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The normal RBC count (4.84 x 1012/L) in this case, together with the decreased hemoglobin (8.4 g/dL) and MCV (59 fl) is an indicator of ineffective erythropoeisis that often points to thalassemia.The RBC morphology shows slight hypochromic microcytosis with codocytes, schistocytes, and basophilic stippling. Schistocytes form by several mechanisms, one being the removal of RBC inclusions.This patient's elevated bilirubin correlates with her presentation of sclera icterus; her splenomegaly is consistent with increased RBC destruction.The Hb electrophoresis demonstrated a normal pattern, initially, but the unstable Hemoglobin H was revealed upon repeat electrophoresis with reduced incubation time. Hemoglobin H is the result of beta globin chain tetramer formation due to the insufficient supply of alpha globin chains in alpha thalassemia intermedia.People with Hemoglobin H disease (alpha thalassemia intermedia) usually have a normal life expectancy without treatment. However, hemolysis may lead to moderate anemia that may be treated with splenectomy.

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.

Acute ITP occurs most often in children who are between 1 and 7 years of age subsequent to a viral infection such as measles, rubella, Epstein-Barr, chicken pox or cytomegalovirus (CMV). The platelet count may drop below 20 x 109/L and the patient may experience excessive bruising, nose bleeds, and petechiae. Spontaneous remission usually occurs within 2 - 6 weeks of onset of acute ITP so that treatment is often not needed unless the platelet count drops below 10 x 109/L, a level at which there is a high risk of bleeding into the central nervous system. The usual course of action is to try to prevent trauma that could result in bleeding and then periodically check the platelet count until it returns to normal.

Transplacental ITP may occur in newborn infants who are born to mothers with ITP. If the mother has had one baby born with thrombocytopenia, it is usually an indication that all subsequent infants will also be born with thrombocytopenia. A very small percentage of babies born with ITP will have severe thrombocytopenia. Neonatal alloimmune thrombocytopenia (NAIT) is caused by platelet destruction that is the result of alloantibodies stimulated by foreign antigens during pregnancy or blood transfusions. Platelet destruction by alloantibodies may occur in neonates if the mother lacks the platelet-specific antigen but the baby has inherited the antigen from its father. When maternal IgG antiplatelet antibodies cross the placenta, immune destruction of the neonate's platelets occurs. The major concern with both of these conditions is intracranial bleeding if the neonate's platelet count is less than 50 X 109/L. NAIT has a high mortality rate due to bleeding into the central nervous system. Prompt diagnosis of the condition and treatment is critical. The thrombocytopenia lasts on average 3 - 4 weeks postnatal until the maternal antibodies have cleared the newborn's system.

Transfusion support is given through the use of Red Blood Cells or Fresh Frozen Plasma (FFP) to replace coagulation factors. However, it is crucial that the underlying disorder that caused the DIC be determined and treated. DIC is always a dramatic event and patients may have some lasting complications.

Laboratory quality indicators are commonly measured as averages or percentages. For example:The turnaround time (TAT) for HIV Western Blot averages 3.5 days.Type O units are available 99.9% of the time in an emergency release.In the first example, it might appears that 3.5 days is a reasonable TAT for a sendout test at first glance, but an average of 3.5 days means the result can be available anytime between the same day to a week later. A patient may have to schedule an appointment at least one week later to ensure the result is available. This may potentially delay treatment. As for the physicians, they want to know when their patients' results will come back; they are not interested in knowing the average but exactly when the result will be available. In the second example, 99.9% might sound impressive but it would translated into 1 out of every 1000 patients requiring emergency transfusion being at risk of ABO hemolytic reaction. In fact if 99.9% is used to measured quality of the processes that happened in our everyday life, that would translate into:18 plane crashes daily17,660 mail mix-ups hourly3,700 medication errors daily10 dropped babies daily$24.8 million worth of incorrect charges hourly500 wrong procedures performed weekly.Other industries realized long ago that measuring quality based on percentage or average is not adequate to satisfy the customers. The need for a higher standard of quality led to the use of Six-Sigma.

Children with beta thalassemia major, also called Cooley's anemia, usually develop clinical signs during their first year of life. They appear to be malnourished and may exhibit abdominal girth expansion. They show bone marrow expansion and skeletal deformations, which are a result of increased erythropoiesis due to low hemoglobin levels. A common finding is facial bone changes caused by this bone marrow expansion (sometimes referred to as Mongoloid facial features). Other clinical signs include frequent infections, hepatomegaly, splenomegaly, gall stones, leg ulcers, iron toxicity, and poor growth and sexual development. In addition, cardiac failure due to increased burden of the heart attempting to oxygenate the tissues, can lead to serious complications and death if the condition is not treated.In general, death usually occurs by the time these patients are in their early twenties unless treated with blood transfusions along with iron-chelating agents. If no chelating agent is used during treatment life will only be prolonged by about a decade.The different genotypes associated with beta thalassemia major are: B0/B0, B0/B+, or B+/B+.

When the technologist accompanies the clinician to assist with the bone marrow aspiration procedure to make smears at the bedside, it is necessary to understand the role of the clinician and the technologist.The clinician is responsible for patient positioning and sterile preparation, pain control, and performing the aspirate and biopsy. The clinician often hands off sample syringes to the technologist, once collected. The clinicians are responsible for providing the procedure kit and fixative for the biopsy, all labels, and obtaining the requisitions and a copy of the clinical history for the hematopathologist. The technologist will set up a mini workspace near the bedside where the samples are split into the required tubes. Smears are then prepared from the aspirate as well as biopsy touchpreps before the biopsy is placed in fixative. In this setting the technologist will usually deliver the samples and requisitions to pathology and continue the processing procedure.The kit the technologist brings to the bedside usually contains mini petri dishes, coverslips, slides, microcapilary tubes or Pasteur pipettes, micro-pipette bulb and the various evacuated blood collection tubes and media flasks required for the standard bone marrow draw.Most institutions will have a standard draw and testing protocol designed to ensure that enough sample is obtained to cover all of the usual testing requirements. An example would be a three-syringe-draw with the first two syringes containing no anticoagulant and the third syringe rinsed with preservative-free heparin. The first dry pull would be split between a green and a purple top evacuated blood collection tube and would be used for morphology (EDTA) and flow cytometry and cytogenetics (green) if needed. The second dry pull is split into two additional purple top tubes plus a green top tube and would be used for molecular assays such as SNP array, Flt-3, JAK2, MPL mutation, etc. The final heparinized syringe could be used for other treatment protocol requirements or to provide sample for additional assays.

