a hematologist's review of the smear is indicated.