Most often a lipid panel measures concentrations of total cholesterol, HDL-C, LDL-C, and triglycerides. HDL-C is measurement of the cholesterol in the lipoprotein HDL, and LDL-C, the measurement of cholesterol in LDL.Cardiovascular disease (CVD) is associated with elevations in LDL-C; increased LDL-C in individuals puts them at risk for CVD and is sometimes considered a pre-AMI condition. The opposite is true for HDL-C. One of the functions of this lipoprotein is to remove excess cholesterol, transporting it to the liver for reprocessing or excretion. To prevent cardiac disease, HDL-C levels should remain up and if below recommended range, steps are prescribed to raise the HDL-C concentration.Recommended ranges for lipids from the 2001 National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III). These were developed in the US as recommended levels that decrease risk for CHD in adults: Cholesterol <200 mg/dL Triglyceride <150 mg/dL LDL-C <100 mg/dL HDL-C >59 mg/dL

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.

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.

Illustrated in the image is the surface of a disk diffusion test including a 30 mg ceftazidime disk (left) and a combintation 30/10 mg ceftazidime/clavulanic acid disk (right). Observe in the photograph that the zone of inhibition around the the combination ceftazidime/clavulanic acid disk (right) is at least 5 mm larger than around the clavulanic acid disk (left). This observation that the presence of clavulanic acid, a beta-lactamase inhibitor, has resulted in such a large increase in the zone of inhibition indicates that an extended-spectrum beta-lactamase (ESBL)is being produced. Additionally, the Clinical and Laboratory Standards Institute (CLSI) Performance Standards for Antimicrobial Testing Standards, published January 2011, proposes in the M100-S21document, table 2A-S1, that cefotaxime (30 mg) and cefotazime-clavulanic acid (30/10 mg) testing per performed alone AND in combination with the ceftazidime and ceftazidime/clavulanic acid testing previously described. When an organism is producing an ESBL, the susceptibility to individual cephalosporins cannot be predicted, thus requiring that each drug must be tested individually.

Piscitelli SC., Shwed J., Schreckenberger P., Danziger LH. Streptococcus milleri group: renewed interest in an elusive pathogen. European Journal of Clinical Microbiology & Infectious Diseases.11:491-8, 1992 The following review examines the bacteriological characteristics, epidemiology, pathogenicity and antimicrobial susceptibility of the "Streptococcus milleri group". "Streptococcus milleri group" is a term for a large group of streptococci which includes Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus. Usually considered commensals, these organisms are often associated with various pyogenic infections including cardiac, intra-abdominal, subcutaneous and central nervous system infections, particularly with the formation of abscesses. Organisms of the "Streptococcus milleri group" are often unrecognized pathogens due to the lack of uniformity in classifications and difficulties in microbiological identification. Penicillin G, cephalosporins, clindamycin and vancomycin all possess activity against these streptococci. Use of agents with poor activity may promote infections with "Streptococcus milleri group" and allow it to exhibit its pathogenicity. An understanding of these organisms may aid in their recognition and proper treatment.

The following table lists the various cell types and macroscopic descriptions of CSF, and the patient conditions that could cause those properties to be present in the patient's CSF: Predominant Cell Appearance Conditions lymphs variable; clear - turbid viral meningitis tubercular meningitis multiple sclerosis drug abuse lymphoma leukemia Guillain-Barré syndrome chronic alcoholism neutrophils variable; clear - turbid bacterial meningitis mycotic meningitis early tuberculosis hemorrhage cerebral abscess tumors monocytes variable chronic bacterial meningitis partial treatment of meningitis tumors macrophages clear - turbid or clear - xanthochromic bloody tuberculosis fungal meningitis following hemorrhage blood contamination eosinophils variable parasitic meningitis fungal meningitis allergic reaction medications shunts dyes tumor cells variable metastatic carcinoma blast cells variable leukemia lymphoma normal to increased lymphs clear - xanthochromic benign tumor spinal cord brain ependymal or orchoid cells (often clumped) variable; may be xanthochromic bloody spinal tap trauma (not clinically significant as these cells are from surrounding tissues due to trauma) Adapted from Saunders Manual of Clinical Laboratory Science. Craig A. Lehrmann, Ed. WB Saunders, 1998.

The nitrites portion of the chemical reagent strip provides a rapid screening test for the presence of gram-negative bacteria that are often responsible for urinary tract infections. Urine cultures are still needed to confirm the diagnosis and monitor any urinary tract or kidney infection. Diagnosis and treatment of cystitis (bladder infection) is important because, if left untreated, it may result in kidney damage, impairment of renal function, hypertension and/or septicemia.

The nitrites portion of the reagent strip provides a rapid screening test for the presence of gram-negative bacteria that are often responsible for urinary tract infections. Although urine cultures are still needed to confirm the diagnosis and monitor any urinary tract or kidney infection, the need for a culture may not be obvious because in some cases of early bladder infection, the symptoms may be vague or the patient may be asymptomatic. Diagnosis and treatment of cystitis (bladder infection) is important because if left untreated it may result in kidney damage, impairment of renal function, hypertension and/or septicemia.

Screening for ketonuria is useful in following the effects of treatment for diabetes and in judging the severity of acidosis. Large amounts of ketones will appear in the urine before serum ketone levels are elevated.

A dermal (skin) puncture may be required when a venipuncture cannot be performed or may be the option of choice for some point-of-care test procedures. A dermal puncture may be a fingerstick or, in the case of small infants, may be a heelstick. Patient safety involves proper identification prior to specimen collection, care in preparing the collection site, proper technique during collection, and treatment of the puncture wound following collection. The technique that is used for collection of the specimen must also prevent the introduction of errors that could cause the specimen to be rejected and require recollection.

Once the required circles on the filter card have been completely saturated with blood and the care of the infant is complete, all necessary patient demographic information on the card must be completed.Every item included in the demographic section must be completed accurately. The age of the infant is important and is often recorded in hours and/or days. Contact information for the parent or guardian as well as the primary care giver is also important so that this information can be used by public health officials to initiate and track the follow-up treatment for the patient. When completing the demographic section of the card, it is advisable to use a ball point pen. Soft or felt tip pens can be absorbed by the filter paper and can possibly affect the test results.Cards should be allowed to air dry completely. Never stack cards in such a way that will allow the blood drops of the cards to come in contact with each other. This could result in transfer of one patient's blood to another patient's card. Many facilities have special racks in which to place cards while drying to avoid the contamination of specimens. After the cards are dry, they should be delivered in a timely manner to the state testing facility.

Lead may be found on surfaces touched by children and adults. Lead may be present in the paint that was used in older homes or apartments, and it has even been detected in the paint used on some toys.Elevated lead levels in children can cause developmental delays. Many state governments closely monitor the presence of lead in children. To accomplish this, government agencies require official forms be completed and submitted for each patient at the time of specimen collection for lead testing. It is the responsibility of both the phlebotomist and healthcare provider to submit the completed form with the specimen. If an elevated lead level is obtained, the government authority can then track and monitor follow-up treatment for the patient. When the phlebotomist determines that a capillary puncture on the finger will be used to collect a specimen for lead testing, it is imperative that the patient's hands be washed with soap and water prior to the start of the collection to ensure the skin is free of any contaminant that could falsely elevate the test result. The patient should thoroughly wash his or her hands or if the patient is a child, the parent or guardian could be asked to assist the child. If necessary, wash the patient's hands yourself.It is important to note that washing hands with soap and water aids in removing surface lead but is not a substitute for the cleaning step in the blood collection procedure. The finger must still be cleansed with alcohol and allowed to dry before a dermal puncture is made.

Coefficient of variation is commonly used as a means of measuring the variability of an instrument. The data are gathered by recording the values for the normal and abnormal controls for each test run. At the end of the month, the standard deviation, mean, and coefficient of variation are calculated. The testing data for a particular instrument might look like this:Normal ControlAbnormal ControlsCVsCVJanuary100.92.432.41209.54.412.11February103.12.992.90211.64.001.89March102.02.212.17206.83.951.91The coefficient of variation stays fairly constant from month to month. If there is a sudden increase, there might be a problem with the method or the equipment.In the clinical laboratory, the use of CV as a measure of relative variability should not be confused with the use of the standard deviation as a measure of absolute variability. For example, support physicians agreed that for accurate patient treatment, the inherent variability in a glucose method should be less than 5 mg/dL. In this case, neither the hexokinase nor the orthotoluidine method is acceptable. It does not matter which is more precise if neither is precise enough to result in adequate patient care.

Patients who have factor deficiencies may or may not require immediate treatment based upon their risk of bleeding. For example, a patient may only need therapeutic treatment if they are having an invasive surgery or a dental procedure. For the patients who do require treatment, some of the current options are: Transfusion of Fresh Frozen Plasma (FFP) Administration of factor concentrates

This course will primarily focus on recommendations made by the American Diabetes Association (ADA) that are related to the diagnosis and monitoring of diabetes. The ADA states on its website, "Our mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes."*Other important agencies and studies referred to in this course are: International Diabetes Federation (IDF): An alliance of 200 diabetes associations; acts as a global advocate for individuals with diabetes.World Health Organization (WHO): An arm of the United Nations; provides programs for prevention, treatment, and care of those with diabetes worldwide.Diabetes Control and Complications Trial (DCCT): A major clinical study 1983-1993; proved the correlation between control of glucose blood level and lowered onset and severity of the complications of diabetes. *Reference: American Diabetes Association. Available at: http://www.diabetes.org/about-us/. Accessed April 14, 2010.

Screening for diabetes of all adults over 45 years of age is recommended. Upon diagnosis of diabetes, many already have experienced some of the complications associated with diabetes. For those with no complications at diagnosis, earlier diabetes treatment delays onset of complications.

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.

An important component of safety training is a working knowledge of first aid and the medical services available to you.This program will explain several common injuries and their treatment.

Submerge the affected part in cold water for 10 to 45 minutes. This will relieve pain and cool tissues to prevent further damage.Give aspirin or ibuprofen to relieve pain and reduce inflammation.Cover second degree burns with a dry nonstick sterile dressing.

Keep the affected eye open using your fingers. Immediately begin flushing the eyes with water and continue for 15 minutes. Use an eyewash, safety shower, or water from the sink.Assist the victim by supporting the head so that water flows across the eyeball from the inside corner of the eye (nearest the nose), outward. This will prevent chemical from getting into the unaffected eye.Get immediate medical help.

Inherited disorders are inborn and have some familial linkage. The hemophilias are inherited coagulation disorders.Hemophilia A is a deficiency of coagulation factor VIII. It is the most commonly encountered hereditary based coagulation disorder. Hemophilia A is found almost exclusively in males, its pattern of inheritance is sex-linked recessive. This disorder presents clinically with hemorrhagic events ranging in severity from mild to severe. Patients often present with spontaneous bleeding into their joints, a classic symptom of this affliction. The treatment of hemophilia A often involves the administration of commercial factor VIII products.Hemophilia B is a deficiency of coagulation factor IX. This disorder is also found almost exclusively in males, its pattern of inheritance is sex-linked recessive. Hemophilia B presents almost identically to hemophilia A in terms of symptoms, and has a very similar pattern of inheritance. Be sure to keep in mind that while similar, hemophilia A and B are caused by a deficiency in different coagulation factors. The treatment of hemophilia B involves therapeutic administration of Factor IX concentrates.

Von Willebrands Disease is a platelet disorder. This disorder is characterized by a functional defect in Von Willebrands factor (vWF) itself. This disease often clinically manifests with a concurrent deficiency of factor VIII, but will present with a normal platelet count. As far as genetics and inheritance, both men and women are affected equally. Von Willebrands factor is essential for platelet binding, therefore, a defect in vWF causes impaired platelet adhesion and aggregation. The treatment of Von Willebrands Disease involves the administration cryoprecipitate, as it is rich in vWF.

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

To aid in the diagnosis of disease or identification of infectious agents, clinical laboratorians use a variety of methodologies to assist them. Knowing what to look for, or the right question to ask, is vital to obtaining the correct answer. Many diseases and agents have unique causes. The cause of the condition then becomes the "target" to be identified and perhaps even quantified.For example: If Patient A is suspected of having disease X, and disease X requires treatment, it is necessary to prove that disease X exists within patient A. We must know something about what causes disease X; is disease X an antigen, a bacteria, a viral particle, a missequenced piece of DNA?Once the target of interest (in this case disease X) has been identified, the clinical laboratorian can choose the methodology most appropriate to answering the question, "Does disease X exist within Patient A?"

Persons with sickle cell disease (SCD) are prone to crises occurring when they experience abrupt changes in temperature or have a fever, are dehydrated, or hypoxic (including entering high altitudes where oxygen is decreased). Physical exertion, pregnancy, and psychological stresses can also precipitate sickle cell crises.Prognosis in SCD is related to the number of sickle cell crisis episodes. Persons who experience more than three episodes of crisis requiring treatment in a single year, have an increased poor prognosis.The average age of survival for women with sickle cell disease (HbSS) is 48 years, while for men the average age of survival is 42 years.

Afenyi-Annan, A., Kail, M., Combs, M.R., Orringer, E.P., Ashley-Kock, A., & Telen, M.J. Lack of Duffy antigen expression is associated with organ damage in patients with sickle cell disease. Transfusion. 2008;48:917-924. Ataka, K. I. et. al.Efficacy and safety of the Gardos channel blocker, senicapoc (ICA-17043), in patients with sickle cell anemia. Blood: 2008; 11(8) 3991-3997.Ballas, S.K., Sickle Cell Anaemia: Progress in Pathogenesis and Treatment. Drugs 2002: 62(8); 1143-1172.Bianchi, N., Zuccato, C., Lampronti, I., Borgatti, N., and Gambari, R. Fetal Hemoglobin Inducers from the Natural World: a novel approach for the identification of drugs for the treatment of B-thalassemia and Sickle-cell anemia. eCAM: 2009; 6(2)141-151.Centers for Disease Control and Prevention. Sickle cell disease: Symptoms and treatments. Available at: http://www.cdc.gov/ncbddd/sicklecell/symptoms.html. Accessed January 21, 2010.Harmening, Denise M., Clinical Hematology and Fundementals of Hemostatis 4th., F.A. Davis, 2001.Inati, A., Koussa, S. Taher, A., & Perrine, S. Sickle cell disease: New insights into pathophysiology and treatment. Pediatr Ann. May 2008.Kaushansky, K., Lichtman, M.A., Beulter, E., Kipps, T.J., and Prchal, J.T. Williams Hematology 8th Ed. McGraw Hill 2010.Lotspeich-Steininger, Stiene-Martin and Koepke, Clinical Hematology Principles, Procedures, Correlations, Lippincott 1992. McKenzie, Shirlyn B., Textbook of Hematology 2nd ed., Williams and Wilkins 1996. Miale, John B, Laboratory Medicine Hematology 6th ed., Mosby 1982. Niscola, P., Sorrentino, F., Scaramucci, L., de Faritiis, P., & Cianciulli, P. Pain syndromes in Sickle Cell Disease: An update. American Academy of Pain Medicine. 2009:470-480.Rodak, Bernadette, Diagnostic Hematology, W.B.Saunders Co., 1995.Yoon, S.L. & black, S. Comprehensive, integrative management of pain for patients with Sickle-Cell Disease. Journal of Alternative and Complementary Medicine. 2006: 12; 995-1001.

Short chain fatty acids that increase levels of butyrate analogues inhibit the switching of hemoglobin chain production from gamma (HbF) to beta (HbA). Use of these compounds in the treatment of sickle cell is still under investigation.In clinical trials, cells containing HbF have been found to increase in number with the use of decitabine, a DNA hypomethilation agent. Also needing further investigation is the use of erythropoietin for treating sickle cell disease. Various colony stimulating factors have been found to increase the production of HbF.

This course is a refresher on current concepts and practices in hemolytic disease of the fetus and newborn (HDFN). As such it is a survey course that provides a broad overview of the field and presents an opportunity to review significant aspects of HDFN and its laboratory investigation and prevention. Because it is a survey course with many topics, not all will be covered in depth. However, Rh immune globulin (RhIg) will be reviewed extensively since it prevents the most severe form of HDFN and is one of the biggest success stories of modern medicine. The course assumes that participants have a basic background knowledge of immunohematology theory and practice. Reading the resources in Further Reading for more information on any topic is encouraged. In brief, the course will: Recap relevant background information on HDFN and its treatment Review the characteristics and uses of Rh immune globulin (RhIg) Discuss typical laboratory findings and their interpretations Examine current best practices in perinatal testing programsThe course is a companion to "Rh negative female with anti-D at delivery: A case study on dealing with the issues" and complements its content.

Prenatal treatment of severe HDFN due to anti-D consists of in utero transfusions. Because of significant risks, transfusion is indicated only if fetal monitoring suggests significant hemolytic disease. 1. Intrauterine Transfusion (IUT)IUTs are done when fetal monitoring indicates severe HDFN and the fetus is too premature for early delivery. IUTs involve the intraperitoneal infusion of packed red cells. The success of the procedure depends on absorption of the red cells through the subdiaphragmatic lymphatic vessels of the fetus. 2. Intravenous transfusion (IVT)Because there may be erratic and inconsistent absorption of intrauterine transfusions in severely hydropic fetuses, IVTs were developed. IVTs involve transfusing donor RBC directly into the umbilical vein.

Besides exchange transfusion, postnatal treatment of HDFN may include the following:RBC TransfusionMany infants who have received IUTs also require simple RBC transfusions in the first few weeks of life to treat ongoing hemolysis caused by persistent maternal antibody in the newborn's circulation.Phototherapy Phototherapy is used to treat jaundice in preterm infants without HDFN and in infants with mild HDFN. Intensive phototherapy has also been used to treat moderate and severe HDFN and decrease the need for exchange transfusion. The newborn is placed under a "blue light" which chemically alters the bilirubin in the surface capillaries to a harmless substance. Human Serum AlbuminHuman serum albumin can also be transfused, either separately or as part of an exchange transfusion in place of FFP. Albumin binds unconjugated bilirubin, thus preventing its deposition in the fat-rich brain cells. Albumin must be used judiciously, because it can aggravate congestive heart failure.

Before ABO HDFN is considered as a possible cause of jaundice and anemia in the newborn, other causes should be considered, for example, erythrocyte membrane defects or red cell enzyme deficiencies. The diagnosis of ABO HDFN in the laboratory differs from diagnosing Rh and other types of HDFN in which clinically significant antibodies must be identified. Diagnosis may be difficult, because the DAT on the newborn's red cells is unreliable. Indeed, many labs do not routinely do a DAT on infants born to Rh positive females, since many will be positive in the absence of clinically significant hemolysis. Cord blood is often retained (e.g., for 7 days) should the infant develop signs of HDFN and required testing.If ABO HDFN is possible, based on incompatible ABO blood groups and a positive DAT, and the mother's antibody screen is negative, many laboratories do not investigate the positive DAT as would be done for unexpected antibodies like anti-D or anti-K (the laboratory does not perform an elution on the newborn's red cells). Instead, the infant's plasma is tested against group A1 (or B cells) and group O screen cells using the indirect antiglobulin test (IAT). A positive reaction with A1 or B cells, but not group O cells, would suffice to report a case of possible ABO HDFN.

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.

This course reviewed some of the key learning goals relevant to HDFN and its investigation, prevention, and treatment. More specifically, the course reviewed the following topics: Historical aspects of HDFN due to anti-D and its prevention; HDFN due to antibodies in the ABO, Rh, and other blood group systems; Clinical symptoms and associated laboratory test results in HDFN; Best practices related to perinatal testing programs to prevent and diagnose HDFN; Characteristics and uses of RhIg; Interpretation of typical serologic test results when investigating HDFN.Before taking the final quiz, for each of the above topics, list as many of the key learning points that you can recall, then review topics that need more study. As well, re-read the learning objectives at the start of the course as these determine assessment questions.It's also worthwhile to read the literature and online resources in Further Reading as these reinforce key points, add to the depth of learning, and enrich the course materials.

Tests for evaluating iron metabolism are generally used as initial or screening tests for hereditary hemochromatosis (HH) as they will detect the phenotypic expression of HH. These tests include serum iron (SI), transferrin (Tf) or total iron binding capacity (TIBC), transferrin saturation, serum ferritin (SF), and unsaturated iron binding capacity (UIBC). The serum ferritin assay is also used to assess the effectiveness of HH treatment.Molecular (DNA) analyses for HFE mutations are considered to be confirmatory tests for HH which may be ordered reflexively in patients with elevated iron results. Laboratories should establish their own reference intervals for assays of iron metabolism. In general, reference intervals vary by sex and by method used for the assays discussed in the following section. Typical reference intervals are included in the following sections for instructive purposes only and should not be used for evaluating actual patient data.The results of laboratory tests assessing iron metabolism should be interpreted with caution because a number of pre-analytical and physiologic factors can affect the results. Repeating elevated test results on fasting specimens is often advisable.

The major determinant of prognosis in cases of hereditary hemochromatosis (HH) is the degree of organ damage from iron overload at the point of diagnosis. The presence of liver cirrhosis reduces life expectancy. Damage that has occurred to tissues and organs is irreversible, but further damage can be halted with treatment. When there is no evidence of cirrhosis at time of diagnosis, life expectancy may be equal to that of persons without HH. With proper management of HH through treatment, affected individuals have good long-term outcomes. Hepatocellular carcinoma associated with cirrhosis, hepatic failure, and cardiac failure are the most common causes of death in persons with HH. Compared to the normal population, liver cancer is many times more prevalent as a cause of death in persons with HH. Cardiomyopathy, diabetes, and cirrhosis are all more common causes of death among persons with HH than among normal persons. The earlier HH is detected, before the onset of severe organ damage, the lower the risk of mortality.

The subject of screening for hereditary hemochromatosis (HH) is controversial and is currently being debated in the medical literature. Using laboratory tests to screen the asymptomatic general population is currently not recommended due to issues of testing costs, low genetic penetrance, and the possible risk of discrimination. Targeted case finding in select high risk populations such as men of Northern European ancestry may be a better approach to screening. (12)Molecular-based (DNA) assays required for confirmation of HH are costly when used for general population screening. Because recent studies have shown that a high percentage of persons with C282Y mutations do not develop iron overload or HH-related clinical conditions, screening for these mutations may falsely label an individual with a disease diagnosis. At the present time, it is impossible to determine which homozygotes or heterozygotes for HFE mutations will eventually develop iron overload. Furthermore, there is potential risk of discrimination in obtaining health insurance for persons identified as having genetic disorders.In contrast, some experts do advocate for screening the general population. Mutations associated with HH are very common in Caucasians in the US. Individuals who know they carry mutations associated with HH may benefit from periodic testing for iron overload. Finally, laboratory tests that assess iron status are relatively inexpensive, widely available, and offer one approach to screening for phenotypic expression of HH. Screening first-degree family members of a person with documented HH is generally considered to be worthwhile. Early detection of HH in relatives with common mutations may permit treatment before the development of substantial iron overload and related disease due to organ damage.

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.

Lifelong treatment of hereditary hemochromatosis (HH) is needed to keep iron at low levels. Without regular treatment, iron stores will re-accumulate. The primary care physician may manage patient care during long-term maintenance. Long-term maintenance typically consists of removal of an average of 2 to 6 units of whole blood yearly, although this number is variable. Monitoring of hemoglobin and serum ferritin levels determine the frequency of phlebotomy. Serum ferritin levels should be maintained at concentrations of no more than 50 ng/mL. (10,13))

Deferoxamine (DFO), an iron chelating agent, may be used to reduce iron overload in patients for whom phlebotomy is contraindicated or not well tolerated. Examples include patients with sickle cell disease or thalassemia whose anemia would be exacerbated by phlebotomies. DFO is seldom used to treat hereditary hemochromatosis (HH) due to the low cost and efficacy of phlebotomy therapy. DFO is typically administered by intravenous or subcutaneous infusion.Patients with HH may be counseled to avoid alcohol use in order to avoid liver damage. With the exception of iron supplements, dietary restrictions on iron ingestion are rarely advised.

A covered entity may use or disclose PHI, without getting an individual's authorization, in order to:Perform requested tests and treatments.Bill for the services performed.Perform essential operations, including quality assessment, accreditation, and compliance.Meet legal reporting requirements, including those mandated by public health departments, workers' compensation, law enforcement agencies, and the US Department of Health and Human Services. Other uses and disclosures require written authorization.

The privacy regulations give covered entities permission to use and disclose PHI for treatment, payment, and health care operations (TPO), without obtaining specific authorization.A covered entity may disclose PHI to other covered entities such as reference laboratories, and home care services, which are providing services to the primary covered entity.The service that the other covered entity is providing must fall within treatment, payment, or health care operations (TPO).If the service being provided does not fall within TPO, an authorization is generally required.An authorization form must state the specific disclosures of PHI to be made, what the information will be used for, and must be signed and dated by the patient.

Your supervisor will refer you for an immediate evaluation and any necessary treatment. Confidentiality will be maintained.Your blood will be tested only with your consent.

HPV DNA testing should not be used as an STI screening test; there is no treatment for HPV as an STI for those who test positive. HPV DNA testing should not be performed to screen for infection prior to vaccination. This would unnecessarily increase the cost of vaccination. HPV DNA testing is not approved or recommended for routine cervical screening for women less than 30 years of age. For adolescents (women 20 years or younger), HPV DNA testing should not be follow-up on abnormal Pap smear test results. HPV is ubiquitous and most young women have infections after becoming sexually active. Most individuals, especially young women, resolve the infection without any intervention. The process of cervical carcinogenesis comprises many years or even decades and most HPV infections do not result in cancer. Unnecessary colposcopy procedures will be performed if young women are tested for HPV. Lesions that are found and treated with cervical excision procedures can increase the risk of premature delivery and low-birth-weight babies. As noted above, HPV DNA testing is recommended for women of any age postcolposcopy of an AGC or ASC-H Pap smear report. The DNA testing is postcolposcopy, not Pap smear follow-up. These lesions may be from non-HPV infections and HPV testing provides information on follow-up options.

They are not immediate. The delayed effect, for example, the long incubation period for some agents, may detract and limit their tactful usefulness as a political statement.They are hazardous to all who come in contact.There is the possibility that the biological agents could also affect the health of the aggressor forces.They are hard to control.The dependence of prevailing winds and other weather conditions such as temperature, sunlight, and desiccation may make it difficult to control distribution of the biological agent.Potential long term effects beyond the initial attack.The persistence of some agents such as spore-forming anthrax in the environment may make an area uninhabitable to aggressor forces for long periods.Results are unpredictable.Morbidity secondary to a biological attack is unpredictable since casualties will be related to the quantity and manner of exposure plus the preventive and treatment measures available.

After the marrow is evaluated, the diagnosis is established and extent of the disease is determined. Follow up bone marrow examinations may be needed to monitor changes in the marrow following treatment or when signs and symptoms of relapse occur. To summarize, a bone marrow examination can provide valuable information to aid in the diagnosis of a variety of disorders. Due to the expense involved and the discomfort to the patient, clear indications of need should be present before this examination is undertaken.

People can help prevent errors in their medical care by understanding their treatment, keeping organized health records, and asking questions. They should feel comfortable talking with medical professionals when things do not seem right.

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

Billing: Highest risk activity a laboratory has. All laboratory activities contribute to the billing process. Many of the risk areas included in this program are components of the billing function. Medical necessity: Medicare is only allowed, by law, to pay for tests that are reasonable and necessary for the diagnosis and treatment of disease. Medical necessity is an underlying principle of the Medicare program. Tests performed for screening or routine exams are not considered medically necessary by the Medicare program.

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.

Organisms that are either present in very low numbers, or that possess a characteristically slow growth rate, may require an extended incubation before they are detected in culture. Amplification and/or detection of unique sequences of either DNA or RNA provide for a more timely identification. This is true whether they are applied to the specimen for direct detection, or in some cases, to culture positive specimens for culture confirmation/identification.Even for organisms that are easy to recover and identify (example: Staphylococcus aureus) various molecular methods offer the ability for either direct detection in clinical material, or more rapid identification that would greatly aid in treatment and/or clinical management decisions.

Many species in the genus Enterococcus possess intrinsic resistance to commonly used antibiotics. Intrinsic resistance represents naturally encoded chromosomal characteristics that are present in most Enterococci. These resistance mechanisms affect primarily the aminoglycosides and beta lactam antibiotics, and create therapeutic challenges for the treatment of serious infections such as endocarditis or septicemia. In addition to intrinsic resistance, Enterococci can acquire genetic determinants that confer resistance to other antibiotics. The emergence and increasing frequency of vancomycin-resistant Enterococci (VRE) has presented both therapeutic and infection control challenges.

Important epidemiological and microbiological differences exist between CA- and HA-MRSA strains so strategies to prevent and treat these infections should also differ. To prevent clinical complications from CA-MRSA, it is recommended that culturing and susceptibility testing of S. aureus clinical isolates become routine practice along with more careful selection and use of antimicrobials when treatment is indicated. MRSA isolates are NOT susceptible to beta-lactam antibiotics, however CA-MRSA infections are susceptible to some currently available non- beta-lactam antibiotics such as clindamycin and trimethoprim/sulfamethoxazole.

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.

Most Clostridium infections arise from endogenous sources. That is, many of the Clostridium species that are associated with disease in humans are part of the normal intestinal microflora, which is true of Clostridium difficile.The organism was originally isolated in 1935 as a component of the normal intestinal flora of healthy newborns. It was dubbed difficile because the organism grows slowly and is difficult to culture. Early investigators also noted that the organism produced a potent toxin, but the relationship between C. difficile antibiotic-associated diarrhea (AAD) and pseudomembranous colitis (PMC) was not elucidated until the 1970's. PMC is an inflammatory disease of the colon caused by toxins of Clostridium difficile. Normal intestinal flora is an important factor in host response to an infectious microorganism. Resistance to intestinal infection is significantly reduced when there is a reduction in the normal flora as a result of antibiotic treatment. The most common manifestation of this decreased host resistance is the development of PMC.

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.

Days to weeks after exposure, the patient may begin to complain of fever, headache, and fatigue. This may also be accompanied by a rash.For the first several months after the infection, the exposed individual may be HIV-antibody negative and the disease may not be detected. However, the individual is still infective and can transmit the disease during this period.The disease may remain silent in the patient for months to years, even with no treatment.When the immune system is weakened enough, the patient will develop opportunistic infections and be classified as having acquired immunodeficiency syndrome (AIDS).

Your supervisor will refer you for an immediate evaluation and any necessary treatment. Confidentiality will be maintained. Your blood will be tested only with your consent.

Your supervisor will refer you for an immediate evaluation and any necessary treatment. Confidentiality will be maintained.Your blood will be tested only with your consent.

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

Pharmacologists determine a drug's pharmacokinetic characteristics empirically during clinical drug trials. From these studies, they are able to determine the solubility and distribution, the average half-life, the levels of protein binding, and the effective concentrations needed for treatment.

Drugs used to inhibit the immune system are part of standard treatment after transplant surgeries. Regarding the use of TDM, there are some reports of hepatotoxicity and nephrotoxicity with some agents, but the main reason for TDM is to ensure that concentrations are adequate to suppress the immune response and prevent rejection. Examples of immunosuppressants that are monitored by TDM include: Cyclosporine Methotrexate Tacrolimus FK778

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.

James Brown, a phlebotomist from the laboratory went to the second floor of Memorial Hospital to draw a STAT BMP (chem-8), CBC, and PT on a patient. The patient was in critical condition so the lab results were crucial for treatment. James quickened his pace in order to speed up the result time. He collected the specimens and took them back to the lab. However, the technologist in hematology and coagulation notified him that he would need to recollect the specimen because the CBC and PT were clotted.

About 2-3% of women will develop gestational diabetes.Since women with gestational diabetes have a higher risk of losing their baby or having a baby with malformations, diagnosis and treatment of gestational diabetes is important.Pregnant women are screened for gestational diabetes at 28 weeks using a modified glucose tolerance test.Patients are given a 50 gm dose of Glucola, and blood is collected for glucose testing one hour later.If the glucose level is greater than 140 mg/dl, a 3 hour glucose tolerance test is required to confirm the diagnosis of gestational diabetes.

Cultures often require 24 or more hours before a pathogen can be recovered. A Gram stain can give preliminary information about the type of bacterial and/or fungal organisms that are present. 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. Intracellular gram-negative diplococci observed in a male urethral specimen may be confirmatory of the diagnosis of gonorrhea. Cultures may not even be needed unless susceptibilities are required. (In the female genital specimen, the presence of gram-negative diplococci is not specific enough to confirm the diagnosis, and a culture or other confirmatory testing must be performed).

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.

The culture smear is used to determine the staining characteristic, size, shape and cellular arrangement of the unknown organism. This data helps the microbiologist to decide on additional culture and identification methods. By correlating the Gram stain reaction, size, shape, and cellular arrangement of the organism with colony morphology and growth requirements, the microbiologist may be able to tentatively identify the organism. This information may help the physician to optimize treatment until definitive culture and antibiotic susceptibility results become available. Gram stain reaction and bacterial shape must be included in the report.The cellular arrangement is usually not included in the report since it may vary depending on the culture medium (liquid or solid) used to isolate the organism. The following 12 screens contain additional ungraded practice questions pertinent to the material covered.

The process of culture, isolation and identification of microorganisms is basic to medical microbiology. When a culture shows signs of growth, the process of identification includes examining the following characteristics:appearance of the colonies in the culture mediumstaining reactionappearance of stained organismssizeshapearrangement of bacterial cellsThis type of preliminary identification may help the physician to initiate the appropriate antibiotic treatment.

Viral load refers to the number of viral genomes present in a patient sample. The measurement of viral load has become important with the increase amount of antiviral medications being created. Clinically, viral load is extremely important in the monitoring and treatment of patients suffering from HIV, hepatitis B and C, and CMV. Tracking the viral load in patient samples can detect the efficiency of antiviral therapy, show potential medication resistance, and indicate possible relapses. Determining viral load is also important for transplant patients. Viral pathogens have a detrimental effect on transplant recipients and antiviral medication is often used to prevent transmission or slow progression of viruses. The use of real-time PCR provides a rapid turn around time that is crucial when treating and monitoring transplant recipients. To determine viral load through real-time PCR, a quantitation standard of known value is incorporated into each value. Such standards are generally included in real-time PCR kits. The results of both the viral and standard amplicons are compared with a standard dilution curve which will then establish the viral load.

Cell TypeImageCellular DescriptionAssociated Diseases and ConditionsNormochromic Small and distinct central pallorNormal MCH and MCHCNormalHypochromic Red blood cells (RBCs) have a larger than normal central pallor (>3 µ in diameter) due to low hemoglobin contentMCHC <32 g/dL or 32%Iron deficiency anemiaThalassemiasSideroblastic anemiaLead poisoningSome cases of chronic inflammationPolychromatophilic Little or no central pallorReddish-blue in colorSlightly larger than normal RBCsSupravital staining identifies these cells as reticulocytesHemorrhage-related conditionsHemolysisDuring treatment for anemiaNewborns

The Kleihauer-Betke test is performed to quantitate the number of fetal cells present in the maternal circulation. Once the size of the FMH is determined, the appropriate RhIg dose can be calculated and administered to prevent the mother from making anti-D.The test is based on the principle that red cells containing fetal hemoglobin (HbF) are less susceptible to acid elution than cells containing adult hemoglobin (HbA).General description A peripheral blood smear is made from the maternal postpartum sample and treated with acid. Fetal cells remain intact because of high concentrations of HbF, while HbA is eluted from the maternal cells. After acid treatment the slides are washed, stained, and examined microscopically. The number of fetal cells (which take up the stain) are counted per number of maternal cells (which appear as ghost cells) to give % fetal cells. The volume of fetal bleed is then calculated to determine how much additional RhIg is required. See Kleihauer-Betke graphic (Source: ENet Answers) Limitations: Despite its widespread use, the Kleihauer-Betke test has significant limitations, including Low sensitivity; Poor reproducibility.

A group O Rh negative female who had received RhIg at 28 weeks gestation had a weak anti-D when a type and screen was done prior to performance of a Cesarean section (C-section). A mini-panel of selected red cells confirmed the presence of anti-D and excluded other antibodies. The laboratory decided that the anti-D was likely passive and consistent with RhIG administration. A group O Rh positive child was delivered by C-section. The newborn had a weakly positive DAT but was healthy and required no treatment. A rosette test to screen for FMH was negative and A.D. was injected with 1500 IU (300 µg) of RhIG within 72 hours of delivery.

Viewing risk management as a process helps set priorities and assists in ensuring a comprehensive risk management effort. There are several different approaches to the risk management process; the approach that is proposed in this course includes these five steps: Identify and analyze loss exposure. Consider alternative risk management treatments. Select what appears to be the best risk management treatment or combination of treatments. Implement the selected treatment(s). Monitor and improve the risk management program.

The final risk management step is to monitor, evaluate, and improve the effectiveness of the treatments employed. As with the other steps in the risk management process, this step should also be a team effort. This step should never become static. Implementations should be monitored accurately, appropriately, and improved as the on-going evaluation indicates. A chart that may be helpful during this phase of risk control is the trend chart. This chart is a performance plotter and addresses the question of "How are we doing?" It helps monitor the effectiveness of performance change over time.

The safety of both the phlebotomist and patient is of utmost concern at all times. In the unfortunate event of an accidental needlestick or if you get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report this immediately to your employer and seek immediate medical attention. It is imperative that the phlebotomist follow facility protocol for reporting the incident. This ensures prompt treatment for the injury. The facility procedure must be followed whether the accidental puncture was from a clean or contaminated needle.The single most important element to prevent an accidental needlestick is for the phlebotomist to fully concentrate during every procedure. Keeping your mind on the task at hand contributes to a successful and safe result.

Immediately following ejaculation, semen is in a gel-like condition.Liquefaction, or resolution of the gel-like consistency, is expected within 15 minutes at room temperature. If liquefaction does not occur within 60 minutes you should note this on the report sheet. Normal liquefied semen may contain jelly-like granules (gelatinous bodies) that do not liquefy. These are not significant and will not interfere with the semen analysis. However, mucus strands may interfere with the analysis.WHO 5th edition recommends continuous gentle mixing or rotation of the sample container on a surface rotator, either at room temperature or in a 37°C incubator during liquefaction to help produce a homogeneous sample. Occasionally a specimen does not liquefy. If this occurs, mechanical mixing or treatment with bromelain, a proteolyic enzyme, may be necessary to promote liquefaction.

Patient-centered health care is care that is delivered in a manner that is "respectful of and responsive to individual's preferences, needs, and values."*Great health care for every patient involves a team approach. All team members contribute in a unique way to ensure successful patient outcomes. The phlebotomist is a key member of the health care team and the team relies on the phlebotomist to obtain quality specimens. Patient diagnosis and treatment is often dependent on laboratory test results. The accuracy and reliability of these results are contingent on a quality specimen. It is easy to see how the phlebotomist directly affects the care of the patient. As members of a professional health care team, phlebotomists should exhibit professional behaviors. Simple things, such as appropriate dress and grooming, reflect a professional image. Language and conversation should also show that you value yourself, your employer, and the patient. Work habits demonstrate to the rest of the team that you provide an invaluable service.*Reference: Committee on Quality of Health Care in America. Crossing the Quality Chasm, A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.

About 2 - 3% of pregnant women will develop gestational diabetes. Since women with gestational diabetes have a higher risk of losing their baby or having a baby with malformations, diagnosis and treatment of gestational diabetes is important.All pregnant women are screened for gestational diabetes at 28 weeks gestation using a modified glucose tolerance test. A fasting blood glucose is collected and then the patient drinks a 50-gram dose of glucose solution. A blood glucose specimen is collected one hour later.If the glucose results of the screen are abnormal, a 3-hour glucose tolerance test may be required. A fasting blood glucose is collected. The patient then drinks a 100-gram dose of glucose solution. Blood specimens are collected at one, two, and three hours after consumption of the glucose beverage. Be sure to label tubes as fasting, one-hour, two-hour, and three-hour. You may also be required to put the exact time of collection on the tube label.

•Influenza A 2009 H1N1 virus-related symptoms range from mild to severe. Many infected individuals are able to recover without medical treatment. Occasionally, some individuals require hospitalization, and these patients receive supportive care and antiviral treatment. Serious infections from the 2009 H1N1 virus have resulted in some patient fatalities, usually due to secondary bacterial pneumonia or other respiratory complications.It is important to note that approximately 70% of the individuals that require hospitalization due to H1N1 infection, have also had one or more previously recognized underlying medical condition that may compromise an effective immune response. These conditions include, but are not limited to: diabetes heart disease asthma kidney disease neurocognitive diseases pregnancy

Most patients who have suspected or confirmed cases of H1N1 infection have a mild, uncomplicated, self-limited illness that may not require antiviral treatment. If infected individuals have a normal immune system, they should be able to recover from the infection with symptomatic treatment only and without antiviral therapy. However, it is the decision of the patient's physician whether to treat or not to treat. The CDC provides this decision tree as a guideline if the illness is mild and uncomplicated:The CDC suggests that patients with suspected or confirmed influenza should be treated if: They are hospitalized as a result of the illness They are at risk for severe disease including these patients: Patients that have certain medical conditions, such as asthma, diabetes, heart disease, or patients with weakened immune systems that may exacerbate the infection. Children younger than 2 years old Adults 65 years or older Pregnant women or women up to 2 weeks post-partum They have a progressive or complicated illness characterized by signs of: lower respiratory tract disease such as hypoxia or abnormal chest x-ray CNS complications such as encephalitis Complications of low blood pressure including shock or organ failure Myocarditis Invasive secondary bacterial infection The treatment options indicated for the 2009 H1N1 infection include oseltamivir (brand name Tamiflu®), an oral tablet, and zanamivir (brand name Relenza®), an inhaled antiviral agent.Reference: Centers for Disease Control and Prevention. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009-2010 season. December 7, 2009. Available at: http://www.cdc.gov/h1n1flu/recommendations.htm. Accessed January 18, 2010.

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

The first component of therapy is to stop the transfusion immediately. Vital signs must be closely monitored. Management involves treatment of hypotension and disseminated intravascular coagulation (DIC). It is essential to maintain blood volume and adequate renal blood flow. Diuretics, substances that increase urine output, may be administered. If the patient enters renal failure, dialysis must be initiated rapidly. It is impossible to prevent all hemolytic transfusion reactions. The purpose of pre-transfusion compatibility testing is to decrease the probability of a hemolytic transfusion reaction by performing ABO/Rh testing, detecting and identifying alloantibodies, and crossmatching compatible blood. Human error, the most common cause of hemolytic transfusion reactions, cannot be completely eliminated. Steps must be taken to reduce the possibility of human error in identification of patient samples, donor units, and recipients. Each person involved in the transfusion process, from collection of the blood sample to administration of the donor unit, must carefully adhere to each step outlined in the standard operating procedures. All appropriate protocols must be followed. Some examples are: Technologist checks blood sample to ensure proper labeling. Patient's previous transfusion records are examined and all transfusion testing is performed correctly and accurately. Technologist ensures correct unit is released from the blood bank. Transfusionist ensures the recipient is correctly identified.There must be a mechanism in place to train and assess all personnel involved in the transfusion process.

Diagnosis of allergic reactions is based on the recognition of a skin rash associated with itching. Treatment involves temporarily discontinuing the transfusion and administering an antihistamine. The rash will usually heal when the transfusion is stopped or when an antihistamine is given. Once symptoms have been alleviated, the transfusion may be resumed. If symptoms continue or progress, the transfusion must be stopped and a new donor unit obtained. Premedication will usually prevent urticarial reactions in patients with a history of allergic reactions. If premedication is unsuccessful, washed cellular products may prevent a reaction. Leukoreduction has no role in preventing an allergic reaction. Anaphylatic and anaphylactiod reactions should be recognized when patients develop symptoms described on the previous page. The transfusion must be stopped immediately. Differential diagnosis includes hypotensive reactions, transfusion-related acute lung injury (TRALI), myocaridal infarction, and pulmonary embolus. An IgA deficiency should be investigated and is confirmed by the presence of anti-IgA. Treatment includes timely administration of epinephrine in addition to other supportive care such as vasopressors and airway support. Prevention involves avoiding transfusion of IgA. Cellular products should be washed to remove residual plasma. Products may also be collected from donors who are known to be IgA deficient. Autologous donations are an alternative.

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

Transfusion-associated graft versus host disease (TA-GVHD) is generally unresponsive to medical treatment. Hematopoetic stem cell transplantation has been successful in rare instances. Gamma-irradiation of blood components containing viable lymphocytes is effective in preventing TA-GVHD. Irradiation is recommended for all Whole Blood, Red Blood Cell (RBC), Platelet, and Granulocyte transfusions to patients at risk. Patients at risk include neonates less than four months, patients with an acquired or congenital immunodeficiency, or patients receiving a directed donation from a family member. Irradiation prevents proliferation of donor lymphocytes with a required dose of 25 Gy to the mid plane of the blood container and a minimum of 15 Gy elsewhere. The dosage must not exceed 50 Gy to prevent harm to the patient from irradiation. Irradiation of blood can result in a decreased survival of red cells and a leakage of potassium from intracellular stores. Because of this, red cell units may only be stored for up to 28 days following irradiation. No reduction in storage time is required for platelets. Because Fresh Frozen Plasma (FFP) and Cryoprecipitate do not contain cells, irradiation is not required to prevent TA-GVHD in patients at risk.

To control the spread of infection, any of these events must occur: Person-to-person transmission is prevented.Host response is effectively stimulated to prevent, control, or eliminate infection.Antimicrobial treatment is effective against M. tuberculosis.Therefore, an effective TB infection control program must include: Prompt detectionAirborne precautionsTreatment

Some procedures increase the potential for TB risk because they create aerosols. They include:Sputum induction and aerosol treatments Bronchoscopy Endotracheal intubation and suctioning Autopsy Microbiology processing TB specimens Surgical drainage of TB abscesses

Recognition and diagnosis of the inherited form of Pelger-Huet anomaly is important because many of these Pelger-Huet neutrophils may be classified as bands, therefore; increased numbers of bands might be erroneously reported in these patients. Since increased numbers bands frequently indicate infection, reporting Pelger-Huet cells as normal band forms could result in inappropriate treatment for infection. Pelger-Huet cells have denser nuclear chromatin than neutrophilic band forms.